Eventide Lincoln Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 4720 Randolph Street, Lincoln, Nebraska 68510
- CMS Provider Number
- 285057
- Inspections on file
- 21
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Eventide Lincoln Care Center during CMS and state inspections, most recent first.
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.
Two residents with complex medical needs experienced repeated delays in staff response to call lights, with documented wait times far exceeding the facility's 5-minute expectation. Both residents reported long waits, and call light logs confirmed multiple instances of extended response times, indicating staff did not meet the facility's standard for timely care.
A resident with multiple diagnoses, including CHF, CKD, COPD, and a recent surgical repair of a right leg fracture, was not properly assessed for changes in condition. Facility staff failed to perform and document daily assessments and vital signs as required for a Medicare skilled stay, despite the resident experiencing significant weight gain, edema, and a weak pulse. Key aspects of the resident's condition were not consistently documented or communicated to the medical provider, as confirmed by staff interviews and record review.
A resident with multiple complex diagnoses, including CHF, CKD, and a recent surgical repair, did not have complete or accurate medical records maintained during a Medicare skilled stay. Required daily documentation of assessments and vital signs was missing, and critical information such as edema, neurovascular status, and respiratory assessments was often omitted. Staff interviews confirmed that the facility did not meet its own policy for daily skilled documentation or notify the medical provider of significant changes in the resident's condition.
The facility failed to implement effective infection control measures, including missing signage for designated zones and improper PPE usage. Observations revealed that staff did not adhere to Enhanced Barrier Precautions or perform adequate hand hygiene during resident care, increasing the risk of cross-contamination. These deficiencies were confirmed through staff interviews and observations.
The facility failed to follow the prescribed recipe for pureed hot dog meals, as Cook-N used a to-do list instead of the recipe, resulting in a watery consistency and omission of bread. The Culinary Director confirmed the deviation, potentially affecting the nutritional needs of 93 residents.
The facility inaccurately reported anticoagulant use in the MDS for a resident, despite the MAR and Comprehensive Care Plan showing no such medication was administered. The MDS Director confirmed the error.
A facility failed to complete a required PASRR Level II evaluation for a resident with serious mental illness, including Generalized Anxiety Disorder and Major Depressive Disorder. The initial evaluation approved the resident's stay for 180 days, but no follow-up evaluation was conducted after this period. Interviews with staff confirmed the oversight, which was against the facility's policy.
A facility failed to include a resident's chronic obstructive pulmonary disease (COPD) in their Comprehensive Care Plan (CCP), despite it being the primary diagnosis and the resident receiving respiratory therapy. The facility's policy required the inclusion of current medical conditions in the care plan, but this was not adhered to, as confirmed by the MDS Director.
A facility failed to obtain a physician's order for CPAP settings for a resident with chronic respiratory conditions. Despite the resident's need for respiratory care, the electronic medical record lacked specific directions for CPAP use, which was confirmed by the facility administrator.
A facility failed to maintain a medication error rate below 5%, with a 25% error rate observed. A resident received several medications late, contrary to the facility's policy, due to the resident's preference to sleep late. Medications were not administered according to specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. An LPN confirmed the errors in administration timing and medication combinations.
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 Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.
Failure to Assess and Document Change in Condition for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to properly assess a resident for a change in condition, specifically neglecting to perform and document daily assessments and vital signs as required for a Medicare skilled stay. The resident, who had multiple complex diagnoses including a surgically repaired right leg trimalleolar fracture, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure, was admitted from an acute care hospital and later discharged back to a hospital. Documentation revealed that the resident experienced significant weight gain (11.4 pounds in ten days), edema in both legs, and a weak pulse in the right foot, but there was no evidence that these changes were communicated to the medical provider or that appropriate assessments were performed and recorded daily. Review of the resident's progress notes and vital signs showed inconsistent and incomplete documentation. Several nursing and Medicare notes failed to address key aspects of the resident's condition, such as edema, neurovascular status of the right foot, and the presence or condition of the cast or splint. The facility's own policy required daily documentation for skilled Medicare residents, including full assessments and vital signs, but this was not consistently done. The resident's weight record indicated a notable increase, yet there was no documentation of provider notification regarding this change. Interviews with facility staff, including a registered nurse, resident care manager, provisional administrator, and director of nursing, confirmed that the required daily assessments and documentation were not present in the electronic health record. Staff acknowledged that, given the resident's diagnoses, assessments should have included respiratory status, oxygen saturation, edema, and neurovascular checks of the right foot at least daily, but these were not documented. The deficiency was identified through record review and staff interviews, which verified the lack of appropriate assessment and documentation for the resident's change in condition.
Failure to Maintain Complete and Accurate Medical Records for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who was admitted following a right leg trimalleolar fracture repair and had multiple complex diagnoses, including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure. Documentation reviews revealed that required daily assessments and vital signs were not consistently recorded during the resident's Medicare skilled stay. Specifically, there were gaps in documentation regarding the resident's edema, neurovascular status of the right foot, and the presence or condition of the cast or splint, despite orders for regular monitoring and the resident's high-risk medical profile. Progress notes and assessments frequently omitted critical information such as edema, neurovascular checks, and respiratory status, even though the resident experienced significant weight gain and changes in condition. The medical provider was not notified of the resident's weight gain, and there was no evidence of daily skilled documentation as required by facility policy and professional standards. The facility's own policy required daily documentation for Medicare skilled residents, including full assessments and vital signs, which was confirmed by staff interviews as not being met in this case. Interviews with nursing staff, the Resident Care Manager, the Provisional Administrator, and the Director of Nursing confirmed the lack of required documentation and assessments. The absence of daily monitoring and communication with the medical provider regarding significant changes in the resident's condition, such as weight gain and edema, contributed to the incomplete and inaccurate medical record. The deficiency was substantiated by both record review and staff interviews.
Infection Control Deficiencies in Signage and PPE Usage
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of appropriate signage and personal protective equipment (PPE) usage in designated zones. Observations revealed that Yellow Zone signs were not posted at the entrances to the 100 hallway, and [NAME] Zone signs were missing at the entrances of [NAME] and Good Houses. Additionally, passive screening education was not visible at the entrances to [NAME], [NAME], and Good Houses, and staff were observed not wearing masks in these areas. Interviews confirmed that these zones were designated due to positive COVID-19 cases, yet the necessary precautions were not communicated or enforced. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations showed that EBP signs were not present in the rooms of residents with visible urinary catheter bags, and staff did not use appropriate PPE during high-contact care activities. Furthermore, during wound care for Resident 39, staff did not perform hand hygiene or change gloves between wound sites, increasing the risk of cross-contamination. Similar lapses were noted during catheter care for Resident 114, where contaminated gloves were used to obtain cleansing wipes, and hand hygiene was not performed for the recommended duration. Additional deficiencies were observed in the facility's adherence to contact precautions and hand hygiene protocols. Staff entered contact isolation rooms without wearing the required gowns and gloves, and hand hygiene was not performed for the required 20 seconds. These failures were confirmed through interviews with staff and the facility's Infection Preventionist, highlighting a systemic issue in the facility's infection control practices.
Failure to Follow Recipe for Resident Meals
Penalty
Summary
The facility failed to adhere to the prescribed recipe for preparing resident meals, specifically the pureed hot dog meal. During an observation of meal preparation, Cook-N was seen using a to-do list instead of the recipe provided for the meal. Cook-N used water from the pot where hot dogs were boiling and added it to a blender with hot dogs and a liquid thickener, without measuring the water or using the recipe instructions. This resulted in a watery liquid consistency for the pureed hot dogs, and no bread or bun was used as required by the recipe. The Culinary Director confirmed that Cook-N did not prepare any buns, did not measure the water used, and did not have the recipe out during meal preparation. This deviation from the recipe had the potential to affect the nutritional needs of the 93 residents who received food from the kitchen, as the facility census was 139. The failure to follow the recipe could impact the quality and consistency of the meals provided to the residents.
Inaccurate MDS Reporting for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. A review of the Resident Assessment Instrument (RAI) User's Manual indicated that the MDS should accurately reflect the number of days an anticoagulant was received by the resident during a 7-day look-back period. However, for one resident, the MDS inaccurately indicated the use of an anticoagulant, despite the Medication Administration Record (MAR) for September and October showing no use of such medication. Additionally, the resident's Comprehensive Care Plan did not document the use of an anticoagulant for cardiovascular status. An interview with the MDS Director confirmed that the anticoagulant should not have been marked for this resident.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident, as required. The resident, who was admitted to the facility, had a history of serious mental illness, including Generalized Anxiety Disorder, Major Depressive Disorder, and Bipolar Disorder. The initial PASRR Level II evaluation, conducted in March 2024, confirmed the need for nursing facility services and approved the resident's stay for 180 days. However, after the 180-day period elapsed, no additional PASRR Level II evaluation was conducted. Interviews with facility staff, including a social worker and the administrator, confirmed that the PASRR Level II evaluation was due in September 2024 but was not completed. This oversight indicates a failure to adhere to the facility's policy, which mandates that all admissions with a Level II screen follow the recommendations on the PASRR screen. The facility's census at the time was 139, and this deficiency was identified for one of the four sampled residents.
Failure to Include COPD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered Comprehensive Care Plan (CCP) that accurately reflected the care needs of a resident with chronic obstructive pulmonary disease (COPD). The facility's policy required the Interdisciplinary team (IDT) to develop a comprehensive care plan that includes the reason for admission, current medical conditions, and treatments. However, the baseline care plan and the CCP for the resident did not include the diagnosis or interventions for COPD, despite it being the primary diagnosis. The resident had been receiving respiratory therapy four times in the prior seven days, indicating the need for such interventions. This deficiency was confirmed during an interview with the MDS Director, who acknowledged that the COPD diagnosis should have been included in both the baseline care plan and the CCP.
Failure to Obtain Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP) for one of the sampled residents, identified as Resident 14. This deficiency was identified through interviews and record reviews. The facility's policy, dated 1/17/14, requires complete provider orders for therapeutic and skilled services that legally require such orders. However, a review of Resident 14's electronic medical record revealed no physician's order for CPAP settings, despite the resident's need for respiratory care. Resident 14 had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, obstructive sleep apnea, and mild persistent asthma. The resident's physician orders dated 12/12/24 included the use of CPAP/BiPAP at home or hospital settings, but no specific directions for the CPAP settings were provided. An interview with the facility administrator confirmed the absence of a physician's order for the CPAP settings, acknowledging that such an order should have been in place.
Medication Administration Errors Result in 25% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 25% error rate observed during the administration of 28 medications, with 7 errors affecting one resident. The facility's policy on medication administration, dated August 2016, requires medications to be administered according to a set schedule, within one hour before or after the scheduled time, and precisely as ordered. However, during an observation, it was noted that the Medication Administration Record (MAR) for a resident was entirely red, indicating that all morning medications were late. The resident's MAR showed several medications scheduled for 6:00 AM, including Metoprolol Succinate, Levothyroxine, Furosemide, Cephalexin, Potassium chloride, Citalopram, and Amlodipine Besylate. These medications were administered late at 12:25 PM, and not according to the specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. The Medication Aide (MA) admitted to administering the medications late because the resident preferred to sleep late. An LPN confirmed that Levothyroxine and Potassium should not have been given together and that all morning medications were administered late.
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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