Falls City Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Falls City, Nebraska.
- Location
- 2800 Towle Street, Falls City, Nebraska 68355
- CMS Provider Number
- 285114
- Inspections on file
- 19
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Falls City Care Center during CMS and state inspections, most recent first.
The facility did not maintain the minimum required number of nurse aides per shift, resulting in prolonged call light response times and missed resident care, such as regular bathing for a resident with a wound. Staff and leadership confirmed that inadequate staffing led to delays in answering call lights and providing essential care, with no formal tracking or action plans in place to address these issues.
Two residents did not receive bathing according to their preferences, with one resident not having a bath for at least a month and another unable to recall their last bath, both due to staff shortages and lack of proper documentation. Care plans lacked bathing interventions or preference assessments, and staff confirmed that regular weekly baths were not consistently provided. The facility did not have a formal bathing policy, and documentation of baths and refusals was incomplete.
A resident was not given the required SNF ABN and NOMNC at least two days before the end of Medicare Part A coverage, as both notices were signed on the last covered day instead. The Social Services Director confirmed the notices were not provided within the required timeframe.
Two residents' care plans did not address all required needs: one resident's plan omitted prescribed antidepressant medications despite a diagnosis of major depressive disorder, and another resident's plan failed to include discharge planning even though a discharge order was present. The DON and SSD confirmed these omissions during interviews.
A resident with a history of falls and moderate cognitive impairment experienced a fall and was sent to the ER, but the facility did not update the Comprehensive Care Plan (CCP) with new fall interventions as required by policy. The DON confirmed that no new interventions were added to the CCP following the incident.
A resident who was dependent for ADLs and had a pressure ulcer was not repositioned or provided incontinence care as required by their care plan and facility policy. Observations showed the resident remained in the same position for extended periods and wore heavily saturated briefs, with staff confirming lapses in care and the DON acknowledging the lack of a wound care policy.
Staff failed to follow infection control protocols during wound care for a resident with a stage 2 pressure ulcer, including not wearing a gown, not changing gloves, and not performing hand hygiene between tasks. The LPN used the same gloves for wound care and peri care, and exposed the wound to a soiled brief, contrary to facility policy and best practices.
The facility failed to ensure sufficient staffing related to 8-hour daily RN coverage, affecting all residents. A review of staffing schedules revealed no 8-hour RN coverage on multiple days and only partial coverage on others. The facility Administrator confirmed these findings, and a review of the Facility Assessment Tool highlighted the federal requirement for 8-hour daily RN coverage.
The facility failed to ensure that five nursing assistants completed the mandatory 12 hours of continuing education annually. Record reviews and interviews confirmed that the NAs did not meet the required education hours, and one NA was unaware of the requirement. This deficiency had the potential to affect all 52 residents in the facility.
A resident with multiple medical conditions, including diabetes and bone cancer, did not receive wound care as ordered by the physician. An LPN misread the order and failed to apply Betadine to the blistered areas on the resident's lower extremities, leading to a deficiency in care.
The facility failed to follow infection control measures during wound care, nebulizer kit cleaning, and catheter care. An LPN did not perform hand hygiene between glove changes and used a contaminated dressing pad, while another resident's nebulizer kit was not cleaned after each use. Additionally, a nurse aide did not perform hand hygiene between glove changes during catheter care.
Failure to Maintain Minimum Nurse Aide Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide the minimum required number of nurse aides on each shift as outlined in its own facility assessment, which specified a minimum of three nurse aides per shift. Staffing records revealed that on several occasions, including the entire month of May and into June, only two nurse aides were scheduled and present on night shifts, and on at least one day shift, there were no nurse aides present. This staffing shortfall resulted in prolonged call light response times, with multiple documented instances of call lights remaining unanswered for over 30 minutes, and in some cases, exceeding an hour. Observations and interviews confirmed that call lights were not answered within the facility's expected timeframe of 5-15 minutes, and staff acknowledged that the lack of adequate staffing contributed to these delays. Additionally, the insufficient staffing impacted resident care, as evidenced by a resident who did not receive weekly baths as preferred and required, with documentation and interviews confirming that the resident had not been bathed for at least a month. The resident also had a wound on the leg and was informed by staff that bathing would help, but the lack of available staff prevented this care from being provided. Staff interviews further corroborated that baths were not being completed regularly due to staffing shortages. The Director of Nursing confirmed that the facility did not track call light response times or have action plans to address the delays, and both the Administrator and DON acknowledged that the staffing levels and response times were not acceptable.
Failure to Provide Bathing per Resident Preference Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to honor and facilitate resident self-determination regarding bathing preferences for two residents. For one resident with polyneuropathy and restless leg syndrome, who was cognitively intact and required maximum assistance for bathing, there were no care plan interventions or social service assessments addressing bathing preferences. Bathing logs and schedules showed infrequent baths, and the resident confirmed not having a bath for at least a month, attributing this to staff shortages. Staff interviews corroborated that baths were not being provided weekly as expected, and the Director of Nursing confirmed that bath logs were discarded after documentation in the electronic medical record. The facility also lacked a specific bathing policy. Another resident, who required supervision or touching assistance with activities of daily living and had a moderate cognitive impairment, was observed with oily hair and could not recall the last time they had a bath or washed their hair. Bathing logs indicated only one or two baths per month, and there was no documentation of bed baths or refusals in the progress notes. The resident's care plan did not include bathing interventions or preferences, and staff interviews confirmed that there was not a daily bath aide scheduled and that staffing shortages impacted the ability to provide regular baths. Throughout the review, it was confirmed by multiple staff, including the Administrator and DON, that the facility did not have a formal bathing policy and that resident preferences for bathing were not consistently assessed or care planned. Documentation of bathing and refusals was inconsistent, and staffing limitations were cited as a reason for not meeting the expected frequency of weekly baths based on resident preferences.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of Medicare Part A covered services. Record review showed that the resident's last covered day for Medicare Part A was 04/30/2025, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted. Both the SNF ABN and NOMNC were signed electronically by the resident on the last covered day, with no date recorded for the Social Services Director's initials. An interview with the Social Services Director confirmed that the required notices were not provided within the mandated timeframe.
Care Plans Lacked Psychotropic Medication and Discharge Planning
Penalty
Summary
The facility failed to ensure that individualized care plans addressed all of the residents' needs, specifically omitting psychotropic medication management and discharge planning for two residents. For one resident with multiple diagnoses including major depressive disorder, hypertension, diabetes, and acute kidney failure, the care plan did not include the prescribed antidepressant medications, despite physician orders for Celexa and Remeron. The Director of Nursing confirmed that medications were not addressed in the care plan as required. For another resident with diagnoses such as hypertension, low back pain, muscle weakness, and unsteadiness, the care plan did not include the resident's discharge plan, even though there was a physician order for discharge to an assisted living facility. The Social Service Director confirmed that the discharge plan was not documented in the care plan. These omissions were identified through record review and staff interviews, and were not in accordance with the facility's care planning policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the Comprehensive Care Plan (CCP) to accurately reflect new fall interventions for a resident following a fall incident. According to the facility's Fall Prevention and Response Policy, the care plan should be updated with any new or revised fall interventions after a fall occurs. Record review showed that the resident, who had a history of falls and moderate cognitive impairment, experienced a fall on 5/7/2025, resulting in being sent to the emergency room. Despite this incident, no new fall interventions were identified or added to the resident's CCP. Further review of the resident's records indicated that the most recent fall intervention documented in the CCP was dated nearly a year prior to the incident, and the fall prevention focus had not been updated since before the fall. The Director of Nursing confirmed during an interview that the CCP lacked new fall interventions after the recent fall and acknowledged that updates should have been made in accordance with facility policy.
Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely repositioning and incontinence care for a resident who was dependent on staff for activities of daily living. Multiple observations over several days showed the resident lying in bed in the same position, with no evidence of being repositioned or having incontinence care provided for extended periods, sometimes up to five hours. Staff interviews confirmed that the resident was not checked, changed, or repositioned during these intervals, despite facility policy and the resident's care plan requiring repositioning at least every two hours and peri care after each incontinence episode. The resident in question had a history of cerebral infarction, dementia, mood disturbance, and anxiety, and was assessed as severely cognitively impaired and fully dependent for ADLs. The resident also had a pressure ulcer related to immobility and was at risk for further skin breakdown, as indicated by a Braden Scale score of 13 and frequent skin moisture. Observations documented the resident wearing heavily saturated briefs with foul odor, and staff acknowledged that the care provided did not meet the required frequency. The Director of Nursing confirmed the expectation for two-hourly checks and repositioning, and that refusals of care should be documented, but also stated there was no facility wound care policy.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection prevention and control protocols during wound care for a resident. Specifically, an LPN did not don a gown prior to providing wound treatment, despite facility policy requiring the use of gowns and gloves for high-contact care activities such as wound care under Enhanced Barrier Precautions. The LPN also failed to change gloves and perform hand hygiene at appropriate times during the procedure, including after cleaning stool from the resident's buttocks and peri area, and before handling clean dressings and briefs. The resident involved had significant medical complexities, including Type 2 Diabetes Mellitus, hypothyroidism, bilateral above-knee amputations, mild cognitive impairment, peripheral vascular disease, and was dependent on staff for all care. The resident had a stage 2 pressure ulcer on the left buttock, which was acquired in the facility, and was at risk for further skin breakdown. The care plan required regular turning and repositioning, as well as adherence to wound care protocols to prevent infection and promote healing. During the observed wound care, the LPN removed a soiled brief and dressing, exposed the wound to a dirty brief, and used the same gloves for multiple tasks, including wound cleaning, dressing application, and peri care, without changing gloves or performing hand hygiene between steps. Both the LPN providing care and another LPN present confirmed in interviews that proper gown use and hand hygiene protocols were not followed, and that the wound should not have been exposed until after peri care and cleaning were completed.
Failure to Ensure 8-Hour Daily RN Coverage
Penalty
Summary
The facility failed to ensure sufficient staffing related to 8-hour daily RN coverage, which had the potential to affect all residents who reside in the facility. A record review of the staffing schedules for 5/1/24 through 5/20/24 revealed no 8-hour RN coverage on 5/12/24 and 5/16/24, and only 4 hours of RN coverage on 5/12/24. An interview with the facility Administrator on 05/23/24 confirmed that after pulling timecards, it was found that the facility did not have RN coverage on 5/6/24 and 5/12/24, and only 4 hours of RN coverage on 5/11/24. A record review of the Facility Assessment Tool dated 6/5/23 revealed that federal law requires nursing homes to have sufficient staff to meet the needs of residents, including the use of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Failure to Ensure Mandatory Continuing Education for Nursing Assistants
Penalty
Summary
The facility failed to ensure that five nursing assistants (NAs) completed the mandatory 12 hours of continuing education annually. A record review revealed that NA-K completed 6.7 hours, NA-L completed 0.50 hours, NA-M completed 5.05 hours, NA-N completed 0.50 hours, and NA-O completed 1.75 hours of continuing education in the last 12 months. This deficiency was confirmed by the facility Administrator during an interview, who acknowledged that the NAs had not met the required education hours despite being employed for more than one year. Additionally, an interview with NA-N revealed that the NA was unaware of the requirement for 12 hours of continuing education annually. The facility's Facility Assessment Tool, dated 6/5/23, outlined the necessity for NAs to complete specific training, including abuse prevention, dementia care, and at least 12 hours of continuing education per year. The failure to meet these training requirements had the potential to affect all residents in the facility, which had a census of 52 at the time of the report.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident 47's wound care was completed as ordered by the provider. Resident 47, who was moderately cognitively impaired and had multiple medical diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, bone cancer, and lung disorders, was observed to have fluid-filled blisters on both lower extremities. The physician's orders specified the use of Betadine Paint on the blistered areas, followed by covering with Telfa and ABD dressings twice daily, and applying Triple Antibiotic Ointment to any ulcerated areas after Betadine application. However, during an observation, an LPN applied Povidone-Iodine swab stick only to the front of the resident's lower legs and did not paint the blistered areas on the sides as required by the physician's orders. In an interview, the LPN confirmed that they had misread the order and thought it was only necessary to paint the open area, not the blisters. As a result, the blisters on Resident 47's lower extremities were not treated with Betadine as prescribed. This failure to follow the physician's orders for wound care represents a deficiency in the facility's care practices for Resident 47.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure all infection control measures were followed during wound care for one resident, proper cleaning of a nebulizer kit and mask for another resident, and hand hygiene between glove changes during catheter care for a third resident. Specifically, an LPN did not perform hand hygiene between glove changes and used a dressing pad that had fallen on the carpeted floor during wound care for a resident with multiple medical conditions including Type 2 Diabetes Mellitus and bone cancer. The resident's care plan did not reflect the presence of wounds, and the LPN confirmed the errors in hand hygiene and the use of the contaminated dressing pad during an interview. Another resident, who was cognitively aware and had a history of COPD and lung cancer, did not have their nebulizer kit and mask cleaned after each use as required by the facility's policy. Observations revealed residual fluid and facial oils on the nebulizer kit and mask on multiple occasions, and the resident confirmed that staff did not clean the equipment after each treatment. An LPN also confirmed that the nebulizer kit should have been rinsed after each use but was not. Additionally, a nurse aide did not perform hand hygiene between glove changes while providing catheter care for a resident with acute congestive heart failure. The nurse aide confirmed the lapse in hand hygiene during an interview, and the facility's Director of Nursing also confirmed that hand hygiene should have been performed between glove changes. The facility's catheter care policy clearly outlined the steps for hand hygiene, which were not followed in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
