St. Joseph's Villa, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in David City, Nebraska.
- Location
- 927 Seventh Street, David City, Nebraska 68632
- CMS Provider Number
- 285249
- Inspections on file
- 22
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at St. Joseph's Villa, Inc. during CMS and state inspections, most recent first.
Surveyors found expired and unlabeled food items, improper storage of staff and resident food, and unclean refrigerators in the facility. Staff failed to perform proper hand hygiene between glove changes during food preparation, and there was no system for labeling or discarding food brought in by families. These issues had the potential to affect all residents consuming food from the kitchen.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Three residents experienced extended periods without documented bowel movements, and staff failed to administer PRN bowel medications as ordered or follow the facility's bowel protocol. Despite clear physician orders and established policies, no interventions were provided during these episodes, and care plans lacked appropriate constipation prevention measures. Staff and DON interviews confirmed the protocol was not followed and required actions were not taken.
A resident with multiple medical conditions and a history of repeated falls was not moved closer to the nurse's station as required by the care plan following a fall. Despite the intervention being documented, staff interviews and observations confirmed the resident remained in a room farthest from the nurse's station, and there was no documentation of refusal by the resident or family. This failure to implement the planned intervention resulted in a deficiency related to accident prevention and supervision.
A resident with chronic respiratory conditions did not receive oxygen therapy as ordered by the physician. Staff set the oxygen concentrator above the prescribed flow rate and failed to ensure the resident wore the nasal cannula, resulting in low oxygen saturation levels before intervention by a nurse.
Staff failed to properly disinfect blood glucose monitoring machines between resident uses, did not consistently perform hand hygiene when administering medications, and did not maintain oxygen equipment according to policy. An LPN was observed skipping required cleaning steps and hand hygiene, while a medication aide did not follow the manufacturer's recommended contact time for disinfectant wipes. A resident with chronic respiratory issues had an oxygen concentrator with a dirty filter and a nasal cannula that was placed on the floor and then used without cleaning.
A facility failed to follow a resident's full code status and CPR protocol when the resident was found unresponsive. Despite the resident's wishes for CPR, the LPN on duty did not initiate it, citing the resident's appearance as signs of clinical death. The agency nurse had not received adequate orientation on the facility's CPR policy, contributing to the deficiency.
The facility failed to report falls resulting in serious injuries to the state agency within the required time frame for two residents. One resident with multiple sclerosis and quadriplegia fell, resulting in a shoulder fracture, while another with dementia sustained a fractured clavicle. Additionally, the facility did not submit investigation reports within five working days for two residents, including one with Alzheimer's and Down Syndrome who suffered a facial laceration.
The facility failed to implement Enhanced Barrier Precautions for residents with catheters and wounds, and did not properly store or clean respiratory equipment. Observations showed catheter bags touching the floor and respiratory equipment improperly stored. Hand hygiene was not followed during wound and catheter care, with staff failing to perform hand hygiene between glove changes. The DON confirmed these deficiencies.
A resident with obstructive sleep apnea and other health conditions was observed to have a C-PAP machine in their room, and records showed its nightly use. However, the MDS did not reflect this treatment, as confirmed by the MDS coordinator, indicating a documentation deficiency.
A facility failed to conduct a Level II PASARR evaluation for a resident diagnosed with schizophrenia. The resident's Admission MDS indicated the presence of this serious mental illness, but the PASARR evaluation incorrectly stated no mental health diagnosis was known or suspected. This oversight was confirmed by the MDS Coordinator, who acknowledged the resident was not referred for the necessary evaluation.
A facility failed to obtain a physician order for a resident's CPAP use, despite the resident's diagnosis of obstructive sleep apnea and consistent use of the device since admission. The oversight was confirmed by the DON, highlighting a lapse in ensuring proper medical documentation.
Deficiencies in Food Storage, Labeling, and Hand Hygiene During Food Preparation
Penalty
Summary
Surveyors identified multiple deficiencies related to food safety and sanitation practices within the facility. During observations, expired food items such as thickened hot cocoa mix, honey thickener, chicken noodle soup, grape jelly, prune juice, and yogurt were found in various storage areas and refrigerators. Opened and undated food items, including chicken strips, breadcrumbs, pudding, pizza, chicken wings, apple sauce, and tomatoes, were also present. Staff food was stored alongside residents' food in unit refrigerators, and some items brought in by family members were not labeled or dated as required. Additionally, refrigerators were found to be unclean, with dried spills and sticky substances, and cleaning logs indicated that cleaning had not been performed for several days. During food preparation, staff failed to perform proper hand hygiene between glove changes. Specifically, a cook did not wash hands before donning new gloves after handling raw ingredients and after removing gloves, as confirmed by the Registered Dietitian. Interviews with the Dietary Manager and Registered Dietitian revealed there was no established system for labeling food brought in by families or for discarding old resident food. These deficiencies had the potential to affect all 52 residents who consumed food prepared in the facility's kitchen.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Monitor and Treat Constipation According to Bowel Protocol
Penalty
Summary
Surveyors identified that the facility failed to monitor bowel status and administer PRN medications to prevent constipation for three residents out of six sampled. For one resident with intact cognitive function and dependent for toileting, the care plan included a diagnosis of constipation but lacked interventions for prevention. Bowel monitoring forms showed multiple extended periods without documented bowel movements, some lasting up to 11 days, and medication administration records revealed that no bowel medications were given during these times, despite clear physician orders and a facility bowel protocol outlining specific interventions for consecutive days without a bowel movement. Interviews with staff and the DON confirmed that the bowel protocol was not followed and that no medications were administered as required. Another resident, admitted with multiple diagnoses including constipation, also experienced repeated periods with no documented bowel movements, sometimes for up to a week. Medication administration records for several months showed that no PRN bowel medications were given, even though physician orders and the facility's bowel protocol required specific interventions after two or more days without a bowel movement. The DON confirmed that the bowel management program was not followed for this resident and that the physician was not contacted when the resident exceeded five days without a bowel movement. A third resident, with severe cognitive impairment and total dependence on staff for toileting, was also found to have multiple periods with no documented bowel movements, some lasting up to ten days. The care plan did not address the risk for constipation or include interventions to prevent it. Despite having PRN bowel medications ordered, medication administration records showed that none were administered during the relevant periods. Staff interviews confirmed that the bowel protocol was not implemented for this resident, and the DON acknowledged that the required interventions were not provided.
Failure to Implement Fall Prevention Intervention for Resident with Repeated Falls
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident with a significant history of falls. According to the facility's Fall Prevention Program, when a resident experiences a fall, the care plan should be reviewed and a new intervention added before the end of the shift. After a fall on 10/24/2024, the intervention identified was to move the resident closer to the nurse's station and offer snacks between meals, as the fall was attributed to dizziness and hunger. However, the resident was not moved closer to the nurse's station, and there was no documentation that the resident or their family refused a room change. Observations confirmed that the resident continued to reside in a room farthest from the nurse's station, approximately 129 feet away, despite the care plan intervention. The resident involved had multiple medical diagnoses, including Paranoid Schizophrenia, Morbid Obesity, ADHD, Anxiety, and Depression, and was moderately cognitively impaired with a BIMS score of 9. The resident required substantial to maximal assistance with several activities of daily living and had a documented history of numerous falls over several months. Interviews with facility staff, including the Social Worker, MDS Coordinator, and Administrator, confirmed that the intervention to move the resident closer to the nurse's station was not implemented, and there was no clear reason documented for this inaction. The failure to carry out the planned intervention constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Follow Physician's Oxygen Order and Monitor Resident's Oxygen Use
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen administration for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's care plan required oxygen to be administered at 2 liters per minute (l/m) via nasal cannula as needed for oxygen saturations below 88%. However, observations revealed the oxygen concentrator was set at 3 l/m, exceeding the ordered flow rate. Additionally, the resident was observed multiple times without the nasal cannula in place, despite the oxygen concentrator running, and staff did not intervene to ensure the resident was receiving oxygen as ordered. Further review showed that the resident's oxygen saturation dropped to 83% while off oxygen, and only after this was noted did a nurse place the nasal cannula on the resident and adjust the flow rate. The failure to ensure the resident received oxygen at the prescribed rate and to monitor the resident's oxygen use as ordered resulted in the resident not receiving appropriate respiratory care according to physician orders and facility policy.
Infection Control Failures in Glucometer Disinfection, Hand Hygiene, and Oxygen Equipment Maintenance
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to the use of blood glucose monitoring machines and hand hygiene. Observations revealed that an LPN did not sanitize the blood glucose monitoring machine before or after obtaining blood sugar readings for multiple residents. The same LPN also failed to perform hand hygiene after removing gloves and before leaving a resident's room, as well as before and after administering medications. These actions were in direct violation of the facility's policies, which require cleaning and disinfecting glucometers between each use and performing hand hygiene at appropriate times. Additionally, a medication aide was observed not following the manufacturer's instructions for disinfecting the glucometer. The aide used a Sani cloth germicidal wipe for only 8 seconds, despite the manufacturer's recommendation of a two-minute wet contact time. The aide was unaware of the required contact time, resulting in improper disinfection of the device between resident uses. There were also deficiencies in the management of oxygen equipment for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's oxygen concentrator filter was observed to have a thick gray fuzzy coating, indicating it had not been cleaned as required. The nasal cannula was found on the floor and was not replaced or cleaned before being placed back on the resident. Staff walked by without addressing the resident's oxygen needs, and the resident was later found with low oxygen saturation. The filter was only cleaned after being pointed out, and the nasal cannula that had been on the floor was used without cleaning.
Failure to Follow CPR Protocol and Resident's Code Status
Penalty
Summary
The facility failed to adhere to Resident 1's wishes for Cardiopulmonary Resuscitation (CPR) and did not adequately train agency staff on code status and the facility's CPR policy and procedures. Resident 1, who was admitted with multiple severe health conditions including acute on chronic respiratory failure, congestive heart failure, and severe pulmonary hypertension, had designated full code status. Despite this, when the resident was found unresponsive, blue, and without a heartbeat, CPR was not initiated by the Licensed Practical Nurse (LPN) on duty. The LPN, identified as LPN-A, called 911 and was informed by the operator that the Sheriff would be sent first for a death investigation before an ambulance could be dispatched. Despite knowing the resident's full code status, the LPN did not initiate CPR, citing the resident's cold and blue appearance as signs of clinical death, which was in line with the facility's policy. However, this decision was made without following the proper protocol of initiating CPR in the absence of obvious signs of clinical death, as per the facility's policy. Interviews revealed that the agency nurse, LPN-D, did not receive adequate orientation regarding the facility's CPR policy or procedures for code situations. The facility's administration was unaware that the orientation competency form was not being completed for agency staff, which contributed to the failure to initiate CPR. The lack of proper training and communication regarding code status and CPR procedures led to the deficiency in following the resident's advance directives and the facility's own policies.
Removal Plan
- We identified other residents that are full codes.
- We updated the CPR policy and Communication of Code Status Policy.
- CPR Orientation document was implemented for orientation procedure for nursing agency.
- All agency prior to their shift will be oriented and educated on the CPR Orientation document.
- We completed the CPR orientation form and educated Night Charge Nurse and Day Charge Nurse via phone by the DON (Director of Nursing).
- All Agency nursing will be orientated by the DON.
- All current staff educated by DON.
- All staff prior to the next working shift will be educated by the DON.
- Code lists were updated and are placed in the narcotic books on the med carts, and on the clip board on the crash cart, and can be found in the chart on PCC (Point Click Care) by the DON.
- The DON will continue to keep the code lists updated with all new admissions and any change in DNR status with residents.
- All new hires will be educated through a PowerPoint on Relias on the following documents: CPR policy and Communication of Code Status policy, CPR Orientation document, and Resident Code Status.
- All New Agency staff will be educated on the following documents: CPR policy and Communication of Code Status policy, CPR Orientation document, and Resident Code Status prior to their shift.
- Administrator and/or DON will complete audits on new hires and agency staff.
Failure to Timely Report Falls and Submit Investigation Reports
Penalty
Summary
The facility failed to report incidents of falls resulting in serious bodily injury to the state agency within the required time frame for two residents. Resident 1, diagnosed with multiple sclerosis and quadriplegia, experienced a fall on September 3, 2024, resulting in a shoulder fracture. The incident was not reported to Adult Protective Services (APS) until later that day, and the investigation report was not submitted to the state agency until September 18, 2024. Similarly, Resident 4, who has dementia, fell on September 15, 2024, and sustained a fractured clavicle. This incident was not reported to APS until September 19, 2024, and there was no documentation of the fall in the progress notes until September 17, 2024. Additionally, the facility failed to submit written investigations within five working days for two residents. Resident 2, with Alzheimer's disease and Down Syndrome, fell on September 6, 2024, resulting in a facial laceration that required sutures. The investigation report for this incident was not sent to the state agency until September 18, 2024. Interviews with the Administrative Trainee confirmed these reporting delays and failures to meet the required timelines for submitting investigation reports.
Inadequate Infection Control and Equipment Storage
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, including those with catheters and wounds. Observations revealed that catheter bags for Residents 41, 25, and 21 were hanging from bed frames with urine bags touching the floor, and there were no EBP supplies in their rooms. Similarly, Residents 13, 50, and 14 did not have EBP for wound care. The Director of Nursing (DON) confirmed the absence of EBP and stated that a policy had been approved but not yet implemented. The facility also failed to properly store and clean respiratory equipment for Residents 28 and 41. In Resident 28's room, a CPAP machine was observed with its mask and tubing improperly stored, while Resident 41's nebulizer equipment was left on a recliner without a barrier. The DON acknowledged that the equipment was not being cleaned and stored as required by the facility's policies. Additionally, hand hygiene practices were not followed during wound and catheter care for Residents 14 and 25. An LPN did not perform hand hygiene before and after wound care for Resident 14, and gloves were taken from a scrub pocket instead of a glove box. Similarly, a Medication Aide (MA) did not use EBP or perform hand hygiene between glove changes during catheter care for Resident 25. The DON confirmed that these practices did not meet the facility's expectations.
Inaccurate MDS Documentation for C-PAP Use
Penalty
Summary
The facility failed to accurately document the use of a C-PAP machine for a resident with multiple health conditions, including obstructive sleep apnea, on the Minimum Data Set (MDS). The resident, who was diagnosed with paranoid schizophrenia, chronic respiratory failure with hypercapnia, morbid obesity with alveolar hyperventilation, obesity, obstructive sleep apnea, and parkinsonism, was observed to have a C-PAP machine in their room. The machine was noted to be connected and present on two separate occasions. Despite the presence of the C-PAP machine and a medication administration record indicating its nightly use, the MDS for the resident did not reflect this treatment under Section O, which is designated for special treatments, procedures, and programs. An interview with the MDS coordinator confirmed that the C-PAP should have been marked on the MDS, indicating a lapse in accurately recording the resident's treatment plan.
Failure to Conduct Level II PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that the PASARR (Pre-Admission Screening and Resident Review) process was accurately completed for a resident with a mental disorder. Specifically, the facility did not conduct a Level II PASARR evaluation for a resident diagnosed with schizophrenia, a serious mental illness. The resident's Admission MDS, dated July 17, 2024, indicated the presence of this diagnosis. However, the current PASARR evaluation, dated July 1, 2024, incorrectly stated that no mental health diagnosis was known or suspected. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident was admitted with a mental illness diagnosis and was not referred for the necessary Level II PASARR evaluation to ensure the facility could meet the resident's needs.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician order for the use of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who was admitted to the facility and had a BIMS score of 14, indicating relatively high cognitive function, was observed using a CPAP with oxygen consistently since admission. Despite the resident's continuous use of the CPAP, confirmed by both the resident and their family member, the facility did not have a physician's order for the device. This was acknowledged by the Director of Nursing during an interview, confirming the oversight in obtaining the necessary medical order for the resident's CPAP use.
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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