Bethany Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Minden, Nebraska.
- Location
- 515 West First Street, Minden, Nebraska 68959
- CMS Provider Number
- 285270
- Inspections on file
- 14
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bethany Home, Inc during CMS and state inspections, most recent first.
The facility did not serve meals within the required 30-minute window, resulting in some residents waiting up to 47 minutes for their food. Staff delays were caused by the need to debone chicken and cut up food at the tables, as well as waiting for meal carts to be returned. A resident reported that long waits for meals were common, and staff confirmed that the observed delays did not meet facility standards.
Dietary staff did not consistently wear required beard and moustache coverings while preparing and serving food, contrary to facility policy. Additionally, the ice machine's filtration system was not maintained according to recommended intervals, with filters overdue for replacement and visible mineral buildup and rust present. Staff interviews confirmed lapses in both facial hair covering use and filter maintenance.
Two residents receiving antipsychotic medications, including one with severe cognitive impairment and another with multiple psychiatric diagnoses, were not provided or documented with education regarding the risks, benefits, or alternative treatments for these medications. Facility staff confirmed the absence of such documentation, resulting in a deficiency related to informed consent for antipsychotic use.
Surveyors found that two residents were prescribed psychotropic medications without proper documentation of approved indications in their medical records. One resident received an antidepressant for depression without a corresponding diagnosis, and another was given a hypnotic for insomnia without insomnia being documented. Facility policy requires such medications to be used only for specific, documented conditions, but this was not followed in these cases.
A resident was discharged from the facility without the required notification to the state ombudsman. Facility policy mandates ombudsman notification upon discharge, but staff interviews and record reviews confirmed that only hospital transfers were reported, and no documentation existed for the resident's discharge notification.
A resident with multiple mental health diagnoses was admitted from another nursing home without a current PASARR Level 1 screening, as required by facility policy. The only available PASARR evaluation was over a year old and completed at the previous facility. The Social Services Director confirmed that a new screening was not requested prior to admission.
A resident experienced two unwitnessed falls, but the care plan was not updated with new interventions or goals until several days after the incidents, despite facility policy requiring prompt updates by the DNS and MDSC.
The facility did not adhere to food safety requirements, including the removal of dented cans, proper hairnet placement, and hand hygiene practices. Observations showed dented cans of apple pie filling in storage, a disconnected syrup fastener connector on the floor, and dietary aides touching the top portion of plates while serving meals. Hand hygiene was not consistently performed for the required 20 seconds, and a dietary aide was seen with a hairnet improperly placed. The Dietary Manager confirmed the lack of a policy for dented cans, improper syrup connector placement, and non-compliance with hand hygiene and plate handling protocols.
A facility failed to treat a resident with dignity by discussing their personal bowel habits in a public dining area. The resident confirmed a preference for privacy, and the DON acknowledged the inappropriateness of the public conversation and the lack of a relevant policy.
The facility staff failed to evaluate a resident's ability to self-medicate, leading to medications being left unattended on a dining room table. The resident did not have a Self-Administration of Medication assessment or a physician's order for self-administration, contrary to facility policies.
The facility failed to properly clean a resident's CPAP equipment, as observed multiple times with white specks inside the mask. Interviews revealed inconsistencies in the cleaning schedule, and the Director of Nursing confirmed the need for cleaning. The resident, who is severely cognitively impaired, was not provided with the required care according to the manufacturer's instructions.
The facility failed to keep a medication cart locked when out of the eyesight of a nurse and did not label and date an eye drop medication for a resident. Both the LPN and the DON confirmed these deficiencies, which were against the facility's policies on administering and labeling medications.
The facility failed to perform proper hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart. An LPN washed hands for only 5 seconds instead of the required 20 seconds and did not perform hand hygiene between residents. Additionally, the LPN picked up a dropped pill with bare fingers and placed it back in the medication cup for another resident. These actions were confirmed by the LPN and the DON, who acknowledged that the facility's hand hygiene policy was not followed correctly.
Delayed Meal Service Due to Insufficient Dietary Staffing and Inefficient Processes
Penalty
Summary
The facility failed to ensure that meals were served within the allotted time frames established by staff, potentially affecting all residents served from the kitchen. Observations during the noon meal revealed that some residents waited up to 47 minutes after the scheduled mealtime to receive their food. Residents were observed seated and waiting, with some consuming desserts and drinks before the main meal was served. Dietary staff were delayed in serving meals due to the need to debone chicken wings and cut up food at the tables, which extended the overall meal service time. The process of serving was further slowed as dietary staff had to wait for meal carts to be returned before continuing to serve additional tables. Interviews with residents and staff confirmed that extended wait times for meals were not uncommon, with one resident stating it was typical to wait up to an hour for lunch and supper. The Dietary Manager acknowledged that all meals are supposed to be served within 30 minutes of service start, and that the delays observed were not acceptable. The facility's posted mealtimes and staff training both indicated a 30-minute window for meal service, but this standard was not met during the observed meal, as confirmed by both dietary staff and the facility administrator.
Failure to Ensure Dietary Staff Facial Hair Coverings and Proper Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure that all dietary staff with beards and moustaches wore appropriate facial hair coverings while working in the kitchen, as required by facility policy. Multiple observations over two days showed that cooks were serving meals without beard and moustache coverings, despite the policy stating that staff must be clean shaven or wear a beard guard or mask covering the entire area. Interviews with the involved staff confirmed that the coverings were not worn at all times, with one staff member indicating they were a new hire and still learning the procedures. Additionally, the facility did not maintain a safe and effective cleaning routine for the ice machine filtration system. Observations revealed that one filter was visibly dirty and past its change date, while other filters had dates indicating they had not been changed according to the required intervals. The area where cups and pitchers are filled with ice showed mineral deposits and rust. Interviews with maintenance staff confirmed that the filters had not been changed as required and that there was no written policy or manual for the filtration system. The facility administrator acknowledged the presence of mineral buildup and rust on the ice machine.
Failure to Inform Residents or Representatives of Antipsychotic Medication Risks and Alternatives
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about the risks, benefits, and alternative treatments associated with the use of antipsychotic medications for two residents. For one resident with severe cognitive impairment and a diagnosis of dementia, Seroquel was administered daily from admission, and documentation showed the resident experienced excessive sleepiness, prompting a physician to note probable overmedication. Despite ongoing administration and monitoring for side effects, there was no documentation in either the electronic or paper medical records that the resident or their family had been educated about the antipsychotic medication. Another resident with diagnoses including unspecified dementia with behavioral disturbance, bipolar disorder, anxiety disorder, and a history of alcohol abuse was also prescribed multiple psychotropic medications, including Seroquel. The care plan and medication records confirmed regular administration of these medications and ongoing behavioral monitoring. However, there was no documentation that the resident or their family had been informed of the risks, benefits, or alternative treatments for the antipsychotic medication. Interviews with facility staff, including the Director of Nursing Services and the Minimum Data Set Coordinator, confirmed the absence of documentation regarding resident or family education on antipsychotic medication use for both residents. The lack of documented education and informed consent for antipsychotic medication use constituted the deficiency identified during the survey.
Failure to Ensure Approved Indications for Psychotropic Medication Use
Penalty
Summary
Surveyors identified that the facility failed to ensure psychotropic medications were prescribed with approved indications for use for two of five sampled residents. Facility policy requires that antipsychotic medications be used only for specific, documented conditions and after non-pharmacological interventions have been attempted, except in emergencies. The policy also mandates that medications such as antipsychotics and antidepressants be prescribed only when necessary to treat specific conditions, and that diagnoses alone do not warrant their use without supporting behavioral symptoms and documentation. For one resident with diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease, anxiety disorder, and insomnia, the medical record showed the use of mirtazapine for depression and insomnia, and Seroquel for dementia-related symptoms. However, there was no diagnosis of depression documented in the resident's medical record or on the active diagnosis sheet, despite the ongoing administration of mirtazapine for that indication. Behavioral monitoring documented symptoms such as sadness, tearfulness, wandering, and anxiety, with interventions attempted but with mixed or unchanged results. Another resident with unspecified dementia, bipolar disorder, and anxiety disorder was prescribed Ambien for insomnia, Klonopin for anxiety, Remeron for bipolar disorder, and Seroquel for bipolar disorder. The care plan referenced the use of psychotropic medications for bipolar disorder and insomnia, but there was no diagnosis of insomnia documented in the medical record or on the active diagnosis sheet, despite the administration of Ambien for that purpose. Behavioral monitoring noted episodes of frustration and verbal aggression, with interventions resulting in either improvement or no change.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge, as required by both facility policy and regulatory standards. According to the facility's Discharge Planning Process policy, notification to the ombudsman should occur by fax on the date of discharge. Record review showed that a resident was admitted and later discharged, but there was no documentation of ombudsman notification for this discharge. The facility's Record of Transfers/Discharges also did not contain evidence of such notification for the resident in question. Interviews with facility staff revealed confusion regarding responsibility for ombudsman notifications. The Social Services Director was initially unsure who was responsible, later indicating that the DON handled notifications. The DON confirmed that the facility only notifies the ombudsman for hospital transfers, not for discharges, and acknowledged that no notification was made for this resident's discharge. This lack of notification was confirmed through both documentation review and staff interviews.
Failure to Complete PASARR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level 1 screening was completed prior to the admission of a resident with mental health diagnoses. According to facility policy, all applicants must be screened for serious mental disorders or intellectual disabilities before admission, and a record of this screening must be maintained in the resident's medical record. The policy also specifies that the Social Services Director is responsible for tracking each resident's PASARR status. Exceptions to this requirement are limited to individuals readmitted directly from a hospital or those certified by a physician as likely to require less than 30 days of nursing facility services. A review of the medical record for a resident admitted from another nursing home revealed that the only available PASARR Level 1 evaluation was completed over 14 months prior to admission to the current facility. There was no evidence of a current PASARR Level 1 screen within 30 days before or after the resident's admission, despite the resident having diagnoses of Post Traumatic Stress Disorder, Anxiety, Depression, and Unspecified Psychosis. The Social Services Director confirmed that a current PASARR Level 1 screen was not requested prior to the resident's admission, and the existing evaluation was from the previous facility.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with new interventions after each fall for one resident. Record review showed that the resident experienced two unwitnessed falls within a five-day period. Despite the facility's policy requiring the care plan to be updated by an interdisciplinary team after such incidents, the last update related to falls was completed over a month prior to the most recent falls, and no new interventions or goals were added following these events. Interviews with nursing staff and administrative personnel revealed that only the Director of Nursing Services (DNS) and the Minimum Data Set Coordinator (MDSC) were responsible for updating care plans. Both confirmed that the care plan for the resident in question was not updated on the same day or the day after the falls, as required by facility policy. The MDSC acknowledged that the care plan had not been revised until several days after the incidents, contrary to established procedures.
Food Safety Protocols Not Followed in Dietary Department
Penalty
Summary
The facility failed to ensure food safety requirements by not removing dented cans for resident consumption, maintaining correct placement of hairnets while prepping and plating food, performing hand hygiene for 20 seconds prior to plating residents' food, preventing contamination by improperly holding dining plates while serving meals, and improperly storing the fountain dispenser line. Observations revealed dented cans of apple pie filling were stored for use in the dry storage area, the syrup fastener connector was disconnected and lying on the floor, dietary aides touched the top portion of plates while serving meals, and hand hygiene was not consistently performed for the required duration. Additionally, a dietary aide was observed with a hairnet improperly placed, allowing hair to be outside the net while handling food for residents. The Dietary Manager acknowledged the lack of a policy for dented or damaged cans, confirmed the presence of the dented cans in storage, and acknowledged the need for proper removal. The manager also confirmed the improper placement of the syrup connector, lack of adherence to hand hygiene protocols, and improper handling of meal plates by dietary aides. Education had been provided to staff previously on these matters, indicating awareness of the correct procedures. Interviews with staff members confirmed the need for adherence to hand hygiene protocols, proper hairnet usage, and correct handling of meal plates to prevent contamination and ensure food safety for the residents.
Violation of Resident Dignity in Public Setting
Penalty
Summary
The facility failed to treat Resident 24 with dignity by discussing their personal bowel habits in a public setting. During an observation in the dining area, a Registered Nurse (RN-A) approached Resident 24 at their assigned seat and held a conversation about their bowel habits loud enough for table mates and others in the room to hear. Resident 24 later confirmed in an interview that they preferred such personal matters to be kept private. The Director of Nursing (DON) acknowledged that private conversations regarding bowel habits should not occur in public spaces and revealed that the facility lacked a policy for handling personal conversations in public areas.
Failure to Evaluate Resident's Ability to Self-Medicate
Penalty
Summary
The facility staff failed to evaluate Resident 42's ability to self-medicate, as required by the facility's policies. Resident 42, who has diagnoses including congestive heart failure, hypertension, atrial fibrillation, vitamin deficiency, and pain, was observed during a morning medication pass. LPN-A placed multiple medications in a cup and left them on the dining room table for Resident 42 without observing the resident taking the medications. The medications remained on the table for an extended period, and LPN-A confirmed that this practice was common with alert and oriented residents due to time constraints, despite acknowledging it was inappropriate. Further investigation revealed that Resident 42 did not have a Self-Administration of Medication assessment completed, nor was there a physician's order for self-administration in the resident's Medication Administration Record. The facility's policies clearly state that residents may only self-administer medications if deemed safe by the attending physician and the Interdisciplinary Care Planning Team. The Director of Nursing confirmed that medications should not be left with residents and should be observed as taken, highlighting a clear breach of protocol in this instance.
Failure to Clean CPAP Equipment
Penalty
Summary
The facility failed to provide proper cleaning for a resident's CPAP equipment. Resident 55, who has a diagnosis of obstructive sleep apnea and is severely cognitively impaired with a BIMS score of 4, was observed multiple times with a CPAP mask that had white specks on the inside. The CPAP mask was found assembled and laying in the bedside drawer on several occasions, indicating it had not been cleaned as required. Interviews with medical assistants revealed inconsistencies in the cleaning schedule, with one assistant stating the mask is cleaned in the mornings and another admitting it had not been cleaned by the designated time. The Director of Nursing confirmed that the CPAP masks need to be cleaned. The manufacturer's cleaning instructions specify daily wipe-downs, gentle washing with mild detergent, thorough rinsing, and air drying. Despite these guidelines, the observations and interviews indicate that the facility did not adhere to the prescribed cleaning regimen for Resident 55's CPAP equipment, leading to the deficiency noted in the report.
Medication Cart and Labeling Deficiencies
Penalty
Summary
The facility failed to keep a medication cart locked when it was out of the eyesight of a nurse. An observation revealed an unlocked medication cart on hall 400 while the nurse responsible for it was inside a resident's room further down the hall. Both the LPN and the DON confirmed that the medication cart should not have been left unlocked when it was not within the nurse's eyesight. The facility's policy on administering medications, revised in April 2007, states that the medication cart must be kept closed and locked when out of sight of the medication nurse or aide, and it must be clearly visible to the personnel administering medications. Additionally, the facility failed to label and date an eye drop medication for a resident. During a medication pass, it was observed that a box of Regener-Eyes eye drops did not have a label indicating who the medication was for or directions on how to administer it. The box and bottle were also not dated to indicate when the eye drop bottle was opened. The LPN and the DON confirmed that the medication should have been labeled and dated. The facility's policy on labeling medication containers, revised in April 2007, requires that all medications maintained in the facility be properly labeled, including over-the-counter drugs, which should have the resident's name, expiration date, and directions for use.
Failure to Perform Proper Hand Hygiene and Medication Handling
Penalty
Summary
The facility failed to perform proper hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart. An observation revealed that an LPN prepared medications for a resident and administered them through a J-tube, followed by nasal spray and eye drops, without performing adequate hand hygiene. The LPN washed hands for only 5 seconds instead of the required 20 seconds and did not perform hand hygiene between residents. Additionally, the LPN picked up a dropped pill with bare fingers and placed it back in the medication cup for another resident. These actions were confirmed by the LPN and the Director of Nursing, who acknowledged that the facility's hand hygiene policy was not followed correctly. The facility's hand hygiene policy requires staff to wash hands for at least 20 seconds with soap and water, covering all surfaces of hands and fingers, including areas under and around fingernails. The policy also states that gloves do not replace hand washing and that hands should be washed after removing gloves. The facility's medication administration policy mandates following established infection control procedures, including handwashing and the use of gloves. The failure to adhere to these policies was observed during the medication administration for three residents, highlighting a significant lapse in infection prevention and control practices.
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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