Sarah Ann Hester Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Benkelman, Nebraska.
- Location
- 407 Dakota Street, Benkelman, Nebraska 69021
- CMS Provider Number
- 285241
- Inspections on file
- 19
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sarah Ann Hester Memorial Home during CMS and state inspections, most recent first.
A facility failed to submit a thorough investigation to the state agency after a resident experienced an unwitnessed fall while attempting a self-transfer, later being found to have a left femoral neck fracture, low Hgb, low BP, and pneumonia. The resident had multiple diagnoses, including dementia, COPD, ataxic gait, osteoarthritis, and weakness, was care-planned for wheelchair use at all times, and had a history of multiple falls and recent illness with fever and low O2 saturation. Although the DON identified weakness and low Hgb as possible causes of the fall, the investigation report submitted by the ADM did not include weakness as a cause and omitted key information such as the resident’s diagnoses, documented symptoms, BP findings, and whether medications had been reviewed.
Two residents who experienced falls did not have their care plans updated with new fall prevention interventions as required by facility policy. Despite staff and MDS Coordinator confirming that care plans should be revised promptly after incidents, no new interventions were documented for these residents, both of whom had cognitive deficits and were at high risk for falls.
The facility failed to sanitize food preparation surfaces after handling raw chicken, affecting all residents. Cook-I was observed transferring raw chicken, with liquid dripping onto the table, and later mixed a sanitation solution incorrectly. The table was used during meal service without proper cleaning, as confirmed by the Dietary Manager.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing specific needs. One resident's plan lacked interventions for behaviors, another's omitted critical aspects like restraint use and guardian changes, and a third's did not reflect antibiotic use accurately. These issues were confirmed by staff, indicating a lack of individualized care planning.
The facility failed to ensure proper antibiotic stewardship for three residents, as antibiotics were prescribed without specified stop dates, contrary to facility policy and CDC guidelines. Interviews confirmed the absence of stop dates, leading to unnecessary antibiotic exposure.
The facility failed to document clinical rationale for declining gradual dose reductions (GDRs) of psychotropic medications for several residents. Despite federal regulations requiring such documentation, physicians marked that no changes were needed without providing written justification. This affected residents with varying cognitive and behavioral conditions, who were on multiple psychotropic medications. Interviews confirmed the absence of required documentation, indicating a systemic issue in medication management.
The facility failed to ensure that three nurse aides completed the required 12 hours of ongoing training annually, as mandated by policy. Record reviews revealed duplicate courses in the training records, resulting in NA-F completing only 3.5 hours, NA-E 9.25 hours, and NA-D 10 hours of training. The DON confirmed the discrepancies and acknowledged the potential impact on all 30 residents.
A facility failed to notify a resident's guardian about the use of a wheelchair lap tray as a restraint, its purpose, duration, and alternatives, despite the resident's severe cognitive impairment and the facility's policy requiring such communication. The resident had multiple diagnoses affecting movement and cognition, and the absence of documentation confirming guardian notification was confirmed by staff interviews.
Facility staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a wound infection. Despite policy requirements, staff did not don gowns or gloves during high-risk care activities, such as changing briefs and transferring the resident. Interviews revealed a misunderstanding of EBP requirements, with staff believing PPE was only needed for direct wound care. The Infection Preventionist was unaware of the PPE requirements during these activities.
A facility failed to conduct a nurse aide registry check for a newly hired NA before allowing unsupervised contact with residents. Despite a policy requiring licensure verification before job responsibilities, the check was delayed until months after the NA's hire and orientation. The DON confirmed the oversight.
Failure to Submit Thorough Investigation After Resident Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete and submit a thorough investigation to the state agency following a resident’s unwitnessed fall that resulted in serious injury and subsequent death. The resident had multiple significant medical diagnoses, including weakness, dementia, COPD, ataxic gait, and osteoarthritis, and had a history of multiple falls and a care plan requiring wheelchair use at all times. Prior to the fall, nursing notes documented elevated temperatures and low oxygen saturation, and after the fall, the resident’s blood pressure readings were low, with documentation that the resident’s blood pressure was chronically low. The fall occurred when the resident attempted a self-transfer without calling for staff assistance, and staff later transported the resident to the emergency room, where a left femoral neck fracture and low hemoglobin were identified. The resident was also found to have pneumonia upon hospital admission. The DON reported that the cause of the fall was weakness, possibly related to low hemoglobin, and that the resident had been sick for two days one week prior to the fall. However, the investigation report submitted to the state agency did not include weakness as a cause of the fall and omitted other relevant clinical information, including the resident’s diagnoses of dementia, COPD, ataxic gait, osteoarthritis, the symptoms documented on the date of the fall, whether medications had been reviewed, and the resident’s low blood pressure. The Administrator confirmed these omissions during interview, acknowledging that the investigation report lacked these details despite their relevance to the incident.
Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans (CCPs) were updated with fall interventions for two of four sampled residents following documented fall incidents. Facility policy requires that CCPs be developed and revised by a team of health professionals within seven days of a comprehensive assessment, and that interventions, including those for fall prevention, be promptly updated and communicated to relevant staff. For both residents, record reviews showed that after experiencing falls, there were no new interventions identified or documented in their care plans to address fall prevention, despite the facility's own policies mandating such updates. Resident 2, who was cognitively impaired and at high risk for falls, experienced a fall but had no new fall prevention interventions added to their care plan. Similarly, Resident 4, who had moderate cognitive deficits and multiple diagnoses including non-Alzheimer's dementia and weakness, also experienced a fall without subsequent updates to their care plan for fall prevention. Interviews with LPNs and the MDS Coordinator confirmed that care plans should be updated the same day or the following day after such incidents, but this was not done for either resident.
Improper Sanitization of Food Preparation Surfaces
Penalty
Summary
The facility failed to properly clean and sanitize food preparation surfaces after handling raw chicken, affecting all 30 residents. During an observation of meal preparation, Cook-I was seen transferring raw chicken breasts from a tote to a metal pan, with pink-tinged liquid dripping onto the preparation table. After placing the chicken in the oven, Cook-I mixed a sanitation solution incorrectly, not following the posted instructions, which required 2 1/2 ounces of sanitizer per full sink of water. Later, during meal service, the preparation table still had drops of pink-tinged fluid from the earlier chicken preparation. The table was used for spicing foods and placing various kitchen items during meal service. The Dietary Manager confirmed that the sanitation solution was not mixed according to instructions and acknowledged that food preparation surfaces should have been sanitized after preparation and before food service, which was not done.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. For Resident 6, the care plan did not include specific interventions for behaviors such as rejection of care and wandering, despite the resident's known anxiety and behavioral triggers. The care plan was identified as a template rather than tailored to the resident's individual needs, as confirmed by the MDS Coordinator. Resident 1's care plan was incomplete and did not reflect several critical aspects of the resident's condition. The care plan failed to address the use of a restraint tray for positioning, did not update the change in the resident's guardian, and omitted concerns related to the resident's poor vision and aphasia. These omissions were confirmed by both the LPN and the MDS Coordinator, indicating a lack of comprehensive planning for the resident's complex needs. For Resident 20, the care plan did not accurately reflect the use of a prophylactic antibiotic, as there was no stop date for the medication. This oversight was confirmed by both the LPN and the MDS Coordinator, highlighting a gap in the medication management aspect of the care plan. These deficiencies indicate a failure to provide individualized and comprehensive care planning for the residents involved.
Failure to Ensure Antibiotic Stewardship in Resident Care
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary antibiotics, as required by their own policy and regulatory standards. Specifically, the facility's policy on Antibiotic Stewardship mandates that all antibiotic prescriptions must specify dose, duration, and indications for use. However, record reviews revealed that Residents 2, 17, and 20 were prescribed antibiotics without a specified duration or stop date. Resident 17 had been receiving Macrobid daily for over a year without an end date, despite not being treated for a current infection. Similarly, Resident 2 was prescribed Trimethoprim for UTI prophylaxis since January 2022, and Resident 20 since September 2024, both without a stop date. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed the absence of stop dates for these antibiotics. The CDC's guidelines on antibiotic stewardship highlight the risks associated with prolonged antibiotic use, particularly for UTI prophylaxis in older adults, which can lead to side effects and resistant organisms. The facility's failure to adhere to its own policy and CDC guidelines resulted in unnecessary antibiotic exposure for these residents, potentially compromising their health outcomes.
Lack of Clinical Rationale for Declined GDRs in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that physicians provided a written clinical rationale for declining gradual dose reductions (GDRs) of psychotropic medications for six residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with federal regulations requiring documentation of clinical rationale when GDRs are deemed clinically contraindicated. The facility's policy on psychotropic medications, dated December 14, 2022, indicated that GDRs should be conducted in accordance with federal regulations, yet this was not adhered to in practice. Resident 13, who had no cognitive impairment or symptoms of depression, was taking multiple psychotropic medications, including Buspar, Abilify, and Duloxetine. Despite the absence of behaviors or depression symptoms, the physician marked that no changes were needed, and the benefits outweighed the risks, but failed to provide a written clinical rationale for not reducing the doses. Similarly, Resident 31, with severe cognitive impairment and worsening behaviors, was on a regimen of antipsychotic, antianxiety, and antidepressant medications. The physician repeatedly marked that no changes were needed without providing a clinical rationale, despite the resident's significant behavioral issues. Other residents, including Residents 20, 23, 16, and 17, were also affected by the lack of documented clinical rationale for not pursuing GDRs. These residents were on various psychotropic medications for conditions such as depression, anxiety, and insomnia. The consulting pharmacist had requested GDRs for these medications, but the physicians did not adjust the dosages or provide the necessary clinical rationale. Interviews with the Director of Nursing confirmed the absence of required documentation, highlighting a systemic issue within the facility's medication management practices.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides completed the required 12 hours of ongoing training annually, as mandated by the facility's policy. This deficiency was identified through record reviews and interviews, which revealed that the training records for the nurse aides contained duplicate courses, leading to an inaccurate total of training hours. Specifically, NA-F had completed only 3.5 hours of training after removing duplicate courses, NA-E had completed 9.25 hours, and NA-D had completed 10 hours of training for the year. The Director of Nursing (DON) acknowledged awareness of the 12-hour training requirement and confirmed the discrepancies in the training hours for the nurse aides. The DON is responsible for tracking the training on a January-to-January basis and confirmed the completion of duplicate courses by NA-F and NA-E, as well as the insufficient training hours for NA-D. This oversight had the potential to affect all 30 residents residing within the facility, as the nurse aides may not have been adequately trained in essential areas such as dementia care and abuse prevention.
Failure to Notify Resident's Guardian of Restraint Use
Penalty
Summary
The facility failed to ensure that a resident's representative was notified of the use of physical restraints, specifically a wheelchair lap tray, as well as the duration and alternatives to its use. The facility's Restraint Policy mandates that residents' care plans should be updated to include interventions addressing risks related to restraint use, and that residents or their representatives should be informed about the potential risks and benefits of using or not using a restraint, along with alternatives. However, a review of the resident's records revealed no evidence of such notification to the resident's guardian, who was responsible for making decisions on behalf of the resident. The resident in question had multiple diagnoses, including cerebral palsy, stroke, non-traumatic brain dysfunction, and impaired cognition, which severely affected their cognitive patterns. The resident's care plan indicated the presence of a guardian to be notified of all medical decisions. Despite this, interviews with facility staff, including an LPN and the DON, confirmed the absence of signed consent or any documentation showing that the guardian was informed about the restraint's purpose, duration, or alternatives. This oversight represents a failure to comply with the facility's own policies and regulatory requirements regarding restraint use and communication with residents' representatives.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to the Enhanced Barrier Precautions (EBP) policy during high-risk care activities for a resident with a wound infection. The policy, implemented on February 5, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms (MDRO). Despite the presence of a sign indicating EBP on the resident's door and a caddy with gowns and gloves, staff members did not don the required personal protective equipment (PPE) while assisting the resident with activities such as changing briefs, dressing, and transferring. Observations revealed that Nurse Aide (NA) - D and NA - H did not wear gowns or gloves during these activities, even though the resident had an active diagnosis of a wound infection. Interviews with the aides indicated a misunderstanding of the EBP requirements, as they believed PPE was only necessary when providing direct wound or catheter care. The Infection Preventionist (IP) was also unaware of the PPE requirements during high-risk care activities, indicating a gap in the facility's implementation and understanding of the EBP policy.
Failure to Complete Nurse Aide Registry Check
Penalty
Summary
The facility failed to complete a nurse aide registry check for one of the three sampled employees before allowing the staff member to have unsupervised contact with residents. The facility's policy, dated December 19, 2023, required checking the licensing website for proof of current licensure before an applicant assumes job responsibilities. However, a review of the personnel file for a nurse aide hired on August 12, 2024, revealed that the registry check was not conducted until January 13, 2025. The Director of Nursing confirmed that the nurse aide began orientation on August 25, 2024, without the necessary registry check being completed, leading to unsupervised contact with residents.
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.
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