Brookestone Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 4330 South 144th Street, Omaha, Nebraska 68137
- CMS Provider Number
- 285242
- Inspections on file
- 17
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Brookestone Village during CMS and state inspections, most recent first.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Infection control practices were not followed during a Norovirus outbreak in a resident room on Droplet/Contact Precautions. An MA entered one isolation room with goggles, then went to another room without disinfecting the eyewear, and stated they did not think cleaning was needed between residents. In a separate event, an NA entered an isolation room without a face shield while carrying a tray of individually wrapped donuts; the ADON confirmed the tray should not have been brought into the room and that this was a breach of isolation procedure.
Failure to report and investigate an allegation of abuse: A cognitively intact resident with rhabdomyolysis and anxiety reported that an NA removed ace wraps roughly and hurt the resident. The resident told an MA and an LPN, but the facility did not suspend the NA, did not open an abuse investigation right away, and did not report the allegation to APS or DHHS until later.
A resident with moderate cognitive impairment and diagnoses including dementia, frontal lobe/executive function deficit, depression, and anxiety was repeatedly identified as high elopement risk, but the care plan did not include an elopement risk focus or any interventions. Staff confirmed the resident was on the elopement list, an alarm was attached to the room door, and the ADON acknowledged the care plan update had not been completed.
Failure to Implement Pressure Injury Prevention: A resident with a hip fx, PVD, lymphedema, foot drop, limited mobility, and a Braden score indicating pressure injury risk developed a left heel pressure injury after the facility did not have pressure-reducing interventions in place. Records showed no turning/repositioning task or skin-related care plan interventions until after the heel blister was found, and staff later observed the resident seated with both heels resting on wheelchair footrests.
The facility failed to maintain complete respiratory orders for two residents on oxygen and one resident using a PAP device. One resident’s oxygen order lacked a dose and route, another resident’s oxygen order lacked a dose, and a third resident had documented PAP use in progress notes and at bedside but no physician order. Staff and the ADON confirmed the missing order details, while observations showed the residents using oxygen at 2 L/min and the PAP machine in the room.
The facility failed to update CCPs for residents, leading to deficiencies in wound care, medication management, and behavior interventions. A resident's skin tear was not included in the care plan, another's pressure injury lacked updated interventions, and a third's new medication was not reflected in their care plan. Additionally, a resident's behavior interventions were outdated, highlighting a failure to maintain current care plans as per facility policy.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Infection Control Breaches During Norovirus Isolation
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during a Norovirus outbreak in a resident room placed on Droplet/Contact Precautions. Survey observations on 02/19/2026 showed Medication Aide J entered the isolation room wearing a mask, gloves, gown, and goggles, then exited and went to another resident room with the goggles still on top of the head without disinfecting them. In interview, Medication Aide J stated they did not think the goggles needed to be cleaned or disinfected between residents, and the ADON confirmed the eyewear was expected to be cleaned and disinfected between residents. The facility also failed to restrict communal food items from entering an isolation room. During another observation on 02/19/2026, Nursing Assistant K entered a Droplet/Contact Precautions room carrying a plastic tray and later exited with a tray containing 7 plates of individually wrapped single donuts. Nursing Assistant K stated they forgot to put on a face shield and did not know whether bringing the tray of donuts into the room was a breach of isolation procedure. The ADON confirmed the NA should have worn a face shield and that the tray of donuts should not have been taken into the isolation room, identifying this as a breach of Droplet/Contact isolation.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of abuse involving Resident 22 within the required timeframe. Resident 22 was admitted with a diagnosis of rhabdomyolysis and had an MDS showing a BIMS score of 14, indicating the resident was cognitively intact. The resident also had a diagnosis of anxiety disorder and required assistance with footwear. The facility’s Abuse and Neglect Prevention Standard required all allegations of abuse to be reported immediately, but no later than 2 hours, and required immediate notification of the Administrator, DON, and Social Services, along with immediate suspension of the suspected team member while an investigation was conducted. Resident 22 reported that on 2/17/2026 at about 8:00 PM, NA G removed ace wraps roughly from the resident’s legs and hurt the resident. Resident 22 told MA D later that evening and also spoke with LPN H about the incident. MA D confirmed the resident said NA G was rough and hurt the resident’s legs, and that the resident did not want NA G to provide care again. ADON B confirmed the facility had not suspended NA G, had not opened an abuse investigation, and had not reported the incident to APS or DHHS. The DON confirmed LPN H called at midnight on 2/17/26 and reported that Resident 22 said NA G hurt them when removing the ace wraps, but the facility did not open an abuse investigation until the afternoon of 2/18/2026.
Care Plan Missing Elopement Risk Focus and Interventions
Penalty
Summary
The facility failed to ensure the complete care plan was developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals for a resident identified as a high elopement risk. Record review showed the resident had an undated care plan that did not include a Risk for Elopement focus and did not contain any elopement interventions, despite repeated elopement risk assessments identifying the resident as high risk on multiple occasions. The resident’s clinical profile showed admission to the facility and a CMS-accepted MDS with a BIMS score of 10, indicating moderate cognitive impairment. The resident’s diagnoses included frontal lobe and executive function deficit following cerebral infarction, unspecified dementia with mood disturbance, major depressive disorder, and generalized anxiety disorder. The resident’s elopement risk assessments repeatedly identified the resident as high risk, and the Elopement Risk Manual contained the resident’s picture and description details. During observation, an electronic alarm was attached to the top exterior of the resident’s room door. Staff interviews confirmed the resident was on the elopement list, that the facility maintained an elopement risk manual and list accessible to staff, and that nursing was responsible for completing the elopement risk assessment while the ADON was responsible for updating the care plan. The ADON confirmed the resident’s care plan did not contain a risk for elopement or interventions and that the care plan update had not been completed.
Failure to Implement Pressure Injury Prevention
Penalty
Summary
The facility failed to implement pressure injury prevention interventions for a resident who was admitted with multiple risk factors, including a right hip fracture, peripheral vascular disease, lymphedema, and left foot drop. The resident’s admission MDS showed moderate cognitive impairment, dependence for many transfers and mobility tasks, and existing skin issues including a stage I pressure ulcer, an unstageable pressure injury, and a surgical wound. The Braden Scale on 01/22/2026 scored the resident at 17, indicating risk for pressure injury, and the resident was chairfast with very limited mobility and friction/shear concerns. Although the resident’s skin was initially documented as without major concerns aside from edema, the record did not show turning/repositioning tasks or other pressure-reducing interventions until the left heel wound was identified. Nursing documentation later described a large fluid-filled blister on the left heel measuring 3 cm by 2.8 cm, dark red and purple in color, and the resident was instructed not to wear shoes and to use gripper socks and Prevalon boots in bed. The pressure ulcer record identified the heel wound as an unstageable pressure ulcer, and the incident report noted predisposing factors including gait imbalance, footwear type, a history of left foot drop, and an extended period lying on the floor after a fall before EMS arrived. Record review showed the care plan did not include a focus area or interventions for potential skin impairment until after the heel wound was found, and the task list did not show pressure injury prevention interventions until that same time. The facility’s air mattress order was not completed until the day after it was placed. During later observations, the resident was seen sitting in a wheelchair with both heels directly on the footrests, and wound care documentation showed the left heel remained an intact partially fluid-filled purple blister. Staff interviews confirmed there were no pressure-reducing interventions in place before the heel wound was discovered, and the ADON acknowledged the resident had been at risk based on the Braden Scale but did not have pressure-reducing interventions in place before the wound developed.
Incomplete Oxygen Orders and Missing PAP Device Order
Penalty
Summary
The facility failed to ensure respiratory orders were complete for two residents receiving oxygen and failed to ensure one resident had a documented order for a PAP device. The deficiency was identified through observation, interview, and record review involving Residents 144, 147, and 160, with the facility census listed as 122. Resident 144’s order summary showed only an order to titrate oxygen to maintain an oxygen level of 90% two times a day for safe mobility, but the order did not include a dose or route. The MAR and TAR showed the oxygen order was marked two times a day except for two shifts. Observations showed the resident using a nasal cannula with the concentrator set at 2 L/min on 02/18/2026 and 02/23/2026, and on 02/23/2026 the resident was observed on an exercise bike without oxygen, with an oxygen saturation of 82%; therapy staff then obtained the oxygen tank and placed the resident on oxygen at 2 L/min, increasing saturation to 95%. Resident 144 stated the resident had been on oxygen at 2 L/min since admission, and the ADON confirmed the only oxygen order did not contain a setting. Resident 147’s order summary listed oxygen via nasal cannula two times a day, but the order did not include a dose. The MAR and TAR showed the oxygen via nasal cannula was marked administered two times a day except for two shifts. Observations showed the resident with a nasal cannula in place and the concentrator set at 2 L/min on 02/18/2026 and 02/19/2026. For Resident 160, the clinical physician orders did not include an order for the PAP device, although progress notes documented use of a PAP machine on multiple dates, the device was observed at the bedside, and the resident stated the PAP machine was brought to the facility on admission and used every night. The ADON confirmed the resident had a PAP device, did not have an order for it, and should have.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCP) for several residents, leading to deficiencies in wound care, medication management, and behavior interventions. Resident 88, who was at risk for developing wounds, had a skin tear on the left lower leg that was not included in the care plan despite being identified and treated. The facility's policy required that all actions and interventions be included in the care plan at the time of identification, but this was not adhered to, as confirmed by interviews with the RN and ADON. Resident 7 had a new pressure area on the right second toe, which was identified during a weekly visual skin check. However, the care plan was not updated with new interventions or revisions after the discovery of the pressure injury, contrary to the facility's Skin and Wound Management policy. This oversight was confirmed by the ADON, who acknowledged that the care plan should have been updated to reflect the new condition. Resident 87 was prescribed Ativan for anxiety, but the care plan was not revised to include this new medication and its management. Similarly, Resident 69's care plan did not reflect specific behaviors and interventions related to their dementia-related diagnosis, despite documented behaviors and staff interventions. The care plan had not been updated since 2019, and the lack of personalized interventions was confirmed by the ADON. These deficiencies highlight a failure to maintain current and comprehensive care plans as required by the facility's policies.
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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