Hillcrest Millard Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 13225 Westwood Lane, Omaha, Nebraska 68144
- CMS Provider Number
- 285302
- Inspections on file
- 26
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Hillcrest Millard Llc during CMS and state inspections, most recent first.
Unqualified Dietary Director: The facility failed to ensure a qualified person served as the director of food and nutrition services. Record review showed the Dietary Director had an Associate degree, but there was no evidence of the coursework required for Dietary Manager certification. The Administrator stated the documentation could not be located, and later confirmed no additional proof of the Dietary Director’s qualifications was available. This had the potential to affect all 55 residents.
Food storage, staff hygiene, and kitchen sanitation deficiencies were observed in the dietary department. Raw chicken was thawing in the same pan as a precooked chicken product, unwrapped hot dogs were found in an unclean food prep sink, a dietary staff member was not wearing a beard restraint while preparing and serving food, and multiple cooking equipment surfaces were heavily soiled with dried-on food spills; the DON confirmed the equipment cleaning schedule was not in place.
Surveyors identified that resident rooms, bathrooms, the dining room, and common areas were not maintained in a clean and sanitary condition. Multiple rooms had floors soiled with debris, dried liquids, popcorn, candies, tissues, and small paper pieces, while several toilets and toilet risers had dried brown substances, brown stains, and white creamy substances on the seats, bowls, and surrounding floors. Trash cans were observed full with used briefs, and paper towels and meal trays were left on floors. A white powdery substance under a bed remained over several days with only partial cleaning. Common and dining areas had a large dark carpet stain, a red stain under a dining table, debris on the dining room floor, and a green-stained drain area under an ice machine, all of which were confirmed by the Administrator during a tour.
Failure to report an allegation of potential physical abuse: A resident with intact cognition reported feeling manhandled and said they told the DOR about the incident. The DOR confirmed the report but did not notify the Administrator or DON, and the Administrator confirmed the concern should have been escalated and that no reports of resident mistreatment had been made.
A resident with a displaced R tibia fracture, fracture with routine healing, and HTN was transferred to the hospital for low BP, but the facility had no evidence that the resident or resident representative was given written notice of the reason for the transfer in a manner they could understand. The DON confirmed the lack of written notification at the time of transfer.
Failure to monitor weight loss and meal intakes: A resident with CHF, major depressive disorder, and a recent femur fracture had a 12.07% weight loss in 6 days. The chart showed incomplete re-weigh follow-through and missing meal intake documentation, despite a re-weigh request from the RD and facility policy requiring ongoing weight monitoring and documented meal intakes.
The facility failed to prepare food according to the recipe, potentially affecting all residents. Chef A was observed making Salisbury steak patties without measuring ingredients or following the recipe, and did not weigh the patties to meet the required ounces. The Culinary Director confirmed that this practice could alter the nutritional value of the food.
A long-term care facility failed to respond to call lights in a timely manner, with residents experiencing delays ranging from 20 minutes to over an hour. The issue was exacerbated by staff not carrying or being trained to use cell phone pagers, leading to prolonged wait times for assistance with personal care needs. Despite a performance improvement project, the facility's efforts to address the problem were ineffective.
A resident with a history of pressure ulcers reported a new ulcer, but the facility failed to notify the physician and obtain treatment orders in a timely manner. Despite a scheduled skin assessment, no treatment was documented, and the issue was only addressed after several days. The facility's policy on skin integrity was not followed.
A resident with a history of COPD, respiratory failure, and amputation required supervision and assistance with personal care. The resident sustained multiple skin tears on the right elbow, reportedly from bumping into a handrail. The facility failed to conduct an event report or investigate the causal factors, contrary to its policy on skin integrity and wound care.
The facility did not identify or monitor specific target behaviors for two residents using antidepressant medications. Both residents, diagnosed with Major Depressive Disorder and Anxiety Disorder, had physician orders and care plans lacking specific target behaviors. Generalized behavior monitoring was documented, but no individualized monitoring was conducted, as confirmed by the Regional Nurse Consultant.
The facility failed to maintain a clean and safe environment, with deficiencies observed in four resident rooms. Issues included worn bathroom door frames, stained carpets, damaged floors, and a blood-stained urinary catheter bag left in a bathroom. Staff interviews confirmed these observations, and the Facility Administrator admitted to a lack of housekeeping schedules.
The facility failed to complete comprehensive baseline care plans for two residents within 48 hours of admission. One resident's BCP lacked information on monitoring for hypertension, diabetes, antidepressant use, and pain, while another's omitted details on blood sugar, depression, and pain monitoring. The Regional Nurse Consultant confirmed these omissions, indicating a failure to meet regulatory requirements for initial care.
Two residents in the facility were not provided timely and adequate care for pressure ulcers. One resident, who was cognitively intact, had excoriation and an open wound to the sacrum, but no treatment was recorded until hospital discharge. Another resident, with a history of pressure ulcers, was admitted without a skin assessment, and despite reporting a pressure ulcer and requesting an air mattress, no treatment was documented until days later. Facility staff confirmed that necessary interventions and treatment orders were delayed.
The facility failed to notify the medical provider of abnormal blood sugar levels for a resident with end-stage renal disease and type 2 diabetes. Despite blood sugar readings of 67 and 59 on separate occasions, the medical provider was not informed as required by the facility's policy.
The facility failed to coordinate medication administration with the dialysis schedule for two residents, resulting in multiple missed doses of critical medications. Interviews with staff revealed a lack of clear protocol for managing medication administration for residents who leave early for dialysis, leading to deficiencies in care and documentation.
The facility failed to label insulin pens with the date they were opened for three residents, leading to the disposal of undated pens and the need to obtain new ones from emergency stock. Interviews confirmed that insulin pens are required to be dated when first used.
Unqualified Dietary Director
Penalty
Summary
The facility failed to ensure that a qualified person served as the director of food and nutrition services. During record review, a certificate dated 11/22/10 submitted on 2/26/26 showed the Dietary Director had completed an Associate degree in Applied Science General Education, but it did not provide evidence that the Dietary Director had completed the coursework required for Dietary Manager certification. In an interview on 2/24/26 at 2:01 PM, the Administrator stated the Dietary Director had completed coursework for the Certified Dietary Manager program, but the documentation could not be located at that time. On follow-up interview on 3/3/26 at 9:52 AM, the Administrator confirmed that no additional documentation of the Dietary Director's qualifications was available. This deficiency had the potential to affect all 55 residents of the facility.
Food Storage, Staff Hygiene, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure foods were stored to prevent cross contamination when raw chicken and a precooked chicken patty product were observed thawing together in the same pan on the lower rack of the walk-in refrigerator. During interview, the Dietary Director confirmed that raw chicken should not be thawed together with a precooked chicken product. The report also noted that unwrapped hot dogs were found lying in the bottom of an unclean food preparation sink, and a staff member stated the hot dogs were planned to be removed, placed in a zip lock bag, and frozen for later use before the Dietary Director confirmed the sink was not clean and the hot dogs could not be used. The facility also failed to ensure a dietary staff member wore a beard restraint while preparing and serving breakfast and while cutting meatloaf for lunch service. In addition, the sides and doors of the oven and range, the sides of the grill, and drawers under the fryer were heavily soiled with dried-on food spills, and later observations showed the outsides of the range, oven, fryer, and grill remained soiled. The Dietary Director confirmed the equipment was soiled and reported there was not currently a cleaning schedule, stating the Dietary Director was doing the cleaning. The facility policy dated 12/5/17 stated each piece of equipment would have a cleaning procedure and a weekly schedule posted in the kitchen.
Failure to Maintain Clean and Sanitary Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms, bathrooms, common areas, and the dining room in a clean and sanitary condition, as required by licensure regulations. Surveyors observed multiple resident rooms with visibly soiled floors, dried liquid spills, debris, popcorn, M&M candies, tissues, and small pieces of paper throughout rooms and bathrooms. Several toilets and toilet risers were noted to have dried brown substances, brown splatters, brown stains, and white creamy substances on the seats, bowls, and surrounding floors. Trash receptacles were observed full with used briefs, and paper towels and meal trays were left on floors. In one room, a white powdery substance was scattered on the floor under the head of the bed and remained over several days, only partially cleaned with smears still visible on subsequent observations. Additional observations extended beyond individual rooms to common and dining areas. Surveyors noted a large dark stain on the carpet near seating in a common area, a red stain under a dining room table near the kitchen entrance, and dining room floors soiled with debris throughout. In the Railroad common area, the drain area in the cabinet under the ice machine was soiled with a green stain. These conditions were repeatedly observed over multiple days, and during a facility tour the Administrator confirmed the presence of the soiled floors, stained carpet, stained area under the ice machine, and the soiled toilets and floors in multiple identified rooms.
Failure to Report Allegation of Potential Physical Abuse
Penalty
Summary
The facility failed to report to the State Agency an allegation of potential physical abuse involving one resident. The resident’s MDS dated 1/16/2026 showed a BIMS score of 15, indicating intact cognition. During an interview on 02/18/2026, the resident stated that they felt manhandled and reported having told someone about the incident. In a follow-up interview, the resident stated they told the Director of Recreation about what happened. The Director of Recreation confirmed the resident reported the incident but acknowledged not informing the Administrator or DON. The Administrator confirmed the Director of Recreation should have reported any concern of roughness or mistreating behavior against residents to the Administrator or DON, and also confirmed there had been no reports concerning resident mistreatment.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify the resident or the resident representative in writing, in a manner understood by them, at the time of hospital transfer of the reason for the transfer for Resident 89. Record review showed the resident was admitted on 11/19/2025 with diagnoses including displaced fracture of the right tibia, fracture with routine healing, and hypertension. Progress notes documented that the resident was transferred to the hospital for low blood pressure, but review of the admission record, progress notes, scanned documents, and assessments found no evidence that written notification of the reason for the hospital transfer was provided to the resident or resident representative at the time of transfer. During interview, the DON confirmed there was no evidence that the reason for the hospital transfer was provided in writing at the time of transfer.
Failure to Monitor Weight Loss and Meal Intakes
Penalty
Summary
The facility failed to implement interventions to prevent weight loss for one resident. The resident was admitted with diagnoses including a right femur fracture, chronic diastolic congestive heart failure, and major depressive disorder. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and that the resident ate independently without staff assistance. Facility policy required daily weights for three days on admission, then weekly for four weeks, with re-weighs for significant weight changes and consultation with the Culinary Director or Dietician. The resident’s recorded weights showed 111.0 pounds on 02/10/2026, 111.2 pounds on 02/12/2026, and 97.6 pounds on 02/18/2026, reflecting a 12.07% weight loss in six days. Meal intake documentation showed several entries of 0-25%, 51-75%, and 76-100%, but the EHR did not contain additional weight information, additional meal intake information, or any refusal of weight. A nurse tech assignment sheet dated 02/21/2026 listed a re-weigh request for the resident, but no weight was recorded, and a later assignment sheet dated 02/22/2026 did not list the resident for re-weigh. The RD confirmed the weight change, requested a re-weigh, and stated meal intakes were expected three times daily, but the record did not show three meal intake entries daily for 02/21/2026, 02/22/2026, and 02/23/2026.
Improper Food Preparation Practices
Penalty
Summary
The facility failed to ensure that food was prepared according to the recipe, which could potentially affect all residents consuming meals from the facility kitchen. During an observation, Chef A was seen preparing Salisbury steak patties without measuring the ingredients or following the recipe as written. Chef A mixed unmeasured amounts of various ingredients, including beef base, tomato ketchup, Worcestershire sauce, garlic, liquid eggs, mustard, breadcrumbs, onion powder, chopped onions, bell peppers, and ground beef, and formed them into patties without weighing them to meet the required ounces specified in the recipe. An interview with Chef A confirmed the deviation from the recipe, and a subsequent interview with the Culinary Director acknowledged that using unmeasured items not in the recipe could alter the nutritional value of the food.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for multiple residents, leading to significant delays in providing necessary assistance. Residents, including those with conditions such as Diabetes Mellitus, COPD, and arthritis, reported waiting times ranging from 20 minutes to over an hour for assistance with transfers, toileting, and other personal care needs. These delays were documented through interviews with residents and review of the facility's Device Activity Logs, which recorded numerous instances of prolonged call light response times. Observations and interviews with staff revealed systemic issues contributing to the delays. Nurse aides and other staff members were not consistently carrying cell phone pagers, which are used to alert them to active call lights. Some staff members reported not being trained on the use of these pagers, while others cited technical issues such as dead batteries. The Director of Nursing confirmed that the facility's expectation was for call lights to be answered within 15 minutes, but acknowledged that this standard was not being met. The facility had previously identified call light response times as a problem and implemented a performance improvement project in an attempt to address the issue. However, the Director of Nursing admitted that the project had been ineffective, as evidenced by the continued long response times. The deficiency was further highlighted by grievances from residents and their families, who expressed concerns about the impact of these delays on resident care and safety.
Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician and obtain treatment orders for a pressure ulcer for a resident, identified as Resident 61. The resident was admitted with a history of pressure ulcers and required staff assistance with bed mobility and transfers. Despite being cognitively intact, as indicated by a BIMS score of 14, the resident reported having a pressure ulcer to the buttocks. A scheduled skin assessment was not completed, and no treatment was documented for the pressure ulcer in the Treatment Administration Record. Observations revealed that a dressing was applied to the resident's buttocks, and the pressure ulcer was confirmed by a Licensed Practical Nurse (LPN) during wound care. The facility's Regional Nurse Consultant confirmed that the physician was not notified, and treatment orders were not obtained until several days after the ulcer was reported. The facility's policy on skin integrity and wound care emphasizes the importance of obtaining correct treatment orders and communicating skin integrity issues to the physician, which was not adhered to in this case.
Failure to Investigate Resident's Skin Tears
Penalty
Summary
The facility failed to investigate and identify causal factors for injuries sustained by a resident, leading to a deficiency. The resident, who has a medical history of Chronic Obstructive Pulmonary Disease, respiratory failure, right below the knee amputation, and anxiety, required supervision with transfers and assistance with personal care. An observation revealed a foam island dressing on the resident's right elbow, which the resident reported was due to bumping the elbow on a handrail. Despite the presence of skin tears, the facility did not conduct an event report or investigation into the causal factors. Further observations and record reviews showed that the resident had multiple skin tears on the right elbow, with no measurements or documentation of an investigation into the cause. The facility's policy required event reports and causal factor investigations for skin tears, but this was not followed. The Director of Nursing confirmed that no investigation was conducted, highlighting a lapse in adherence to the facility's skin integrity and wound care policy.
Failure to Monitor Specific Target Behaviors for Antidepressant Use
Penalty
Summary
The facility failed to identify and monitor specific target behaviors for the use of antidepressant medications for two residents, both diagnosed with Major Depressive Disorder and Anxiety Disorder. Resident 58 was admitted with a physician order for Mirtazapine, an antidepressant, but the physician orders and the Comprehensive Care Plan (CCP) did not specify target behaviors to be monitored. The Medication Administration Record (MAR) documented generalized behavior monitoring without individualized target behaviors, and the Electronic Medical Record (EMR) lacked documentation of specific target behaviors and monitoring. Similarly, Resident 73, who was also diagnosed with Major Depressive Disorder and Anxiety Disorder, was prescribed Escitalopram Oxalate. The physician orders and CCP did not identify specific target behaviors for monitoring. The MAR showed generalized behavior monitoring, and the EMR did not document specific target behaviors or monitoring. An interview with the Regional Nurse Consultant confirmed the absence of resident-specific target behaviors and monitoring for both residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed in four resident rooms. In one room, the bathroom door frame had scratches with paint and drywall worn away. Another room had a noticeable carpet stain right inside the resident's room. Additionally, a toilet riser in a different room had its foot pegs sunken into the floor, with the cement around them worn away, and the floor around the toilet was stained. Furthermore, a urinary catheter bag stained with blood was found sitting on a shower chair in a bathroom, which should have been removed. Interviews with facility staff confirmed these observations. The Maintenance Director, who had recently accepted the position after a three-month vacancy, acknowledged the issues with the bathroom door frame, carpet stain, and floor condition. The Regional Nurse Consultant confirmed that the blood-stained urinary catheter bag should not have been left in the room. The Facility Administrator admitted that there had been no housekeeping schedules in place, and they had been overseeing maintenance, laundry, and housekeeping during the absence of a Maintenance Director.
Incomplete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that the baseline care plan (BCP) for two residents was completed with significant medical information within 48 hours of admission. Resident 58, who was admitted with diagnoses including Diabetes Mellitus Type 2, Hypertension, Atrial Fibrillation, and Major Depressive Disorder, had physician orders for monitoring various conditions such as blood glucose levels, antidepressant behavior, and side effects of diuretic medication. However, the BCP for Resident 58 did not include necessary information related to monitoring for hypertension, diabetes, antidepressant use, bleeding risk from anticoagulant use, diuretic medication, or pain monitoring. Similarly, Resident 73, admitted with Diabetes Mellitus Type 2, Hypertension, and Major Depressive Disorder, had physician orders for monitoring blood glucose levels, antidepressant behavior, and pain. The BCP for Resident 73 only identified a fall risk and failed to include information on blood sugar monitoring, depression monitoring, or pain monitoring. The Regional Nurse Consultant confirmed the absence of these critical details in the BCPs for both residents. The deficiency was identified through record reviews and interviews, highlighting the facility's failure to develop comprehensive baseline care plans that address the immediate and significant medical needs of newly admitted residents. This oversight in the BCPs for Residents 58 and 73 indicates a lack of adherence to regulatory requirements for providing initial effective and person-centered quality care.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to identify, evaluate, and provide timely treatment for pressure ulcers in two residents, leading to deficiencies in care. Resident 155, who was cognitively intact and required assistance with mobility and dressing, was admitted with blanchable redness on the buttocks. Despite this, the baseline care plan did not document any skin issues, and a subsequent skin evaluation revealed excoriation and an open wound to the sacrum. However, no treatment was recorded until the resident was discharged to the hospital, indicating a lack of timely intervention. Similarly, Resident 61, who had a history of pressure ulcers and required staff assistance for mobility, was admitted without a skin assessment being conducted. The resident, who was also cognitively intact, reported having a pressure ulcer and requested an air mattress, which was not provided. A Braden Scale assessment indicated a moderate risk for pressure sore development, yet no treatment was documented until several days later when a dressing was observed on the resident's buttocks. The resident's healthcare practitioner later confirmed the presence of a stage 2 pressure ulcer. Interviews with facility staff, including a Regional Nurse Consultant, confirmed that necessary interventions and treatment orders were not obtained in a timely manner for both residents. The facility's policy on skin integrity and wound care was not followed, as evidenced by the lack of documentation and communication regarding the residents' skin conditions and the absence of appropriate preventive measures.
Failure to Notify Medical Provider of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to ensure the medical provider was notified of blood sugar levels outside of the specified parameters for one resident. Resident 4, who had diagnoses of end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus without complications, had orders for blood glucose monitoring four times per day with instructions to notify the physician if blood sugars were less than 70 or greater than 400. On two occasions, the resident's blood sugar levels were outside these parameters, but the medical provider was not notified as required by the facility's policy and the resident's care plan. On 4/8/24, Resident 4's blood sugar was recorded at 67, and on 4/4/24, it was recorded at 59. In both instances, the resident was given a snack, and the blood sugar levels were subsequently rechecked and found to be within normal limits. However, there was no documentation indicating that the medical provider was informed of these abnormal blood sugar levels. The Director of Nursing confirmed the lack of notification during an interview, acknowledging that the medical provider should have been notified according to the facility's policy.
Failure to Coordinate Medication Administration with Dialysis Schedule
Penalty
Summary
The facility failed to ensure the coordination of medication administration with the dialysis schedule for two residents requiring dialysis. Resident 2, who had diagnoses including pneumonia, type 2 diabetes mellitus, and end-stage renal disease, had multiple instances where medications were not administered due to being out of the facility for dialysis. Specifically, medications such as Amlodipine Besylate, Aspirin, Calcitrate Plus D, Cholecalciferol, Glargine insulin, Potassium Chloride ER, Toresemide, Valsartan, Acidophilus, Amoxicillin-Pot Clavulanate, Carvedilol, Entresto, Insulin Aspart, and sliding scale insulin were not given on several occasions. Interviews with staff revealed that there was no clear protocol for administering medications to residents who leave early for dialysis, leading to missed doses and lack of proper documentation in the care plan and MAR (Medication Administration Record). Resident 2's blood sugar was also not checked before leaving for dialysis, and insulin was not administered as scheduled, resulting in a high blood sugar level upon return from dialysis. Similarly, Resident 4, who had diagnoses including end-stage renal disease and type 2 diabetes mellitus, also missed several doses of medications due to being out of the facility for dialysis. Medications such as CertaVite Senior Oral Tablet, Sertraline, Tracrolimus, Calcium Citrate plus D, Cholestyramine, Medroxyprogesterone, Mycophenolate sodium, Nystatin Powder, Aspart insulin, and Sildenafil Citrate were not administered on multiple occasions. Interviews with staff indicated that there was no established procedure for administering medications to residents who leave early for dialysis, leading to missed doses and lack of proper documentation in the care plan and MAR. Resident 4's blood sugar was also not checked before leaving for dialysis, and insulin was not administered as scheduled. The facility's policy on dialysis monitoring, dated 1/1/2023, stated that the facility would coordinate care with the dialysis provider to develop an appropriate plan of care, including any recommended medication schedule changes. However, the facility failed to implement this policy effectively, resulting in missed medication doses and inadequate care for residents requiring dialysis. Interviews with the Director of Nursing and other staff members revealed that there was no consistent approach to managing medication administration for residents going to dialysis, leading to deficiencies in care and documentation.
Failure to Label Insulin Pens with Date Opened
Penalty
Summary
The facility failed to ensure that insulin pens were labeled with the date they were opened for three residents. During observations, it was noted that Resident 2's Aspart and Glargine insulin pens were not dated with the date opened. LPN A had to obtain a new Aspart insulin pen from the facility's emergency medication stock for administration to Resident 2. Similarly, Resident 3's Glargine insulin pen was also found to be undated, and a new pen had to be obtained from the emergency stock. Additionally, Resident 3's Aspart pen was not labeled with the resident's name or the date it was opened, leading to its disposal and replacement with a new pen from the medication refrigerator. Resident 4's insulin pen was also found to be undated and was discarded accordingly. Interviews with LPN A and RN Consultants E and F confirmed that insulin pens are required to be dated when first used. The review of the Medication Administration Records (MAR) for Residents 2, 3, and 4 indicated that insulin pens should be discarded 28 days after initial use. The facility's failure to label the insulin pens with the date they were opened led to the unnecessary disposal of medication and potential risks to the residents' health management.
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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