Omaha Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 4835 South 49th Street, Omaha, Nebraska 68117
- CMS Provider Number
- 285240
- Inspections on file
- 27
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Omaha Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, total dependence for ADLs, and a documented fall risk with prior falls had a care plan that included Dycem on the wheelchair cushion as a fall-prevention intervention. Policy required staff to ensure appropriate and immediate interventions were implemented after incidents. On multiple observations, including while the resident was in the therapy gym, the wheelchair lacked the care-planned Dycem on or under the cushion. The ADON confirmed the absence of Dycem, resulting in a deficiency for not implementing a prescribed fall intervention.
A resident with a stage four pressure ulcer and chronic pain received a wound dressing change without appropriate pain management, despite exhibiting clear signs of severe pain such as crying, yelling, and verbalizing distress. Staff did not pause the procedure to assess or address the pain, and interviews confirmed that additional pain medication should have been administered prior to the treatment but was not.
An LPN did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The LPN changed gloves multiple times during the procedure without using hand sanitizer or washing hands in between, and later confirmed this omission.
The facility did not follow individualized care plan interventions for two residents: one with a history of falls did not have required fall-prevention measures in place, and another dependent on staff for transfers was assisted by only one staff member instead of two, resulting in a significant leg injury. Staff interviews confirmed a lack of awareness and adherence to care plan requirements.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple chronic conditions and significant pain did not receive several scheduled doses of prescribed medications, including pain management and other treatments, due to delays in pharmacy delivery and the absence of a facility policy for handling unavailable medications. Facility staff confirmed the missed doses and the lack of a system to ensure medication availability.
Two residents with documented medication allergies were prescribed and administered drugs to which they had known or potential allergies. In both cases, alerts for allergies were either overridden or not followed up, and there was no evidence of provider consultation or evaluation. The DON confirmed that the facility lacked a policy for addressing medication allergies.
A resident with multiple chronic conditions and moderate cognitive impairment had conflicting documentation regarding CPR preferences, with both DNR and full code forms present in the record. The facility did not consistently update or confirm the resident's code status in the electronic health record, and staff interviews revealed inconsistent processes for verifying advance directives, leading to a failure to ensure the resident's wishes were clearly documented and communicated.
A resident with multiple medical conditions and a vegetarian diet experienced significant unaddressed weight loss. Staff did not complete a requested re-weigh, failed to assess the weight loss, and did not implement new interventions. Dietary staff were unaware of the resident's nutritional needs, and the resident was observed receiving inadequate meals.
Staff did not follow ordered interventions to prevent pressure ulcers for two residents at risk. One resident was observed in bed without the required Prevalon boot, and another was repeatedly found without heel elevation or use of heel protection boots, despite care plans and practitioner orders. Both staff and residents confirmed these interventions were not consistently implemented.
A resident with multiple diagnoses and a high risk for falls experienced two falls during care due to staff not implementing additional interventions beyond those already in place. The care plan required two staff for bed mobility and proper positioning, but these measures were not consistently followed, and no new interventions were added after the incidents, as confirmed by the DON.
Facility staff did not complete all required background and registry checks for two housekeeping staff members prior to hire, as confirmed by the facility administrator. Facility policy mandates screening for abuse, neglect, exploitation, or misappropriation history before employment, but documentation was missing or incomplete for these employees.
A resident with hypertension, severe sepsis, and diabetes had specific wound care orders for their left foot's second toe, which were not followed by an LPN. Instead of using mild soap and water as ordered, the LPN used saline to cleanse the toe. The LPN acknowledged the deviation from the practitioner's orders during an interview.
The facility failed to maintain a safe and clean environment in nine resident rooms, affecting 14 residents. Observations included unsanitary conditions, structural issues, and non-functional equipment, confirmed by the Maintenance Director and Administrator.
The facility failed to maintain functional ambulation for a resident post-toe amputation surgery, as therapy services were discontinued without a follow-up mobility program, leading to a decline in ambulation. Additionally, another resident did not receive follow-up audiology services for hearing aids, despite a prior recommendation, due to the facility's inaction.
A resident with multiple medical conditions, including post-traumatic seizures, did not receive a complete dose of Dilantin as ordered due to improper medication administration via a gastric tube. The LPN responsible failed to ensure all medication particles were fully dispersed in water, leaving remnants in the cup. This resulted in a significant medication error, as confirmed by the DON.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, including not wearing gowns during high-contact care activities and improper handling of medical equipment. A nursing assistant did not wear a gown while performing catheter care for a resident, and an RN failed to wear a gown while flushing a feeding tube. Additionally, an oxygen nasal cannula was used on a resident after being on the floor, and a stethoscope was not sanitized after use on a resident under EBP.
Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The facility’s incident and accident policy dated 12-2023 states that staff are to report, investigate, and review accidents or incidents and ensure appropriate and immediate interventions are implemented to prevent recurrences and improve resident care management. Record review showed that the resident had severe cognitive impairment with a BIMS score of 2 and required total assistance with bed mobility, toileting, dressing, personal hygiene, transfers, and bathing. The resident’s comprehensive care plan identified them as at risk for falls related to incontinence, weakness, osteoarthritis of both hips, and a history of falls at home, and documented multiple fall-related interventions, including the use of Dycem on the wheelchair cushion starting on 11-09-2025 following a fall. The facility incident log showed the resident had falls on 11-09-2025 and 03-15-2026, and the care plan included Dycem to the wheelchair cushion as a fall intervention. However, during observations on 04-01-2026 at 5:50 AM and again at 11:15 AM, the resident’s wheelchair did not have Dycem on or underneath the wheelchair cushion, including while the resident was in the therapy gym working with therapy. In an interview later that day, the Assistant Director of Nursing confirmed that there was no Dycem in place on the resident’s wheelchair cushion. This lack of implementation of the care-planned Dycem intervention for a resident with a known fall risk and prior falls constituted the cited deficiency in ensuring the area was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
Facility staff failed to implement appropriate pain management interventions during wound care for a resident with a stage four pressure ulcer. The resident, who had diagnoses including depression, osteoarthritis, and chronic pain, was admitted with a significant sacral wound and had a history of almost constant pain, frequently rated as severe. The resident's care plan included both scheduled and as-needed pain medications, specifically acetaminophen and oxycodone, and the facility's policy required staff to anticipate, evaluate, and manage pain in accordance with the resident's assessment and plan of care. On the day of the observed incident, the resident received scheduled acetaminophen and a PRN dose of oxycodone several hours before a negative pressure wound therapy (NPWT) dressing change. During the procedure, the resident exhibited clear signs of pain, including yelling, crying, facial grimacing, and verbalizing distress. Despite these indications, the staff performing the wound care did not pause the procedure to assess the resident's pain or offer additional pain relief. Instead, they continued the treatment while providing only verbal encouragement and distraction techniques. Interviews with staff confirmed that the procedure was known to be painful and that the resident was in significant distress during the dressing change. The Assistant Director of Nursing acknowledged that a PRN dose of oxycodone should have been administered prior to the treatment but was not. The resident later reported experiencing pain at the highest level during the procedure and stated that staff did not offer the option to stop the treatment or address the pain further.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During wound care treatment for one resident, an LPN failed to perform hand hygiene between glove changes as required by facility policy. The facility's hand hygiene policy, revised in October 2022, specifies that staff must use an alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after handling used dressings and contaminated equipment, and after removing gloves. Observation revealed that the LPN washed hands and donned gloves and a gown at the start of the procedure, but subsequently removed gloves and donned new ones multiple times without performing hand hygiene in between. This sequence occurred while providing wound care to the resident's posterior thighs and right posterior heel. The LPN confirmed in an interview that hand hygiene was not performed between glove changes and acknowledged that it should have been done.
Failure to Implement Care Plan Interventions for Transfers and Fall Prevention
Penalty
Summary
The facility failed to implement and follow individualized care plan interventions for two residents, resulting in a significant injury for one and failure to prevent potential falls for another. For one resident with moderate cognitive impairment and a history of repeated falls, the care plan included specific interventions such as pinning the top blankets to the fitted sheet to prevent entanglement and offering bathroom assistance at designated times. Multiple observations revealed that the top covers were not pinned as required, and staff interviews confirmed a lack of awareness regarding this intervention. This failure to implement the care plan intervention was directly observed on several occasions and acknowledged by both nursing assistants and an LPN. For another resident with cirrhosis, muscle weakness, generalized edema, and diabetes, the care plan specified that transfers from bed to wheelchair required two staff members and the use of a slide board or Hoyer lift. Despite this, the resident was transferred by only one staff member, a Certified Medication Aide, without the use of a gait belt or slide board. The aide reported that the resident claimed to transfer independently and instructed the aide on how to position the wheelchair. During the transfer, the resident sustained a laceration to the left lower leg after hitting the wheelchair pedal bracket, requiring hospital transport and stitches. Interviews with staff and the resident confirmed that only one staff member was present during the transfer, contrary to the care plan requirements. Facility policies reviewed indicated that individualized care plans are to be developed and interventions provided according to professional standards and the resident's needs. The failure to follow these care plans and ensure staff awareness of required interventions led to a significant injury and the lack of fall prevention measures for the residents involved. The deficiencies were identified through observation, record review, and staff interviews.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for a resident with multiple chronic conditions, including pneumonia, chronic inflammatory demyelinating polyneuritis, neuropathy, chronic pain, and osteoarthritis. Record reviews showed that the resident was admitted with significant pain and required scheduled and PRN pain medications, among other treatments. Despite these needs, the Medication Administration Records (MARs) revealed multiple instances where prescribed medications, including buprenorphine for pain, fish oil, polyethylene glycol, lubiprostone, Bactrim DS, and Metamucil, were not administered on several dates across multiple months. Notably, there were 11 consecutive missed doses of buprenorphine and several other missed doses of various medications. Interviews with facility staff, including the Unit Manager and DON, confirmed that the resident did not receive all scheduled medications on the identified dates. The DON further confirmed that some missed doses were due to waiting for pharmacy delivery, and acknowledged that the facility did not have a policy regarding unavailable medications. The lack of a system or policy to ensure timely medication availability and administration directly contributed to the resident not receiving necessary medications as ordered.
Failure to Evaluate and Address Medication Allergies
Penalty
Summary
The facility failed to properly evaluate and address medication allergies for two residents. For one resident with a history of respiratory failure, COPD, pneumonia, and chronic inflammatory demyelinating polyneuritis, records showed an allergy to Bactrim with a previously observed mild adverse reaction resulting in increased serum creatinine. Despite this documented allergy, the resident was prescribed and administered Bactrim DS on multiple occasions, and the provider overrode the allergy alert without documented consultation or follow-up in the electronic health record. The Director of Nursing confirmed that the allergy was not addressed at the time of order entry and that there was no facility policy regarding medication allergies. Another resident with acute respiratory failure and documented allergies to aspirin, codeine, penicillin, and zaleplon was prescribed Diclofenac sodium gel, a nonsteroidal anti-inflammatory drug. An alert for a possible drug allergy was generated in the electronic medical record, but there was no evidence of evaluation or follow-up regarding the potential allergy to Diclofenac. The Director of Nursing confirmed that no follow-up was completed and that the facility lacked a policy for addressing potential drug allergies when alerts were triggered.
Failure to Ensure Accurate and Updated Advance Directive Documentation for Code Status
Penalty
Summary
The facility failed to ensure that a signed Advance Directive Code Status Form was properly completed and updated to confirm a resident's directives for Cardiopulmonary Resuscitation (CPR). The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, congestive heart failure, and chronic obstructive pulmonary disease, and was assessed as having moderate cognitive impairment. Upon admission, the resident's care plan indicated full code status, and interventions required quarterly review of code status during care plan conferences. However, there were inconsistencies in the documentation of the resident's code status. The medical record contained both a form signed by the resident's representative indicating Do Not Resuscitate (DNR) and a form signed by the resident indicating full code. Hospital discharge orders also indicated DNR status, but the facility's electronic health record did not reflect an updated Advance Directive Code Status form confirming the DNR status. Multiple orders and practitioner notes alternated between DNR and full code, and the process for updating and confirming code status was not consistently followed as outlined in facility policy. Interviews with facility staff revealed that code status was typically determined at admission and entered into the medical record, but there was no consistent process for verifying or updating this information, especially on readmission or during care plan reviews. The facility's policy required that advance directives be reviewed, validated, and communicated to the care team, but this was not consistently documented or implemented for the resident. As a result, there was a failure to ensure the resident's wishes regarding CPR were clearly documented and communicated prior to an emergency event.
Failure to Address Significant Weight Loss and Dietary Needs
Penalty
Summary
Facility staff failed to evaluate and implement interventions to prevent significant weight loss for a resident with multiple medical conditions, including hyperlipidemia, hypokalemia, muscle weakness, dysphagia, and protein calorie malnutrition. The resident, who followed a lacto-ovo-vegetarian diet, experienced a weight loss of 20.4 lbs (11.11%) over 90 days. Despite this significant weight loss, there was no documented assessment or follow-up by the registered dietitian (RD) or other staff after a re-weigh was requested. The care plan did not include specific interventions to address the resident's vegetarian diet or food preferences, and the dietary staff were unaware of how to meet the resident's nutritional needs. Observations showed the resident was served inadequate meals, such as a salad without protein or dressing and a small drink, which the resident expressed dissatisfaction with. Interviews with the dietary supervisor and RD revealed a lack of awareness regarding the resident's significant weight loss and dietary needs. The director of nursing confirmed that the re-weigh requested by the RD was not completed and that no new interventions were implemented despite the resident's ongoing weight loss.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Facility staff failed to implement ordered interventions to prevent pressure ulcer development for two residents identified as at risk. For one resident with multiple diagnoses including malnutrition, muscle weakness, and impaired cognition, the care plan and practitioner orders required the use of a Prevalon boot on the left foot while in bed. Observations on multiple occasions revealed the resident was in bed without the Prevalon boot, and the device was found on the chest of drawers instead of being used as ordered. A nursing assistant confirmed the boot was not in place during an interview. For another resident with diagnoses including schizoaffective disorder, depression, and obesity, the care plan and practitioner orders required the resident's heels to be elevated while in bed to prevent skin breakdown. Multiple observations showed the resident in bed without their feet elevated, and heel protection boots were found on top of the dresser rather than in use. The resident reported that staff did not elevate their feet or use the heel boots, and a nursing assistant confirmed the resident's feet were not elevated during an interview.
Failure to Implement Additional Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement additional interventions to prevent falls for a resident who was identified as being at risk for falls. The resident, who had diagnoses including schizoaffective disorder, depression, obesity, and required assistance with personal care, was assessed as cognitively intact and dependent on staff for transfers and bed mobility. The resident's care plan included interventions such as keeping the bed in the lowest position, ensuring appropriate footwear, and requiring two staff members for bed mobility. Despite these interventions, the resident experienced two falls during care provision, one in which the resident's legs hung over the bed and they were lowered to the floor, and another where the resident slid off the bed. After the first fall, the only intervention added was to ensure the resident was positioned in the middle of the bed. Following the second fall, the intervention was updated to require two staff for bed mobility. The Director of Nursing confirmed that two staff should have been assisting during both incidents and that the resident should have been positioned in the middle of the bed, but no new interventions were implemented after these falls.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
Facility staff failed to complete required background and registry checks for two of five employee files reviewed. Specifically, one housekeeping staff member was hired without documentation of a Nurse Aide registry check, and another housekeeping staff member was hired with only Adult/Child Protection Services background checks completed, lacking other required screenings. The facility administrator confirmed during interview that the necessary background checks had not been completed for these two staff members. Facility policy requires screening of potential employees for history of abuse, neglect, exploitation, or misappropriation prior to hire, including documentation from licensing or registration boards and other registries.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility staff failed to follow the practitioner's orders for wound care for a resident with a history of hypertension, severe sepsis with septic shock, and diabetes. The resident was admitted with a specific treatment order for the left foot's second toe, which included cleaning with mild soap and water, applying betadine, and covering with a non-adherent dressing. However, during an observation, an LPN was seen using saline instead of mild soap and water to cleanse the toe, which was not in accordance with the practitioner's orders. The LPN confirmed during an interview that the correct procedure was not followed.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed in nine rooms on the second-floor north hallway. These deficiencies included unsanitary conditions such as a dark brown smeared substance resembling bowel movement on a toilet riser and seat, and a ventilation cover in a resident bathroom covered with a gray fuzzy substance resembling dust. Structural issues were also noted, such as an open and exposed floor radiator cover, missing and damaged drawer components in dressers, gouged and broken floor tiles, and protruding sharp edges from vent covers and baseboards. Additional observations included a continuously running shared toilet, a non-functional bathroom vent, and various holes and cracks in the drywall. The environmental tour conducted with the Maintenance Director and Administrator confirmed these issues, which had the potential to affect all 14 residents utilizing the affected rooms. The facility census at the time was 58, indicating that a significant portion of the resident population was impacted by these environmental deficiencies.
Failure to Maintain Ambulation and Follow Up on Audiology Appointment
Penalty
Summary
The facility staff failed to maintain functional ambulation for a resident who had undergone toe amputation surgery earlier in the year. Despite being cognitively intact and having a history of high blood pressure, peripheral vascular disease, end-stage renal disease, diabetes mellitus type 2, and heart failure, the resident reported not receiving therapy and feeling weaker post-surgery. The resident's last recorded physical and occupational therapy session was in mid-February, and there was no subsequent functional mobility program implemented. The Director of Rehabilitation confirmed the resident had not received therapy services since then, leading to a decline in the resident's ability to ambulate. Additionally, the facility staff did not follow up on an audiology appointment for another resident who was supposed to be fitted for hearing aids. This resident, also cognitively intact, had a history of diabetes mellitus, Parkinson's disease, heart failure, and high blood pressure. The resident had an audiology appointment in March of the previous year, with a recommendation to be fitted for hearing aids within 1-3 months. However, there were no further audiology appointments recorded, and the Director of Nursing confirmed the facility did not assist the resident in obtaining the hearing aids.
Incomplete Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received a complete dose of seizure medication as ordered, resulting in a significant medication error. Resident 34, who was admitted with multiple diagnoses including cerebral infarction, hydrocephalus, and post-traumatic seizures, was dependent on staff for all activities of daily living and received all nutrition and medications through a gastric tube. The resident had a physician's order for Dilantin 100 mg every 8 hours via the g-tube. During an observation, it was noted that the LPN responsible for administering the medication crushed the Dilantin tablet and mixed it with water, but visible remnants of the medication remained in the cup after administration, indicating that the full dose was not delivered to the resident. The facility's policy for medication administration via feeding tube requires that tablets be crushed to a fine consistency and fully dispersed in water before administration. However, the LPN did not ensure that all particles were in solution, leading to the incomplete administration of the medication. The Director of Nursing confirmed that the resident did not receive the complete dose of Dilantin, which constituted a significant medication error. This incident highlights a failure in adhering to the facility's medication administration procedures, resulting in a deficiency in the care provided to Resident 34.
Infection Control Deficiencies in EBP and Equipment Handling
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during care activities for several residents, as observed by surveyors. For Resident 215, nursing assistants NA-D and NA-E did not wear gowns while performing catheter care, despite the EBP sign on the resident's door indicating the requirement for gown and glove use. Both the nursing assistants and the Director of Nursing (DON) acknowledged the oversight. Similarly, for Resident 53, Registered Nurse (RN) F did not wear a gown while flushing the resident's feeding tube, even though the care plan and EBP signage specified the need for gown and glove use due to the resident's high risk of infection from a multidrug-resistant organism (MDRO). In another instance, the facility failed to maintain proper infection control practices concerning oxygen equipment. An oxygen nasal cannula for Resident 3 was observed lying on the floor, and later, a nursing assistant placed the same cannula into the resident's nose without cleaning it. The facility's policy requires that any nasal cannula that comes into contact with the floor should be replaced, a fact confirmed by both the nursing assistant and the DON. Additionally, the facility did not ensure proper sanitization of medical equipment used on residents under EBP. LPN H used a stethoscope on Resident 34, who was under EBP, and failed to sanitize it before leaving the room. The stethoscope was then carried to another area of the facility, potentially risking cross-contamination. The DON confirmed that the stethoscope should have been cleaned before being taken out of the resident's room.
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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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