St. Joseph Villa Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 2305 South 10th Street, Omaha, Nebraska 68108
- CMS Provider Number
- 285078
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at St. Joseph Villa Nursing Center during CMS and state inspections, most recent first.
Multiple residents experienced failures in ordered monitoring and follow-up. A resident with heart failure did not receive ordered daily weights or documented fluid intake tracking despite a fluid restriction. A resident with diabetes and a foot ulcer used an air mattress that repeatedly showed a low-pressure warning without timely action. Another resident with recurrent UTIs had a specialized urine test completed, but the positive results were misdirected to an outdated email and not communicated to the provider until much later. A resident with CHF on diuretics had an order for weekly weights, yet weight records showed repeated multi-week gaps despite visible edema. In addition, after an unwitnessed fall, a resident did not receive the neurological checks required by the facility’s post-fall policy.
A resident with anxiety disorder, bipolar disorder, and schizophrenia was receiving multiple doses of Seroquel and required total assistance with activities of daily living. Facility policy required that an AIMS score of 2 or higher, suggesting possible TD, be communicated to the physician and discussed with the resident and family. The resident’s AIMS score increased from 0 to 4 after antipsychotic dose increases, but the physician and resident representative were not notified of this change. The DON confirmed that the increase occurred and that required notifications were not made.
A resident with hemiplegia, dysphagia, and dementia, who required staff supervision for oral hygiene, did not receive or was not offered morning oral care as required by facility policy and physician orders. Despite a care plan calling for staff assistance with hygiene and a dental note documenting very poor oral hygiene and the need for daily assisted tooth brushing, staff progress notes showed only two documented refusals over several months. During a surveyed morning care episode, a NA assisted the resident with getting out of bed, dressing, hair care, and eyeglasses but did not provide or offer tooth brushing, later confirming that oral hygiene was omitted even though it should have been part of the morning routine.
A resident with malnutrition, Inclusion Body Myositis, moderate cognitive impairment, total dependence for ADLs, incontinence, recent weight loss, and identified risk for pressure ulcers had a care plan that included use of an air pressure mattress to maintain skin integrity. Surveyors observed multiple times that the air mattress pump was either turned off while the resident was in bed or displaying a persistent low-pressure warning light while in use. A MA confirmed the mattress should have been on when it was not, and the wound nurse acknowledged the low-pressure light but was unsure of its meaning without consulting the manual, demonstrating a failure to ensure the ordered pressure-relieving device was properly functioning for this high-risk resident.
An LPN did not wear a gown while providing wound care to a resident with a left heel wound, despite facility policy requiring both gowns and gloves for such procedures. The LPN acknowledged the omission, and the facility's policy specified that PPE must be used during high-contact activities like wound care.
A resident with Alzheimer's and dementia, requiring extensive assistance, was improperly transferred using a Hoyer lift with an incorrect sling, leading to a tibial and fibula fracture. Nursing staff lacked guidance on determining sling size, as the facility's policy did not provide instructions, resulting in a major injury.
Facility staff failed to secure medications properly, with two incidents of unlocked and unattended medication carts on the 100 hall. These lapses were confirmed by interviews with staff, who acknowledged the carts should have been locked. The facility's policy requires all medications to be stored in locked compartments when not in use.
The facility did not adhere to the planned menu for residents on pureed diets, affecting several individuals. Instead of receiving the scheduled pureed hot dog with bun and gravy, they were mistakenly served pureed mashed potatoes with gravy, resulting in a lower intake of protein and calories. This error was confirmed by staff, including the RD.
The facility failed to follow Enhanced Barrier Precautions (EBP) and infection control protocols, as staff did not wear gowns during high-contact care for residents on EBP. Instances included an LPN administering water via a G-tube and NAs providing care without gowns. Additionally, an oxygen nasal cannula was found on the floor, and the Laundry Supervisor mishandled laundry, risking cross-contamination.
A facility breached a resident's privacy by posting dietary instructions on their door, revealing personal health information. The resident, with moderate cognitive impairment and Diabetes Mellitus, had a sign indicating dietary restrictions, which was confirmed by the DON as a privacy violation.
A resident with Peripheral Vascular Disease and Cellulitis did not have compression stockings or Prevalon boots applied as per physician's orders. Observations confirmed the absence of these items, and an LPN noted that the orders were entered incorrectly, leading to the oversight.
A facility failed to evaluate and implement a toileting program for a cognitively intact resident who was frequently incontinent of urine and always incontinent of bowel. Despite the resident's ability to express the need to use the toilet and use a bedpan, the care plan lacked a toileting program, contrary to the facility's policy. Interviews confirmed the absence of such a program, highlighting a deficiency in care planning.
The facility failed to document the indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. One resident received Amoxicillin/Augmentin without a documented reason, and another was prescribed doxycycline without a stop date or rationale. This indicates a lapse in the facility's adherence to its antibiotic stewardship policy, which emphasizes appropriate use and documentation of antimicrobials.
The facility failed to offer and document the updated COVID-19 vaccination for 2024-2025 to two residents, despite their vaccination history. The EHR lacked documentation of education or opportunities for these residents to accept or decline the vaccine, as confirmed by the DON. This oversight violated the facility's policy and CDC recommendations.
Multiple Failures to Follow Orders for Monitoring, Equipment, Lab Results, and Post-Fall Assessments
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to practitioner orders and facility policies for several residents. One resident with heart failure was discharged from the hospital with orders for a 2000 ml fluid restriction and daily weights. Record review showed multiple gaps where no daily weights were documented over several multi‑day periods, and the Assistant Director of Nursing confirmed that daily weights were not done as ordered. The resident’s electronic health record also lacked documentation of daily fluid intake monitoring, and interviews with a nursing assistant and an LPN confirmed that the resident’s fluid intake was neither recorded nor tracked to ensure compliance with the 2000 ml restriction. Another resident with diabetes and a documented diabetic foot ulcer had a care plan intervention for use of an air mattress to protect skin and promote healing. Over several days of observation, the air mattress consistently displayed a low‑pressure warning light. The wound nurse acknowledged the low‑pressure light and indicated the need to consult the owner’s manual to determine its meaning. The ADON later confirmed that the mattress was being replaced and provided manufacturer information stating that if the low‑pressure light remained on for longer than 30 minutes, the mattress should be serviced, indicating that the mattress had not been functioning properly for an extended period while in use for this resident. A third resident with a history of recurrent UTIs, ESBL resistance, and prior sepsis had a provider order for a DNA/Microgen urinalysis after completing an antibiotic course. Progress notes documented that a urine specimen was collected and sent, and the physician documented that staff were to monitor closely and await culture and sensitivity results. The MicroGenDX report showed the specimen was collected, received, and reported as positive for a UTI, but the results were not present in the resident’s record and were not communicated to the provider until much later. The DON confirmed that the Microgen UA results had been sent to the ADON’s old email address and were not discovered until they were specifically requested, resulting in a delay in notifying the provider and initiating a new antibiotic. Another resident with chronic diastolic CHF, abnormal weight loss, and diuretic therapy had an order for weekly weights and a care plan intervention to monitor weights and notify the physician of changes. The weight record showed repeated multi‑week gaps where no weights were obtained, despite the resident having documented weight fluctuations and edema requiring additional diuretic therapy. Observations noted significant edema in both legs and feet, and an LPN confirmed that cardiology was following the resident and adjusting medications. The DON confirmed that weekly weights were not being completed as ordered. A further deficiency involved a resident with delusional disorder, epilepsy, and a history of falls, who experienced an unwitnessed fall when staff found the resident on the floor in front of a wheelchair after rolling out of bed. The facility’s post‑fall assessment policy required initiation of neurological assessments for all falls and documentation every shift for 72 hours. Review of the resident’s electronic medical record, including progress notes and scanned documents, revealed that neurological checks were not completed following this unwitnessed fall. The DON confirmed that no neurological checks were found in the resident’s record for this event.
Failure to Notify Physician and Representative of Significant AIMS Score Increase
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative of a significant change in the resident’s Abnormal Involuntary Movements Scale (AIMS) score. Facility policy dated 02-2021 stated that an AIMS score of 2 or higher is evidence of Tardive Dyskinesia (TD), and that if a resident’s score suggests TD, the results should be discussed with the physician, resident, and family, and the need for continued antipsychotic therapy should be considered. Record review showed that the resident, who had anxiety disorder, bipolar disorder, and schizophrenia, was rarely able to make self understood and required total assistance with activities of daily living. The resident was receiving Seroquel 25 mg daily, and additional doses of Seroquel 100 mg at bedtime and 25 mg at noon were later added. An AIMS assessment conducted on 09-17-2025 showed a score of 0, but a subsequent AIMS assessment on 11-04-2025 showed an increased score of 4. Despite this documented increase, which met the facility’s policy threshold for possible TD and required discussion with the physician and family, there was no evidence that the physician or the resident’s representative were informed of the change in the AIMS score. In an interview on 01-08-2026, the DON confirmed that the resident had an increase in the AIMS score and that the facility did not update the resident’s representative or the physician of this increase and acknowledged that they should have done so.
Failure to Provide Required Morning Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide or offer required oral hygiene during the morning routine for one resident who was dependent on staff assistance. Facility policy on oral hygiene, last reviewed in May 2021, required oral care every morning and at bedtime. The resident, admitted in late December 2024, had diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, dysphagia, and dementia, and was assessed on the MDS as rarely or never understood, rejecting care on one to three days during the assessment period, and requiring supervision to complete oral hygiene. The resident’s comprehensive care plan included an intervention for assistance of one staff member for dressing and hygiene, and a nursing order dated July 2025 directed staff to assist with tooth brushing every morning and night, with refusals to be documented in progress notes. Progress notes from October 2025 through early January 2026 documented refusals of oral care only on two dates in October. A dental visit note from late October 2025 described the resident’s oral hygiene as very poor, with heavy plaque and food debris and moderate tartar accumulation, and stated that the resident’s special needs rendered them incapable of maintaining adequate oral health without daily assistance, encouraging staff to assist with tooth brushing. On a morning in early January 2025, observation showed the resident in their bedroom with food debris in their mouth. A subsequent continuous observation of the resident’s morning care showed a nursing assistant assisting the resident out of bed, dressing them, styling their hair, and cleaning and donning their eyeglasses, but not offering or providing assistance with tooth brushing. In an interview immediately afterward, the nursing assistant confirmed that oral hygiene was not performed or offered and acknowledged it should have been part of the resident’s morning care.
Failure to Ensure Proper Functioning of Ordered Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper functioning of an ordered air pressure mattress for a resident assessed as at risk for pressure ulcer development. The resident’s MDS documented diagnoses of malnutrition and Inclusion Body Myositis, moderate cognitive impairment (BIMS score 10), total dependence for all ADLs including bed mobility, and constant bowel and bladder incontinence, with recent weight loss and a current weight of 93 pounds. The care plan identified the resident as at risk for pressure ulcers related to weakness and reduced mobility, with a goal for skin to remain intact, and included use of an air pressure mattress as a specific intervention. Surveyor observations over multiple days showed repeated problems with the air mattress not being powered on and/or not functioning properly. On one occasion, the resident was observed in bed with the air mattress pump not on; on several other occasions, the pump was on but the low-pressure light was illuminated, and on multiple subsequent observations the air mattress was again off while the resident was in bed. A medication aide confirmed that the air mattress was not on and should have been. The wound nurse confirmed the low-pressure light was on and stated they would need to refer to the owner’s manual to determine its meaning. The ADON confirmed the mattress was being replaced and provided manufacturer information indicating that if the low-pressure light remained on for longer than 30 minutes, the mattress should be serviced.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a left heel wound. The resident had a practitioner order for wound treatment, and the facility's EBP policy required the use of gowns and gloves for residents with wounds, regardless of known infection or colonization status. During an observed wound care procedure, an LPN performed hand hygiene and donned gloves but did not wear a gown at any point while providing care, including when removing soiled dressings and cleaning the wound. The LPN confirmed during an interview that a gown should have been worn during the procedure. The facility's EBP policy, revised in March 2024, specifically states that PPE, including gowns and gloves, must be worn during high-contact resident activities such as wound care. The failure to don a gown during the wound care procedure constituted noncompliance with the facility's infection prevention and control program.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer a resident, identified as Resident 9, in a manner that would prevent injury. Resident 9, who was admitted to the facility, had both short-term and long-term memory problems and was diagnosed with Alzheimer's and dementia with behavioral disturbances. The resident was dependent on staff for eating, bed mobility, transfers, and toileting, requiring extensive to total assistance with activities of daily living. The Comprehensive Care Plan indicated that two staff members were needed to transfer the resident using a full body sling, but it did not specify the size of the sling required. During a transfer from the bed to a wheelchair using a Hoyer lift, Nursing Assistants Q and R used a divided leg Hoyer sling instead of a full body sling. As a result, Resident 9 began to slide out of the sling, causing the nursing assistants to intervene to prevent further sliding. Despite their efforts, Resident 9 experienced extreme pain during the transfer and was later diagnosed with a tibial fracture and an anterior displaced fibula fracture after being sent to the emergency room. Interviews with the nursing staff, including NA Q, NA R, LPN N, and the MDS Coordinator, revealed a lack of knowledge regarding the appropriate sling size for the Hoyer lift. The facility's Nursing Policy and Procedure Manual did not provide instructions on determining the correct sling size, contributing to the improper transfer and subsequent injury of Resident 9. The Director of Nursing confirmed the incident resulted in a major injury for the resident.
Medication Security Lapses in Facility
Penalty
Summary
The facility staff failed to secure medications properly, as observed on two separate occasions. On the first occasion, a medication cart was found unlocked and unattended on the 100 hall at 7:10 AM. This was confirmed by interviews with a Registered Nurse (RN) and a Medication Assistant (MA), who acknowledged that the cart should not have been left unlocked and out of sight. This oversight had the potential to affect 10 residents identified as self-mobile who resided on the 100 hall. On a second occasion, another medication cart was left unlocked and unsupervised by a Medication Assistant (MA) between 6:12 and 6:18 AM. Additionally, a card of Acetaminophen was left unsecured on top of the cart. The MA confirmed during an interview that the medication card should not have been left on top of the cart and that the cart should have been locked and secured. The facility's medication storage policy, dated August 2018, mandates that all medications and biologicals be stored in locked compartments when not in use or left unattended.
Failure to Follow Pureed Meal Menu
Penalty
Summary
The facility failed to follow the menu to meet the nutritional needs of residents requiring pureed meals, affecting 7 out of 13 residents identified as needing such meals. On a specific day, the menu planned for lunch included a pureed hot dog with bun and gravy, among other items. However, during lunch service, residents on pureed diets were mistakenly served pureed mashed potatoes with gravy instead of the planned pureed hot dog and bun. This error was confirmed by staff interviews, including one with the Registered Dietician, who noted that the residents received less protein and calories than intended due to the menu not being followed.
Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for several residents, leading to potential cross-contamination risks. Observations revealed that staff members did not wear gowns during high-contact care activities for residents on EBP. For instance, a Licensed Practical Nurse (LPN) administered water via a G-tube to a resident without donning a gown, despite the resident being on EBP due to a gastrointestinal tube. Similarly, a Nursing Assistant (NA) emptied a foley catheter bag for another resident without wearing a gown, even though the resident was on EBP due to an indwelling medical device. Further deficiencies were noted with other residents on EBP. A Nursing Assistant provided care to a resident with a Multi-Drug Resistant Organism (MDRO) without wearing a gown, despite the resident being on EBP for having a gastrostomy tube. Another instance involved two Nursing Assistants transferring a resident to a commode without gowns, even though the resident was on EBP due to a gastrostomy tube. Additionally, a Licensed Practical Nurse administered medications through a gastrostomy tube to a resident on EBP without wearing a gown. The facility also failed to maintain proper infection control practices in other areas. An oxygen nasal cannula for a resident was repeatedly observed on the floor, contrary to the facility's policy requiring it to be stored in a plastic bag when not in use. Furthermore, the Laundry Supervisor was observed delivering laundry with clothing and linens touching their body and dragging on the floor, which is against the facility's protocols for preventing cross-contamination.
Privacy Violation of Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical information. Specifically, information regarding a resident's dietary restrictions was posted on the outside of their door, visible to anyone passing by. The resident, identified as having a moderate cognitive impairment with a BIMS score of 9 and a diagnosis of Diabetes Mellitus, had a sign on their door indicating dietary instructions, such as avoiding snacks full of sugar and allowing Glucerna and half a sandwich. This action was confirmed by the Director of Nursing to be a violation of privacy, as it disclosed personal health information publicly.
Failure to Apply Compression Stockings and Prevalon Boots as Ordered
Penalty
Summary
The facility failed to ensure that a resident's compression stockings and Prevalon boots were applied according to the physician's orders. The resident, who had diagnoses of Peripheral Vascular Disease, Cellulitis of the right lower leg, and Unspecified Dementia, was dependent on staff for all activities of daily living and was at risk for developing pressure ulcers. Despite these conditions, the resident's Medication Administration Record and Treatment Administration Record from June to August 2024 did not show that compression stockings or Prevalon boots were applied until late August. Observations on multiple occasions revealed that the resident was not wearing compression stockings or Prevalon boots as prescribed. A Licensed Practical Nurse confirmed that the orders were entered incorrectly into the system, which resulted in the oversight. The nurse also confirmed that the resident would not have refused to wear the compression stockings or Prevalon boots, indicating that the failure was due to administrative error rather than resident non-compliance.
Failure to Implement Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to evaluate and implement a toileting program for a resident who was frequently incontinent of urine and always incontinent of bowel. The resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, expressed awareness of the need to use the toilet and the ability to use a bedpan if provided. Despite this, the resident's care plan did not include an evaluation or implementation of a toileting program, which is a requirement based on the facility's policy and procedure for urinary incontinence. Interviews conducted with the resident and the MDS Coordinator confirmed the absence of a toileting program for the resident. The facility's policy, dated June 2021, outlines the need for assessing urinary continence status upon admission, quarterly, and with any significant change of condition. It also requires developing an incontinence plan of care, particularly for cognitively intact residents who can participate in their care. However, these procedures were not followed for the resident in question, leading to the deficiency noted in the report.
Deficiency in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to provide an indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. For Resident 28, a physician order for Amoxicillin/Augmentin was issued without a documented reason for its administration. The medication was administered for 20 doses over a period of ten days, yet there was no indication in the resident's records, including practitioner orders, progress notes, or laboratory work, to justify the use of the antibiotic. An interview with the Infection Preventionist Coordinator confirmed that the antibiotic use did not meet the criteria set by McGeer's tool for determining the necessity of antibiotic use. Similarly, Resident 144 was prescribed doxycycline without a specified stop date, and there was no documented rationale for the continued use of the antibiotic. The facility's policy requires that when a resident is admitted on an antibiotic, staff must verify the reason for its use and obtain a stop date or rationale from the physician. This was not adhered to in the case of Resident 144, indicating a lapse in the facility's antibiotic stewardship practices. The facility's Infection Control Policy and Procedure Manual outlines the importance of a quality antibiotic stewardship program, emphasizing the need for appropriate use of antimicrobials and minimizing antibiotic overuse and resistance. The policy includes procedures for the interdisciplinary antibiotic stewardship team to ensure antibiotics are used appropriately, with proper follow-up on cultures and sensitivities. However, the failure to document the indication for antibiotic use for both residents highlights a significant deficiency in adhering to these established protocols.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to prevent potential COVID-19 infection by not offering, providing education, or documenting the opportunity for two residents, Resident 15 and Resident 25, to accept or decline the updated COVID-19 vaccination for 2024-2025. The facility's policy, dated May 2021, mandates that all residents should be educated about the COVID-19 vaccine, including its risks and benefits, and be given the opportunity to be vaccinated. However, the Electronic Health Records (EHR) for both residents did not show any documentation of education, the vaccine being offered, or any opportunity for the residents to decline or accept the updated vaccination. Resident 15 had a history of receiving COVID-19 vaccines on three occasions in 2021, while Resident 25 had a history of receiving vaccines on five occasions between 2020 and 2022. Despite these histories, there was no documentation in the EHR for the 2024-2025 vaccination. An interview with the Director of Nursing confirmed that these residents were not offered the updated COVID-19 vaccination, nor were they provided with the necessary education. This oversight is a direct violation of the facility's policy and the CDC's recommendations for COVID-19 vaccination.
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Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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