Srmc Long Term Care, Llc Dba Pole Creek Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Sidney, Nebraska.
- Location
- 1855 Greenwood Rd, Sidney, Nebraska 69162
- CMS Provider Number
- 28E302
- Inspections on file
- 12
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Srmc Long Term Care, Llc Dba Pole Creek Estates during CMS and state inspections, most recent first.
Staff did not change gloves between tasks or after contact with contaminated surfaces or residents during meal service, including handling cups, plates, food, and food coverings, leading to potential cross-contamination for all residents in the Memory Care Unit.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident experienced a significant decline in functional abilities, increased behavioral symptoms, and became wheelchair-bound, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS within the required 14-day period after the change was identified, as confirmed by staff interviews and record review.
A resident with severe Alzheimer's and a hand contracture did not receive appropriate care, as staff failed to follow up on therapy referrals, did not document or attempt alternative interventions after the resident refused a washcloth due to pain, and did not include contracture management in the care plan. No OT evaluation or ROM exercises were provided, and staff confirmed no further interventions or monitoring occurred.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
The facility failed to dispose of expired food products, maintain proper hand hygiene during food preparation, and ensure food temperatures were at the required levels during meal serving. Expired food items were found in the kitchen, and Cook-G did not consistently perform hand hygiene between tasks. Additionally, meal temperatures for pureed meat and ground cauliflower rice were below the required 135 degrees Fahrenheit.
The facility failed to implement proper hand hygiene practices while passing water pitchers, during medication administration, and dining services. Observations revealed that staff did not consistently perform hand hygiene as required, including a Domestic Aide, a Medication Aide, a Licensed Practical Nurse, and the Activities Director. These lapses had the potential to affect all residents in the facility.
The facility failed to develop and implement comprehensive care plans for two residents, omitting critical medical information such as a history of recurrent UTIs and continuous oxygen use. This led to deficiencies in the care provided to these residents.
The facility failed to provide ongoing care for a resident's lower extremity edema. Despite wearing TED hose, the resident's edema persisted, and there was no documentation of treatment or follow-up actions. Interviews revealed staff were aware of the condition, but the DON was not, and no medications were prescribed to treat the edema.
The facility failed to ensure residents were free from unnecessary antibiotic use. One resident with severe cognitive impairment was on Keflex for UTI prophylaxis without a stop date, despite a pharmacist's recommendation to discontinue. Another resident continued to receive Macrobid for UTI prophylaxis despite a urine culture showing resistance and a lack of follow-up on a provider's reassessment recommendation.
The facility failed to administer medications at the correct time for two residents, resulting in a medication error rate of 8%. A Medication Aide administered levothyroxine while the residents were eating breakfast, contrary to instructions requiring it to be given at least 30 minutes before food. This was confirmed through observations, interviews, and record reviews.
Improper Glove Use During Meal Service
Penalty
Summary
Staff failed to follow proper glove use practices during meal service, as observed in the Memory Care Unit. Nurse aides and a medication aide were seen donning gloves and then performing multiple tasks without changing gloves between tasks or after contact with potentially contaminated surfaces, residents, or items. Specific actions included handling residents' cups, pouring drinks, touching the rims of cups and plates, opening and closing cupboard doors, and handling a towel that had been in contact with a resident's body, all without changing gloves. Staff also touched food and food coverings, such as removing food covers and plastic wrap, and then directly handled residents' food and dessert bowls with the same gloves. Facility policy and CDC guidelines require hand hygiene before and after glove use and mandate changing gloves between tasks and after contact with contaminated surfaces or residents. Interviews with staff and the infection preventionist confirmed that gloves should have been changed to prevent cross-contamination, but this was not done during the observed meal service. These failures had the potential to affect all 15 residents in the Memory Care Unit.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days after determining a significant change in a resident's condition, as required by both state licensure and federal guidelines. According to the facility's policy and the Resident Assessment Instrument (RAI) Manual, an SCSA is required when there is a major decline in a resident's status that is not expected to resolve, such as changes in functional abilities, mood, or behavior. In this case, a resident experienced a notable decline in functional abilities, requiring increased assistance with mobility and transfers, and exhibited increased anxiety and behavioral symptoms, including hitting staff. The resident, who was previously ambulatory, became wheelchair-bound and showed worsening behavioral symptoms and mild depression, as documented in progress notes and MDS assessments. Despite these significant changes, the facility did not complete the required SCSA within the mandated timeframe. Interviews with facility staff, including the Social Services Director and Infection Preventionist, confirmed that the resident's decline met the criteria for a significant change and that an SCSA should have been completed according to the RAI Manual. However, the assessment was not performed as required, resulting in noncompliance with both facility policy and regulatory standards.
Failure to Provide Contracture Management and Follow-Up for Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a hand contracture. The resident, who had severe Alzheimer's dementia with agitation, was noted to have contracted and painful fingers in the left hand. Staff reported the issue and attempted to contact the primary care physician (PCP) for an occupational therapy (OT) order, but the PCP was unavailable and there was no evidence that the secondary provider was contacted or that follow-up occurred. The care plan did not include a focus area for the hand contracture, and although a rolled washcloth was attempted as an intervention, the resident refused due to pain and no alternative interventions were documented. Further review of the resident's records showed no evidence that an OT evaluation was completed, nor were other interventions or monitoring for complications such as skin breakdown attempted. Minimum Data Set (MDS) assessments indicated that no physical therapy, OT, range of motion (ROM) exercises, or splint/bracing assistance were provided in the relevant periods. Staff interviews confirmed the lack of additional interventions and the absence of a facility policy on contracture management. Observations confirmed the resident's hand remained tightly closed.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency are not provided in the report.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure food products were disposed of prior to expiration dates, utilize proper handwashing practices to prevent potential food contamination during food preparation, and maintain food temperatures at the required levels during meal serving. During an initial observation of the kitchen's reach-in refrigerator, expired food items, including an opened container of Heavy Whipped Cream and two opened containers of Hiland's Cottage Cheese, were found. The Certified Dietary Manager confirmed the expiration and disposed of the items. Additionally, multiple observations revealed that Cook-G did not consistently perform hand hygiene between tasks, such as after touching personal body parts, refrigerator handles, or other potentially contaminated surfaces, before handling food items or cooking equipment. This was confirmed by Cook-G during an interview, acknowledging that hand hygiene should be done between each task and after contamination. Furthermore, the final meal temperatures on the steam table for pureed meat and ground cauliflower rice were found to be below the required 135 degrees Fahrenheit, with temperatures recorded at 122 degrees and 120 degrees, respectively. Cook-G confirmed that these temperatures were below the regulatory requirement and should have been maintained at least 145 degrees.
Failure to Implement Proper Hand Hygiene Practices
Penalty
Summary
The facility failed to implement proper hand hygiene practices while passing water pitchers to resident rooms, during medication administration, and during dining room services. Observations revealed that a Domestic Aide (DA) did not consistently perform hand hygiene before taking clean water pitchers into residents' rooms after handling soiled pitchers. This was confirmed during an interview with the DA, who acknowledged not routinely performing hand hygiene as required. The facility's policy on hand hygiene, dated 4/18/24, mandates hand hygiene after each resident contact and after handling contaminated objects, which was not adhered to in this case. Further observations showed that a Medication Aide (MA) and a Licensed Practical Nurse (LPN) did not wash their hands with soap and water for the required 20 seconds after completing medication passes. The MA washed hands for 15 seconds, and the LPN for 11 seconds, both of whom were aware of the 20-second requirement. This was confirmed through interviews with both staff members. The facility's hand hygiene policy, last reviewed on 4/18/2024, specifies that hand hygiene with soap should be completed for at least 20 seconds. Additionally, the Activities Director (AD) was observed touching their hair and then delivering a food plate to a resident without performing hand hygiene. The AD confirmed in an interview that hand hygiene should be completed after touching any contaminated object. The facility's infection prevention and control policy, last reviewed on 1/19/2024, emphasizes avoiding unnecessary touching of surfaces to prevent contamination and transmission of pathogens. These lapses in hand hygiene practices had the potential to affect all residents in the facility, which had a census of 43 at the time of the survey.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For Resident 29, the facility did not include the resident's history of recurrent urinary tract infections (UTIs) or the prophylactic use of antibiotics in the care plan. Despite multiple medication orders for Macrobid, an antibiotic, to treat and prevent UTIs, the care plan dated 5/3/23 did not reflect these critical aspects of the resident's medical history and ongoing treatment. The MDS Coordinator confirmed that prophylactic drugs were not included in care plans because they were not used to treat acute conditions, which led to the omission in Resident 29's care plan. For Resident 30, the facility failed to address the resident's continuous oxygen use in the care plan. Resident 30, who had severe cognitive impairment and a diagnosis of hypoxemia, required continuous oxygen. However, the care plan did not include any focus area addressing this critical need. The Director of Nursing confirmed that the care plan should have included the resident's oxygen use, indicating a lapse in the facility's adherence to its own care planning policies.
Failure to Address Resident's Lower Extremity Edema
Penalty
Summary
The facility failed to provide ongoing care and services to address a resident's lower extremity edema. The resident, who had severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, was observed multiple times with edema in both lower legs. Despite wearing TED hose, the resident's edema persisted, and there was no documentation of treatment or follow-up actions to address the condition. The resident had a significant weight gain over a short period, which was noted in the progress notes, but no further assessments or treatments were documented. Interviews with staff revealed that the resident had been wearing TED hose for about a month, but the Director of Nursing (DON) was unaware of the ongoing edema. The resident's electronic health record showed no diagnoses related to edema and no medications prescribed to treat it. The lack of awareness and follow-up by the facility staff contributed to the deficiency in providing appropriate care for the resident's condition.
Failure to Ensure Residents Were Free from Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary antibiotic use, specifically for two residents who were administered antibiotics for urinary tract infection (UTI) prophylaxis. Resident 1, who had severe cognitive impairment, was admitted on 7/1/2019 and had been taking Keflex for UTI prophylaxis since 1/29/2024 without a stop date. Despite a pharmacist's recommendation to discontinue the antibiotic and switch to a conjugated estrogen, the physician had not responded as of 5/29/2024. The Director of Nursing (DON) confirmed the use of Keflex for prophylactic purposes and acknowledged awareness of the CDC's recommendation against such use for UTIs. Resident 29, who had a history of UTIs and occasional bladder incontinence, had been prescribed Macrobid for UTI prophylaxis over several months. Despite a urine culture showing resistance to Macrobid, the resident continued to receive the antibiotic. A pharmacist had identified a medication irregularity and recommended clarifying the duration of the prophylactic use, but the provider's response to reassess the medication in 30 days was not followed up. The DON confirmed the lack of follow-up and the continued use of an ineffective antibiotic for UTI prophylaxis.
Medication Administration Timing Errors
Penalty
Summary
The facility failed to administer medications at the correct time for two residents, resulting in a medication error rate of 8%, which exceeds the acceptable threshold of 5%. Specifically, Medication Aide (MA) - E administered levothyroxine to two residents while they were eating breakfast, contrary to the administration instructions that required the medication to be given at least 30 minutes before food. This was observed during a survey, and the errors were confirmed through interviews and record reviews. The facility's Medication Administration policy was last reviewed on 2/15/2024, but it was not followed correctly in these instances.
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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