Maple Crest Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 2824 North 66th Avenue, Omaha, Nebraska 68104
- CMS Provider Number
- 285149
- Inspections on file
- 24
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Maple Crest Health Center during CMS and state inspections, most recent first.
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.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and while providing care under Enhanced Barrier Precautions. An LPN performed serial blood glucose checks for two residents with T2DM without changing gloves between residents, without performing hand hygiene when changing gloves, and without cleaning the glucometer between uses, while also handling test strips directly from the cannister with contaminated gloves. In a separate incident, a resident with ESRD on dialysis and a documented care plan for EBP, including gown use for high-contact care such as brief changes, received incontinence care from a NA who did not wear a gown, despite posted EBP signage and later acknowledgment that a gown should have been used.
A facility failed to secure medications properly, with a bottle of Miconazole 2% powder found unsecured in a resident's room and a medication cart left unlocked. The resident had multiple health issues, including moderate cognitive impairment, and no physician's order for the powder. The facility's policy requires all medications to be secured and carts locked when unattended.
The facility failed to maintain the nutritive value of pureed food for 18 residents. Staff used inappropriate methods, such as adding boiling water and excessive thickener, which could alter the nutritional value and taste. The dietician confirmed these methods were not appropriate, and the taste of the pureed eggs was poor.
The facility failed to offer Pneumococcal vaccinations to four residents, despite having a policy in place. Residents with conditions like congestive heart failure, chronic respiratory failure, and Parkinson's disease were not assessed or offered the vaccine. The Assistant Director of Nursing confirmed the oversight.
A resident with End Stage Renal Disease missed a dialysis appointment due to staffing issues at the dialysis center. The facility failed to notify the resident's physician about the missed session, despite the resident's care plan indicating a need for dialysis. The Director of Nursing confirmed the oversight, which was against the facility's policy requiring immediate notification of significant changes in a resident's condition.
A facility failed to investigate and report an alleged staff-to-resident abuse incident within the required timeframe. A resident with moderate cognitive impairment reported that a caregiver had slammed their feet on the bed. The incident was not documented in the resident's medical records, and no report was sent to DHHS within the mandated period. Interviews confirmed that the facility's policies on abuse investigations and reporting were not followed.
The facility failed to accurately document special treatments for two residents on the MDS. One resident's MDS did not reflect dialysis treatment despite having renal issues, and another resident's MDS failed to indicate hospice care. These inaccuracies were confirmed by the MDS Coordinator.
A facility failed to complete a new PASRR referral for a resident after several new psychiatric diagnoses, including major depressive disorder and PTSD, were identified. Despite policy requirements for re-screens due to changes in condition, no new PASRR screening was conducted since the resident's initial screening in 2017.
A resident's Level I PASARR screen was inaccurately completed, failing to identify diagnoses that should have triggered a Level II screen. The resident had conditions such as vascular dementia, moderate intellectual disabilities, and major depressive disorder, which were not reflected in the initial PASARR assessment. The facility's administrator confirmed the oversight, and no additional PASARR screens were conducted since the initial one.
A resident with Alzheimer's, Lewy body Dementia, Schizophrenia, and Depression did not receive timely incontinence care and position changes as per their care plan. Observations showed no assistance from 8:15 AM to 12:15 PM, and the resident's brief was wet by 2:30 PM. Interviews confirmed the lack of care, highlighting a deficiency in the facility's adherence to the care plan.
The facility failed to implement assessed interventions for two residents, leading to deficiencies in accident prevention. One resident, with severe cognitive impairment, did not consistently have a Rooke boot in place to protect fragile skin, while another resident, at high risk for falls, lacked necessary fall prevention measures such as Dycem in the wheelchair and signage to use the call light. Staff were unaware of these interventions, contributing to the risk of injury.
A resident was not provided timely follow-up dental services after being fitted for dentures, resulting in a delay of several months. The facility failed to maintain communication with the dentist, as required by their policy, leading to the resident not receiving their dentures as expected.
Two residents in a long-term care facility were subject to improper infection control practices. A resident receiving catheter care was handled by staff who failed to change gloves and perform hand hygiene correctly, risking cross-contamination. Another resident, dependent on staff for personal care, was provided perineal care with washcloths potentially contaminated by being placed in a sink. These actions violated the facility's infection control guidelines.
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.
Failure to Follow Infection Control Practices for Glucose Monitoring and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow infection prevention and control practices during blood glucose monitoring for two residents. Policy review showed the facility required glucometers to be cleaned before and after each use, and gloves to be single-use with handwashing before donning and after doffing. Resident 14 and Resident 15 both required routine blood glucose monitoring for Type 2 Diabetes Mellitus. During continuous observation, an LPN exited one resident’s room wearing gloves, discarded a used test strip, and without removing gloves, performing hand hygiene, or cleaning the glucometer, retrieved new test strips directly from the cannister and other supplies, then entered Resident 14’s room, performed a fingerstick, and exited without cleaning the glucometer or performing hand hygiene. The same LPN then, still wearing the same gloves, retrieved another test strip from the cannister and additional supplies and entered Resident 15’s room. After realizing a new lancet was needed, the LPN exited, removed gloves, and without performing hand hygiene, obtained a new lancet, donned new gloves, and completed the blood glucose check. The LPN again exited, disposed of supplies, removed gloves, and wrote on a piece of paper. In a subsequent interview, the LPN confirmed using the same gloves between three different residents, confirmed the glucometer was not cleaned between uses and should have been, and acknowledged that hand hygiene was not performed when gloves were changed. The Assistant Director of Nursing/Infection Preventionist confirmed that using the same gloves between residents, not disinfecting the glucometer between uses, and omitting hand hygiene presented the potential for cross-contamination and that gloves are single-use and should be changed between residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a dialysis catheter. Record review showed Resident 5 had End Stage Renal Disease requiring dialysis, Type 2 Diabetes Mellitus, Atrial Fibrillation, COPD, and Chronic Heart Failure, with moderate cognitive impairment and total assistance needs for hygiene, toileting, bathing, dressing, bed mobility, and transfers. The care plan documented that Resident 5 was on EBP due to having a dialysis catheter, with interventions for staff to use barrier precautions such as disposable gowns when providing care. An EBP sign outside the resident’s room instructed that staff must clean their hands before entering and when leaving the room and must wear gloves and a gown for high-contact resident care activities, including changing briefs. Observation of a nursing assistant changing Resident 5’s incontinence brief revealed no gown was used during the brief change, and in interview the nursing assistant confirmed a gown should have been worn and was not because it was forgotten.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to secure medications properly, resulting in a deficiency. During an observation, a white bottle of Miconazole 2% powder with a worn prescription label was found sitting unsecured in the windowsill of a resident's room. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and moderate cognitive impairment, did not have a physician's order for the Miconazole Powder. The Director of Nursing confirmed that medications should not be kept unsecured in resident rooms and subsequently removed the powder. Additionally, a medication cart on the first floor was found unlocked and unattended. The cart, identified as the East Treatment Cart, was located in a hallway near a resident's room. The Director of Nursing confirmed that all medication and treatment carts should be locked when unattended. The facility's Medication Storage policy mandates that all medications must be secured in a locked storage area, and medication carts should be locked when not in use or unattended by authorized nursing personnel.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to maintain the nutritive value of pureed food, which had the potential to affect 18 residents on a pureed diet. Observations revealed that staff members were using inappropriate methods to prepare pureed foods. For instance, a staff member was observed using a slotted spoon to scoop an indeterminate amount of cooked green beans into a blender, adding two teaspoons of salt, two scoops of liquid butter, and an indeterminate amount of boiling water before blending and adding four ounces of thickener. Similar methods were used for preparing pureed ground beef and turkey breast, where boiling water and thickener were added inappropriately. The dietician confirmed that the use of boiling water in the preparation of pureed foods was not appropriate and noted that the taste of the pureed eggs was not good. The facility's recipe for pureed foods, which follows the International Dysphagia Diet Standardization Initiative (IDDSI) Level 4 guidelines, suggests adding small amounts of gravy, sauce, or other liquids to achieve the desired consistency, but does not recommend the use of boiling water. The improper preparation methods observed could potentially alter the nutritional value and palatability of the pureed foods served to residents.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility staff failed to identify and offer the Pneumococcal immunization to four out of five sampled residents, despite having a policy in place since August 2016 that mandates offering the vaccine to all residents. The policy requires that residents be assessed for eligibility to receive the Pneumococcal vaccine series upon admission and be offered the vaccine within 30 days unless medically contraindicated or previously vaccinated. However, record reviews revealed that Residents 122, 138, and 80 were not identified or offered the vaccine, and Resident 130, who had previously received a PPSV23 vaccine, was not offered any additional Pneumococcal vaccination. The residents involved had various medical conditions that could increase their vulnerability to infections. Resident 122 had conditions such as congestive heart failure and vascular dementia, while Resident 138 suffered from chronic respiratory failure and severe malnutrition. Resident 80 had a history of cerebral infarction and heart disease, and Resident 130 had Parkinson's disease and respiratory failure. Despite these conditions, there was no evidence in their immunization reports that the facility staff had offered the necessary Pneumococcal vaccinations. The Assistant Director of Nursing/Infection Preventionist Nurse confirmed the oversight during an interview.
Failure to Notify Physician of Missed Dialysis Appointment
Penalty
Summary
The facility staff failed to notify the physician of a missed dialysis appointment for a resident who required hemodialysis due to End Stage Renal Disease (ESRD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was dependent on staff for transfers and required substantial assistance with bed mobility and toileting. The resident's care plan indicated a need for dialysis, and the missed appointment was documented in the progress notes. However, the facility did not inform the resident's physician about the missed dialysis session, which was rescheduled due to staffing issues at the dialysis center. During an interview, the Director of Nursing confirmed that the resident's practitioner had not been notified of the missed appointment, which was a requirement according to the facility's policy on changes in a resident's condition. The policy mandates immediate notification to the resident, their representative, and the physician in cases of significant changes in condition or treatment. The failure to notify the physician was a deviation from this policy, as the facility's procedure requires documentation of such notifications and any new orders in the resident's medical record.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough written investigation and report an allegation of staff-to-resident abuse within the required timeframe to the Department of Health and Human Services (DHHS). The incident involved a resident with moderate cognitive impairment, who reported that a male caregiver had slammed their feet on the bed. This allegation was reported to Adult Protective Services (APS) a week after the incident occurred. However, the facility did not document the incident in the resident's medical records or report it to DHHS within the mandated five-day period. Interviews with the facility's social worker and administrator confirmed that no written investigation was completed, and no report was sent to DHHS within the required timeframe. The facility's policies on abuse investigations and reporting were not followed, as the investigation was not documented, and the necessary notifications were not made. The resident involved had a history of adult failure to thrive, diabetes mellitus, Alzheimer's disease, and Parkinson's, and required substantial assistance with daily activities.
Inaccurate MDS Documentation for Special Treatments
Penalty
Summary
The facility failed to accurately identify and document special treatments for two residents on the Minimum Data Set (MDS), a federally mandated assessment tool used for care planning. Resident 54, who was admitted with diagnoses including dependence on renal dialysis, had an MDS that did not reflect dialysis treatment in Section O, Question J 1, despite having renal insufficiency, renal failure, and End Stage Renal Disease (ESRD) marked. The MDS Coordinator confirmed that the MDS should have been coded for dialysis treatment while the resident was in the facility. Similarly, Resident 122, who was readmitted and started on hospice services, had an MDS that failed to mark hospice care in Section O, Question K 1. The MDS Coordinator confirmed that the MDS should have indicated hospice care while the resident was in the facility. These inaccuracies in the MDS documentation were identified through record reviews and interviews with the MDS Coordinator.
Failure to Conduct New PASRR Referral After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new PASRR (Pre-Admission Screening and Resident Review) referral for a resident after several new psychiatric diagnoses were identified. The resident, who was initially screened in 2017 and found not to have a mental illness or intellectual disability, received multiple new psychiatric diagnoses over the years, including adjustment disorder with depressed mood, generalized anxiety disorder, vascular dementia with behavioral disturbance, PTSD, and major depressive disorder. Despite these new diagnoses, the facility did not conduct a new PASRR screening to determine if a Level 2 evaluation was necessary. The facility's policy requires re-screens or status updates of residents due to changes in condition or new diagnoses. However, the facility did not adhere to this policy for the resident in question. The facility administrator confirmed that no new PASRR referral had been made since the resident's initial screening in 2017, despite the resident's significant changes in mental health status.
Inaccurate PASARR Screening for a Resident
Penalty
Summary
The facility failed to accurately complete a Level I PASARR screen for a resident, identified as Resident 23, who was part of a sample of two residents. The PASARR screen, dated May 4, 2018, incorrectly assessed Resident 23 as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). However, a review of the facility's diagnosis report for Resident 23 revealed several admission diagnoses that should have triggered a Level II PASARR screen. These diagnoses included vascular dementia with mood disturbance, moderate intellectual disabilities, major depressive disorder, generalized anxiety disorder, and unspecified psychosis. Further review of Resident 23's medical records and medication administration records from July 2024 confirmed the presence of these conditions, yet no additional PASARR screens had been completed since the initial one in 2018. An interview with the facility's administrator confirmed the inaccuracy of the initial PASARR screen and acknowledged that a Level II PASARR should have been triggered for further review. The facility's policy on admissions and PASRR updates, last reviewed in May 2023, outlines the process for identifying individuals with serious mental illness or intellectual disabilities to ensure they receive necessary specialized services and appropriate placement, which was not adhered to in this case.
Failure to Provide Timely Incontinence and Position Change Care
Penalty
Summary
The facility failed to provide necessary care for Resident 33, who was diagnosed with Alzheimer's Disease, Lewy body Dementia, Schizophrenia, and Depression. The resident was dependent on facility staff for various activities of daily living, including eating, oral hygiene, bathing, dressing, toileting, bed mobility, and transfers. According to the resident's care plan, staff were required to assist with position changes and skin care every two hours and check incontinence briefs every three hours. However, during a continuous observation period from 8:15 AM to 12:15 PM, no assistance with position changes or incontinence care was provided to Resident 33. Further observation at 2:30 PM revealed that the resident's incontinence brief was wet, indicating a lack of timely care. Interviews with Nurse Aids D and E confirmed that Resident 33 had not been repositioned or provided with incontinence care from 8:15 AM until 2:30 PM. Additionally, an interview with LPN D confirmed that the resident's routine care, which included checking for incontinence between breakfast and lunch and transferring to bed after lunch, was not followed. This failure to adhere to the care plan resulted in a deficiency in the care provided to Resident 33.
Failure to Implement Assessed Interventions for Accident Prevention
Penalty
Summary
The facility failed to implement assessed interventions to prevent skin injuries for Resident 105, who had severe cognitive impairment and a history of skin tears. Despite the care plan indicating the use of a Rooke boot to protect the resident's fragile skin during transfers, observations revealed that the boot was frequently not in place. Interviews confirmed that staff removed the boot during transfers due to concerns about slipping, and the boot was often found on the floor rather than on the resident's leg. Additionally, the facility did not implement fall prevention measures for Resident 63, who had moderate cognitive impairment and was at high risk for falls. The care plan included interventions such as using Dycem in the wheelchair, applying blue tape to indicate bed height, and posting signage to remind the resident to use the call light. However, observations showed that these interventions were not in place, and staff were unaware of the need to check for them. The resident was not assisted to the main lounge by the designated time, further indicating a lack of adherence to the care plan. The facility's failure to implement these interventions resulted in deficiencies in accident prevention for both residents. The lack of communication and adherence to care plans contributed to the risk of injury, as evidenced by the absence of necessary protective measures and staff's lack of awareness regarding the interventions.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 55, received follow-up dental services in a timely manner. Resident 55, who had no teeth, was seen and fitted for dentures in April 2024. However, by July 8, 2024, the resident was still waiting for the dentures to be delivered. A review of the resident's medical records showed that there was no evidence of any contact between the facility and the dentist from May 21, 2024, through July 8, 2024, indicating a lack of follow-up on the part of the facility. An interview with the facility's Social Worker on July 9, 2024, confirmed that the facility was unaware of the delay in the delivery of the dentures. The facility's policy on dentures, revised in April 2007, states that the facility is responsible for timely referral for dental services, within three days for an appointment, and that residents will not be charged for repair or replacement of dentures if the loss or damage was incurred by facility staff. The lack of timely follow-up and communication with the dentist led to the deficiency in providing necessary dental care for Resident 55.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control practices, leading to deficiencies in hand hygiene and gloving, which were observed in the care of two residents. Resident 122, who was severely cognitively impaired and required substantial assistance with daily activities, was observed receiving catheter care. During this procedure, a nursing assistant and an LPN failed to change gloves and perform hand hygiene appropriately. The LPN applied hand sanitizer over soiled gloves and continued to assist with personal care, which could lead to cross-contamination. Resident 33, diagnosed with Alzheimer's Disease, Lewy body Dementia, Schizophrenia, and Depression, was also subject to improper infection control practices. The resident was dependent on staff for personal care, including perineal care. During observations, a nurse aide placed washcloths in the bottom of a sink, potentially contaminating them, before using them for perineal care. This practice was confirmed by the nurse aide and an LPN, acknowledging the risk of cross-contamination from the sink. The facility's infection control guidelines and policies were not followed, as evidenced by the improper hand hygiene and use of potentially contaminated washcloths. The guidelines require staff to perform hand hygiene before and after resident contact and to use personal protective equipment to prevent exposure to infectious materials. The failure to adhere to these guidelines resulted in deficiencies in infection prevention and control, as observed by the surveyors.
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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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