Northfield Retirement Communities Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsbluff, Nebraska.
- Location
- 2100 Circle Drive, Scottsbluff, Nebraska 69361
- CMS Provider Number
- 285271
- Inspections on file
- 19
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Northfield Retirement Communities Care Center during CMS and state inspections, most recent first.
Multiple residents with known fall risks, cognitive impairment, and mobility limitations experienced repeated falls, including unwitnessed falls and falls with major injuries, because staff did not consistently identify fall causes or implement effective interventions. One resident on anticoagulants with delirium and intermittent confusion self-transferred to the bathroom and later self-transferred again, sustaining head and fracture injuries, while a bed alarm cited in the fall investigation was never added to the care plan. Another cognitively impaired resident with dementia and agitation had numerous falls from a w/c and recliner despite dycem and a gel cushion, with fall reports lacking immediate preventive measures and the daily pocket care plan omitting key fall interventions. A third resident with a history of sliding from seating had multiple falls from a w/c and recliner, with inconsistent fall documentation, delayed addition of an intervention that would have required 1:1 supervision, and conflicting care-plan directions about seating after meals. A fourth resident with a BKA and dependence on a mechanical lift had repeated falls from bed and was repeatedly observed sitting on the edge of an elevated bed, while the care-planned low-bed intervention was not included in the pocket care plan or other tools used by NAs and nurses, and staff knowingly did not keep the bed low during meals.
The facility failed to submit complete and thorough investigative reports to the State Agency for two residents who sustained major injuries from falls. In one case, a resident fell in their room, resulting in head laceration and fractures of the wrist and femur, and the report submitted attributed the fall to non-compliance with transfers but omitted documented post-hospital interventions. In the other case, a resident had an unwitnessed fall in a sitting area, leading to facial lacerations and a fractured nose, and the report submitted lacked a thorough investigation of the circumstances surrounding the fall.
The facility did not ensure an RN was on duty for at least 8 consecutive hours each day as required, with multiple days lacking RN coverage due to staffing shortages and absences, despite having procedures in place to address such gaps.
Surveyors found spoiled grapes and a tomato with mold in the walk-in refrigerator, and staff lacked a process for monitoring and disposing of fresh produce. The dietary policy addressed checking expiration dates for packaged foods but did not include guidance for fresh fruits and vegetables. The CDM confirmed these items should have been discarded immediately.
A review of staff records revealed that several new employees did not have documented completion of required orientation training on topics such as resident rights, emergency procedures, dementia care, and medical emergency directives. This lack of training documentation was confirmed by HR and had the potential to impact all residents in the facility.
The facility did not ensure that nurse aides and medication aides completed the required annual training hours, including specific training on abuse/neglect and dementia care. Record reviews showed that sampled staff had not met the mandated training requirements, with some training hours unrelated to their job duties and insufficient or missing dementia and abuse/neglect education. This deficiency had the potential to impact all residents in the facility.
Nursing staff did not inform the medical provider about a resident's repeated high blood pressure readings, despite facility policy requiring notification for significant changes in condition. The resident, who had a history of hypertension and other health issues, had multiple elevated BP measurements over several weeks without any documented physician notification. The DON confirmed that staff failed to act on these abnormal values.
Two residents receiving psychotropic medications did not have gradual dose reductions (GDRs) attempted or clinical rationales documented for not attempting GDRs. One resident with dementia and anxiety was prescribed mirtazapine and quetiapine, and a pharmacist's recommendation for a GDR was not addressed by the physician. Another resident with major depression and behavioral symptoms was prescribed Lexapro, but there was no evidence of a GDR attempt or documented rationale. The DON confirmed that GDRs were only considered if recommended by the pharmacist, and no documentation existed for these cases.
A resident with multiple complex medical conditions and significant care needs was admitted without a baseline care plan (BCP) being developed within 24 hours, as required by state regulation. The facility's policy allowed for BCP development within 48 hours, which did not meet the regulatory requirement, and no BCP was found in the resident's record. The DON confirmed the omission during an interview.
A resident with multiple chronic conditions did not receive bumetanide as ordered by the physician, with several doses missed or only partially administered due to medication unavailability and order clarification issues. Nursing documentation showed ongoing symptoms and a decline in condition, and the DON confirmed the medication should have been administered as ordered.
A resident with Parkinson's Disease developed painful contractures in both hands, but staff did not provide or document any interventions, therapy, or monitoring to address the contractures. The care plan referenced the contractures only in relation to nutrition and ADL assistance, with no specific interventions implemented. Interviews with PT and the DON confirmed the absence of interventions or documentation regarding the management of the contractures.
A resident with a supra pubic catheter and history of urinary retention was prescribed a long-term prophylactic antibiotic without clear clinical indicators or documented rationale for its continued use. Nursing staff questioned the necessity of the antibiotic, and the only justification provided was 'UTI prophylactic,' with no stop date specified in the order.
A facility did not provide a written summary of a baseline care plan to a resident within 48 hours of admission, as required by policy. The policy mandates that a baseline care plan be developed and a summary provided to the resident or their representative. A review of the resident's records showed no evidence of the summary being provided, which was confirmed by the Social Services Director.
The facility did not notify the State Agency of a change in administrator within the required 5 working days. The change occurred, but the notification was sent nearly a month later. This delay was confirmed in an interview with the Administrator and had the potential to affect all 51 residents.
The facility failed to adhere to the recipe for Turkey Tetrazzini, as Cook-K was unable to find the scale and estimated the portions of spaghetti noodles and turkey. This deviation from the recipe potentially affected the nutritive value of the meal for all 47 residents.
The facility failed to ensure proper food storage and sanitation, affecting all 47 residents. Expired food items were found, and some lacked proper labeling. Improper storage practices included food on the floor and raw meat next to uncovered ice cream. Sanitation issues were noted, with debris on shelves and buildup around the ice machine. Staff confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and lacked a comprehensive water management program to prevent Legionella growth. The resident had no signage or PPE indicating precautions, and the facility only used standard precautions unless a resident had an MDRO. The Plant Director confirmed the absence of a detailed water system assessment and monitoring measures.
The facility failed to provide the required CMS-10055 form to three residents, as mandated by their policy. The Minimum Data Set Coordinator found that the correct form was not available, and instead, an incorrect form was used. This issue was confirmed during an interview, highlighting a systemic problem in notifying residents about potential non-coverage of services.
The facility failed to ensure monthly medication regimen reviews by a licensed pharmacist for three residents, as required by policy. These residents, with various medical conditions including hypertension and dementia, had no documented reviews or physician evaluations of pharmacist recommendations since admission. The Director of Nursing confirmed the lack of documentation.
A resident's oxygen concentrator was left on and unattended, with the nasal cannula placed on the bed, contrary to the facility's oxygen safety protocols. The resident was not present in the room, and the Director of Nursing confirmed the oversight.
A resident with severe cognitive impairment and a diagnosis of pain did not receive consistent pain management in a LTC facility. Despite having an order for acetaminophen as needed, the medication was not offered during multiple documented instances of pain. The facility's policy required standardized pain assessments, but interventions were not consistently implemented, leading to unmanaged pain. Interviews with staff confirmed the responsibility for pain assessments, yet the prescribed medication was not administered as needed.
A facility failed to limit PRN antipsychotic medication use to 14 days and lacked documented rationale for continued use for a resident with dementia and anxiety. The resident had an ongoing PRN order for Seroquel without a stop date or duration, and no recent physician documentation was found. Interviews with the DON confirmed these deficiencies.
The facility exceeded the acceptable medication error rate with an 11.11% error rate due to improper crushing of medications. A Medication Aide crushed medications that should be swallowed whole, affecting two residents. The aide confirmed the practice of crushing all tablet medications, leading to errors with Potassium Chloride, Ferrous Sulfate, and Enteric Coated Aspirin.
The facility failed to conduct required background checks and nurse aide registry verifications for five employees, including a Dietary Aid and a Nurse Aide. A Medication Aide with a negative criminal background finding was hired without documented rationale. Human Resources confirmed these oversights, which could potentially affect all 47 residents.
Failure to Implement and Communicate Effective Fall-Prevention Measures for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify causal factors for falls and to implement and communicate effective fall-prevention interventions for multiple residents with known fall risks. One resident with congestive heart failure, atrial fibrillation, dizziness, and intermittent confusion was admitted requiring one-person assist with a walker and gait belt in the room and a wheelchair outside the room. This resident was on anticoagulants and later had a care plan problem for delirium with fluctuating cognition and confusion. The resident experienced an unwitnessed fall in the bathroom after going alone without using the call light, resulting in a head hematoma and subsequent hospital admission for a brain bleed. The care plan contained general fall interventions such as non‑slip footwear, environmental safety, night light, and dycem, and later added a sign to call for assistance and frequent checks, but the resident was known to refuse to use the call light due to embarrassment and was toileted about every two hours. A subsequent fall occurred when the resident was self‑transferring, with major injury including a left femur and wrist fracture and a scalp laceration. The fall investigation cited environmental factors and a bed alarm as an immediate measure, but there was no evidence in the care plan that a bed alarm was actually implemented, and the investigation did not identify why the resident was self‑transferring. Another resident with unspecified dementia with psychotic disturbance, generalized anxiety disorder, restlessness, agitation, severe cognitive impairment, and impaired cognition, mobility, and safety awareness had multiple falls over a short period. These included falls from a wheelchair in the dining room, from a wheelchair with head impact, from a recliner while self‑transferring, and from a wheelchair during a fire drill despite dycem and a gel cushion. The care plan listed interventions such as environmental safety, bed in lowest position, dycem and gel cushion in wheelchair, not leaving the resident alone in the dining room, dycem to recliner, a different lower wheelchair, and routine checks with recognition that the resident did not use the call light. However, the daily pocket care plan used by staff did not include these fall interventions. Fall event reports for several of the falls documented no immediate measures to prevent future falls, and one investigation recorded “I don’t know” as the root cause, with only first aid and rest noted. Progress notes did not document reevaluation of interventions or attempts at different strategies despite repeated falls, and staff confirmed that existing interventions were not successful and that confused residents could not be educated. A third resident with a long‑standing fall care plan and a history of sliding from wheelchair and recliner had multiple falls from wheelchair and recliner, including events in common areas and the hall, with injuries requiring emergency room evaluation and sutures. The care plan contained numerous interventions over time, such as keeping the bed low and locked, frequent checks, dycem on wheelchair, avoiding the recliner, placing the resident in bed after meals, placing food within reach, and not leaving the resident alone in the wheelchair with increased checks. Fall documentation for one event showed inconsistent accounts of when the resident was last toileted and last checked, with one page signed by a dietary aide who would not have known those details. The intervention “do not leave alone in wheelchair, increase checks” was recognized by the MDS nurse as effectively requiring 1:1 supervision, which the facility could not sustain, and this intervention was not added to the care plan until 11 days after the fall review. Staff also confirmed that the care plan contained conflicting guidance about whether to keep the resident in the common area or put them in bed after meals. A fourth resident with a left below‑knee amputation, dependence on staff and a mechanical lift for transfers, extensive assist needs for turning and positioning, and a history of falls had multiple documented falls, including being lowered to the floor during transfer, sliding out of a recliner, falling out of bed, and being found in the doorway after crawling from bed. The care plan included an intervention to keep the bed in the lowest position with brakes locked, later reiterated after falls, and a fall checklist documented that the resident had been in bed five minutes before being found on the floor in the doorway. Observations on the survey date showed the resident repeatedly sitting on the edge of an elevated bed with legs dangling several inches above the floor while eating and reading, with an overbed table in front, and multiple staff entering and leaving the room without lowering the bed. The bed was only observed in low position briefly before being raised again while the resident sat on the edge. Staff interviews confirmed that the bed was not kept in low position at mealtimes because it was considered uncomfortable for the resident, and that nurse aides did not have access to care plans and instead used a pocket care plan that did not include the low‑bed intervention. Nurses also relied on other documents that did not contain the low‑bed requirement, resulting in the care‑planned fall intervention not being communicated or implemented in daily practice. Across these residents, the facility’s fall investigations often lacked clear identification of root causes, did not consistently document or implement immediate measures, and failed to ensure that care‑planned interventions were reflected in the tools actually used by direct care staff. In some cases, interventions were delayed, internally inconsistent, or not feasible given staffing patterns, and documentation about key details such as last toileting or checks was inconsistent or completed by staff who would not have known the information. These actions and omissions led to repeated falls, including unwitnessed falls and falls with major injuries, in residents with known fall risks and documented histories of confusion, impaired safety awareness, and mobility limitations.
Incomplete Investigative Reports Submitted After Falls With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to submit comprehensive investigative reports to the State Agency for two residents who experienced falls with major injuries. Facility policy on Abuse, Neglect, Exploitation and Misappropriation Prevention, revised April 2021, required the facility to investigate and report any allegations within timeframes required by federal requirements. For one resident admitted on an unspecified date and discharged on 2/22/2026, progress notes dated 2/20/2026 documented a fall on 2/19/2026 that resulted in a laceration to the left side of the head, a left wrist fracture, and a left femur fracture. The Investigation Report dated 2/24/2026 described the incident and stated that no permanent measures were put into place to prevent recurrence, noting that the resident was admitted to the hospital and that the family elected not to have surgery due to a heart condition. The outcome section attributed the fall to the resident being non-compliant with transfers, attempting to self-transfer, and not calling for assistance. The Director of Nursing confirmed that this Investigation Report was the document submitted to the State Agency and that it did not contain information regarding interventions implemented after the resident returned from the hospital, despite such information existing. For another resident admitted on an unspecified date and discharged on 10/17/2025, progress notes dated 10/3/2025 documented an unwitnessed fall in a sitting area that resulted in a laceration on the nose requiring sutures and a subsequent diagnosis of a fractured nose. A facility document labeled “October 2025 Reportable” described the incident timeline and indicated that a fall committee would meet to discuss current interventions and decide on modifications, and that staff would increase checks on rounds while the resident was in bed and that the resident was not to be left in a wheelchair without supervision. The DON confirmed that the investigative report submitted to the State Agency for this fall did not contain a thorough investigation into the resident’s fall.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by Nebraska Revised Statute 71-6018.02(2)(a). Record reviews of Payroll-Based Journal Staffing Data Reports and facility-provided timecards revealed multiple days within several months where there was no evidence of RN coverage for the required hours. Specifically, the facility lacked RN hours on several dates, including 8/10/2024, 8/11/2024, 9/22/2024, 2/8/2025, 2/15/2025, 2/16/2025, 4/5/2025, 4/6/2025, and 4/12/2025. These findings were confirmed through interviews with facility staff, including the Nurse Consultant and the Nursing Home Administrator. The facility had a census of 45 residents at the time, and the absence of RN coverage was attributed to factors such as vacations and unexpected staffing turnovers. The process in place for ensuring RN coverage involved scheduling an RN for at least 8 consecutive hours daily and attempting to find replacements in the event of callouts or shortages. Despite these procedures, the facility was unable to provide documentation of RN coverage on the identified dates, resulting in noncompliance with the regulatory requirement.
Failure to Dispose of Spoiled Produce in Kitchen Storage
Penalty
Summary
The facility failed to properly identify and dispose of spoiled fruits and vegetables stored in the walk-in refrigerator, as observed during a kitchen tour. Two bags of grapes with a greenish black fuzzy substance and a cloudy light greenish liquid, as well as a tomato with a fuzzy greenish black substance around the stem, were found in the refrigerator. The facility's dietary policy required staff to check expiration dates and discard expired foods, but did not provide guidance on monitoring or disposing of fresh fruits and vegetables. The Certified Dietary Manager confirmed that these spoiled products should not have been present and acknowledged that staff only check foods with expiration dates, with no clear process for monitoring fresh produce. This deficiency had the potential to affect all 45 residents in the facility.
Failure to Provide Required Initial Staff Training
Penalty
Summary
The facility failed to implement an effective initial training program for new employees, as evidenced by missing documentation of completed orientation training for three out of five sampled staff members. Specifically, a dietary aide had no evidence of completing initial orientation training on resident rights, emergency procedures, or dementia. Additionally, a nurse aide and a medication aide had no documentation of completed training on dementia or medical emergency directives. These findings were confirmed through personnel record reviews and an interview with Human Resources. The facility's own assessment tool rated training on abuse, neglect, emergency preparedness, and resident rights as high priority, and dementia training as medium priority, but there was no evidence of the importance of training regarding medical emergency directives. The lack of documented training for these staff members had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Provide Required Ongoing Training for Nurse Aides and Medication Aides
Penalty
Summary
The facility failed to ensure that nurse aides and medication aides completed the required ongoing training, including at least 12 hours per year on topics appropriate to their job duties, abuse/neglect training, and a minimum of 4 hours of dementia training. Record reviews for five sampled staff members showed significant deficiencies in completed training hours and content. For example, one aide completed only 1.75 hours of ongoing training with no evidence of dementia training, while another completed 3 hours, with some training unrelated to their job duties and no dementia training. Other aides had partial completion of required hours, with minimal or no dementia or abuse/neglect training documented. The facility's own assessment tool identified nurse aide education on abuse and neglect as a high priority and dementia training as a medium priority, but did not specify time requirements for ongoing training. An interview with the Nurse Consultant confirmed that the facility had not met the required ongoing training standards for the sampled staff. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Notify Physician of Elevated Blood Pressure Readings
Penalty
Summary
Nursing staff failed to notify the medical provider of a resident's consistently elevated blood pressure readings over a period of several weeks. The facility's policy required nurses to inform the physician or on-call physician in situations where there was a need to alter medical treatment or when a significant change in the resident's physical, emotional, or mental condition occurred. Despite multiple blood pressure measurements that were significantly above normal parameters, there was no documentation in the nursing progress notes that the physician had been notified. The resident involved had a history of dementia, hypertension, cognitive communication deficit, anxiety, and chronic pain, and was under an active order for blood pressure and pulse monitoring twice daily, with instructions to recheck if out of parameters. However, the care plan and physician orders did not specify a recommended blood pressure range or parameter. The Director of Nursing confirmed that staff did not notify the medical provider of blood pressure values outside the resident's baseline and acknowledged that additional blood pressure measurements should have been taken to ensure the resident's well-being.
Failure to Attempt or Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) were attempted or that clinical rationales for not attempting GDRs were documented for two residents receiving psychotropic medications. For one resident with dementia, anxiety, drug-induced dyskinesia, and chronic pain, active orders for mirtazapine and quetiapine were in place. The consultant pharmacist recommended considering a GDR for one of the medications, but there was no documented response from the physician, nor was there any clinical rationale provided for not attempting a GDR. The Director of Nursing confirmed that no GDR was attempted and no rationale was documented. For another resident with major depression and significant behavioral symptoms, including disorganized thinking and physical behaviors towards others, there was an active order for Lexapro. The care plan indicated that a drug reduction would be done as recommended by the pharmacist and approved by the physician. However, the medical record contained no evidence that a GDR was attempted or that a clinical rationale for not attempting a GDR was documented. The DON stated that GDRs are only completed if identified by the pharmacist during monthly reviews, and confirmed the absence of documentation for this resident.
Failure to Develop Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 24 hours of admission for one resident, as required by state regulation. A review of the facility's policy indicated that BCPs were to be developed within 48 hours, which does not meet the 24-hour requirement. There was no evidence in the medical record that a BCP was created for the resident, and this was confirmed by the Director of Nursing during an interview. The resident involved had multiple complex medical conditions, including dementia with severe cognitive impairment, pressure-induced deep tissue injury, Refsum's disease, pain, acute kidney failure, a history of blood clots, atrial fibrillation, hypertension, depression, anxiety, urinary retention, and abnormal weight loss. The resident required significant assistance with activities of daily living, had a urinary catheter, was always incontinent of bowel, had a history of falls, required a mechanically altered diet, had multiple pressure ulcers, and was on several medications including an antidepressant, anticoagulant, antibiotic, and opioid. Despite these needs, no BCP was developed to address the resident's immediate health and safety needs within the required timeframe.
Failure to Administer Ordered Medication as Prescribed
Penalty
Summary
The facility failed to follow physician's orders for a resident with multiple complex medical conditions, including lobar pneumonia, heart failure, COPD, diabetes type 2, and chronic pulmonary edema. After returning from a hospital stay for respiratory failure and pneumonia, the resident experienced significant weight gain and edema, prompting the physician to order bumetanide, a diuretic, with specific dosages and administration times. Despite these orders, the medication administration record showed several missed doses of bumetanide due to reasons such as waiting for delivery, drug unavailability, and the need for order clarification. In some instances, only partial doses were given, and at other times, the medication was placed on hold. The nursing progress notes documented ongoing symptoms, including persistent edema, shortness of breath, and a decline in the resident's physical condition. The Director of Nursing confirmed that the medication should have been obtained from the contracted or back-up pharmacy and administered as ordered. The resident was eventually placed on comfort care and subsequently died. The deficiency centers on the facility's failure to provide treatment and care according to physician orders, as evidenced by the missed and incomplete administration of prescribed medication.
Failure to Provide Care and Interventions for Hand Contractures
Penalty
Summary
A resident with a primary diagnosis of Parkinson's Disease developed contractures in both hands, which were observed to cause pain and limit the ability to perform certain tasks. The resident reported that staff were not providing any interventions or therapy related to the contractures, and denied receiving services from physical therapy, occupational therapy, or floor staff for this issue. Review of the resident's records showed that earlier Minimum Data Set (MDS) assessments did not indicate any functional limitations, but a later MDS documented functional limitations in both upper and lower extremities, indicating the presence of contractures. The care plan for the resident included a focus on nutrition, noting the risk related to hand contractures and the offer of adaptive silverware, which the resident refused. However, there was no documented evidence of other interventions for the contractures. The care plan also addressed ADL assistance due to contractures, instructing staff to observe for decline and notify the physician or therapy as needed, but lacked specific interventions to address or monitor the contractures. Interviews with the physical therapist and DON confirmed that there were no current interventions in place to monitor or prevent worsening of the contractures, and there was no documentation of previous attempts or refusals of splint use.
Lack of Clinical Justification for Prolonged Prophylactic Antibiotic Use
Penalty
Summary
A review of medical records and interviews revealed that a resident with a history of urinary retention and a supra pubic catheter was prescribed a routine antibiotic, cephalexin, for prophylactic use. The antibiotic order, which began in 2019, was continued with updated orders and diagnoses over the years, including a recent order with no specified stop date and a diagnosis of 'Prophylactic measures, unspecified.' Documentation showed that the resident was taking the antibiotic for UTI prophylaxis, but there was no clear clinical rationale or specific indicators documented to justify the ongoing use of the antibiotic. Further review of progress notes and referral forms indicated that nursing staff questioned the reason for the continued prophylactic antibiotic, and the only documented justification was 'UTI prophylactic.' The Nurse Practitioner confirmed the antibiotic was ordered for prophylaxis. Reference to CDC guidelines in the report highlighted that UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions in nursing homes, but there is little evidence to support this practice, especially in older adults. The facility failed to provide adequate clinical justification for the continued use of the antibiotic in this resident.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan for a resident within 48 hours of admission, as required by their policy. The policy, last revised in March 2022, mandates that a baseline care plan addressing the resident's immediate health and safety needs be developed and a written summary provided to the resident or their representative. A review of the resident's admission and medical records showed no evidence of such a summary being provided. This was confirmed in an interview with the Social Services Director, who acknowledged that the written summary had not been given to the resident or their representative.
Delayed Notification of Administrator Change
Penalty
Summary
The facility failed to notify the State Agency of a change in administrator within the required timeframe of 5 working days. The change in administrator occurred on October 11, 2024, but the facility did not send the notification email to the State Agency until November 8, 2024. This delay in notification was confirmed during an interview with the Administrator on January 15, 2025. The failure to comply with the notification requirement had the potential to affect all 51 residents residing in the facility.
Failure to Follow Recipe for Turkey Tetrazzini
Penalty
Summary
The facility failed to follow a recipe to ensure the nutritive value of a meal was preserved, potentially affecting all 47 residents who reside and eat at the facility. During a continuous observation of meal preparation, Cook-K was unable to find the scale and therefore portioned out an approximate amount of spaghetti noodles for the Turkey Tetrazzini dish. Later, Cook-K found the scale but was unable to weigh the turkey because it was too heavy, leading to an estimation of the turkey amount placed into the meal. Interviews with Cook-K confirmed the inability to find the scale initially and the subsequent guessing of the spaghetti noodle portion. Additionally, Cook-K confirmed that the turkey was too heavy to weigh, resulting in an estimated amount being used. A review of the facility's recipe for Turkey Tetrazzini indicated specific amounts of 3 pounds 12 ounces of spaghetti noodles and 7 pounds 8 ounces of cooked diced turkey, which were not adhered to during the meal preparation.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices, which had the potential to affect all 47 residents. During a kitchen tour, it was observed that several food items, including Thick It Clear Advantage Cranberry Juice Blends, ReaLime Juice, Reduce Fat Ice Cream Chocolate Mixes, and Vanilla Soft Serve Mixes, were past their expiration dates. Additionally, some food items, such as hotdog buns, tortillas, and fruit mixes, lacked proper labeling with preparation or use-by dates. The Assistant Food Supervisor (AFS) confirmed these deficiencies during interviews. Further observations revealed improper storage practices, such as food items being stored on the floor in the walk-in freezer and raw meat being stored next to uncovered ice cream. Expired items, including Smucker's Platescapers Raspberry and various spices, were found on kitchen shelves. The kitchen also had sanitation issues, with old flour, salt, and debris on shelves, and a buildup of fuzzy gray matter around the ice machine. The AFS and Dietary Aides confirmed these findings, acknowledging that the items should have been disposed of and the areas cleaned.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as observed during a survey. The resident was found in their room without any signage or Personal Protective Equipment (PPE) indicating EBP was in place. A review of the resident's physician's orders showed catheter care was to be performed every shift, but there were no orders for EBP. Interviews with the Assistant Director of Nursing (ADON) confirmed that the facility did not have any residents on precautions at the time and only used standard precautions unless a resident had a multi-drug resistant organism (MDRO) like MRSA. Additionally, the facility did not have a comprehensive water management program to prevent the growth and spread of Legionella and other waterborne pathogens. The Plant Director (PD) revealed that the facility had not conducted an assessment of potential growth areas for these pathogens within the water system and lacked a detailed description and diagram of the water system. The facility performed random water temperature checks and ran water in empty rooms monthly, but no other measures or monitoring systems were in place to manage waterborne pathogens effectively.
Failure to Provide Required Medicare Notification Forms
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS)-10055 form, known as the Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), to three residents (Residents 23, 33, and 41) who were sampled during the survey. The facility's policy, last revised in September 2022, mandates that if the director of admissions or benefits coordinator believes Medicare will not cover a skilled service, the resident or their representative must be notified in writing about the potential non-coverage and their liability for payment. However, the facility did not adhere to this policy. The Minimum Data Set Coordinator (MDS) completed reviews for the residents who received Medicare Part A services and found that the SNF-ABN, CMS-10055 form, was not provided to any of the three residents. Instead, the facility only had form 10123, which was not the correct form required for this purpose. The MDS Coordinator confirmed in an interview that the facility did not have the SNF-ABN, Form CMS-10055, and had not provided it to the residents or their representatives, indicating a systemic issue in the facility's process for notifying residents about potential non-coverage of services.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly medication regimen reviews for residents, as required by their policy. This deficiency was identified for three residents out of a sample of five, with a total facility census of 47. The facility's policy, last revised in May 2019, mandates that the pharmacist reviews each resident's medication regimen monthly, documents any irregularities, and makes recommendations. These recommendations are then supposed to be reviewed and documented by a physician as part of the resident's permanent medical record. For Resident 21, who had diagnoses including hypertension, dementia, and anxiety, there was no evidence of a pharmacist's review of medications over the past year. Similarly, Resident 1, with conditions such as hypertension and non-Alzheimer's dementia, had no documented pharmacist reviews since admission. Resident 39, with multiple diagnoses including anemia and heart failure, also lacked evidence of the required monthly medication reviews since admission. Interviews with the Director of Nursing confirmed the absence of documentation for these reviews and the subsequent physician evaluations.
Oxygen Safety Protocols Not Followed
Penalty
Summary
The facility failed to ensure that an oxygen concentrator was turned off when not in use and that the nasal cannula was not left on the resident's unoccupied bed while the concentrator was left on and unattended. This deficiency was observed in the case of one resident, who was cognitively intact and receiving oxygen therapy at 2 liters per minute (LPM) as per physician's orders. The facility's policy on oxygen administration, last revised in October 2010, required that residents, their families, visitors, and roommates be instructed on oxygen safety precautions, including turning off the oxygen when not in use and not placing the cannula on the bed or chair if the oxygen is turned on. During an observation, it was noted that the resident was not in their room, yet the oxygen concentrator was running at 2 LPM, and the nasal cannula was placed on the resident's bed. This was confirmed by the Director of Nursing (DON) during an interview. The facility's failure to adhere to its own oxygen safety policies and procedures resulted in this deficiency, as the oxygen concentrator was left on and unattended, posing a potential safety hazard.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately manage and assess pain for a resident with severe cognitive impairment, as evidenced by the lack of consistent administration of prescribed pain medication. The resident, who had a diagnosis of non-Alzheimer's dementia and pain, was documented to have experienced varying levels of pain, ranging from mild to severe, on multiple occasions. Despite having an order for acetaminophen to be administered as needed for pain, the medication was not offered or documented as given on numerous instances when the resident's pain was recorded. The facility's policy required the use of a standardized pain assessment tool appropriate to the resident's cognitive level, such as the Wong-Baker FACES Pain Rating Scale. However, the resident's Treatment Administration Record (TAR) showed that pain assessments were conducted, but the necessary interventions, including offering the prescribed acetaminophen, were not consistently implemented. The resident's care plan indicated the potential for pain and discomfort, yet the interventions outlined were not followed, leading to the resident experiencing unmanaged pain. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), confirmed that the charge nurse on duty was responsible for completing pain assessments each shift. The RN noted that due to the resident's cognitive impairment, a licensed nurse was required to complete the pain assessment, and various scales were used depending on the resident's orientation. Despite these assessments, the resident's pain was not adequately addressed, as evidenced by the lack of administration of the prescribed pain medication during documented episodes of pain.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that PRN antipsychotic medication use was limited to 14 days and that a rationale for continued use was documented by the provider as required. This deficiency was identified for one resident out of five sampled, with a facility census of 47. The facility's policy on antipsychotic medication use, revised in July 2022, indicated that PRN medications should not be renewed beyond 14 days unless a healthcare practitioner evaluates the resident and documents the rationale for continued use. However, a review of Resident 21's orders revealed an ongoing PRN order for Seroquel 25 mg for agitation, initiated on 9/9/2023, without a stop date or duration. Additionally, there was no recent documentation from a physician justifying the continued use of the antipsychotic. Interviews with the Director of Nursing confirmed the absence of a stop date and documented rationale for the medication's continued use.
Medication Error Rate Exceeds 5% Due to Improper Crushing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an 11.11% error rate observed during medication administration. Out of 36 medications administered, 4 errors were identified, affecting two residents. The errors involved the improper crushing of medications that should not be crushed, including Potassium Chloride, Ferrous Sulfate, and Enteric Coated Aspirin. These medications were administered to residents while they were eating, contrary to the guidelines that specify these medications should be swallowed whole. The errors were observed during the administration of medications by a Medication Aide (MA-A), who confirmed that all medications in tablet form were routinely crushed for the residents involved. This practice was observed with Resident #5, who received crushed Potassium Chloride and Ferrous Sulfate, and Resident #22, who received crushed Enteric Coated Aspirin and Potassium Chloride ER. The Medication Aide, who has been in this role for a year, confirmed the practice of crushing all tablet medications for these residents.
Failure to Conduct Background Checks and Registry Verification
Penalty
Summary
The facility failed to adhere to its policy on conducting background checks and criminal conviction checks for potential direct access employees. The policy, revised in March 2019, required that these checks be initiated within two days of an employment offer and completed before employment commenced. However, a review of employee records revealed that background checks were not completed for five employees, and a nurse aide registry check was not conducted for direct care employees who were not nurse's aides. Specifically, there was no criminal background check or Nurse Aide Registry check for a Dietary Aid (DA) and a Nurse Aide (NA). Additionally, a Medication Aide (MA) with a negative finding on a criminal background check was hired without documented rationale. Interviews with Human Resources (HR) confirmed that the facility did not conduct criminal background checks on employees who were legally minors, as those records are sealed. HR also admitted that they did not run nurse aide registry checks on staff unless they were hired as nurse aides. This oversight included the failure to conduct a nurse aide registry check on the DA and MA, and the lack of documentation for hiring the MA with a criminal record. These actions and inactions had the potential to affect all 47 residents residing within the facility.
Latest citations in Nebraska
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
