Hillcrest Shadow Lake Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Papillion, Nebraska.
- Location
- 1507 E Gold Coast Road, Papillion, Nebraska 68046
- CMS Provider Number
- 28E299
- Inspections on file
- 23
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hillcrest Shadow Lake Llc during CMS and state inspections, most recent first.
Two residents at risk for pressure ulcers did not receive consistent prevention, assessment, or wound management in accordance with facility policy. One resident with quadriplegia and moderate cognitive impairment had no documented weekly skin evaluations for a two-week period after admission, did not receive pressure-reducing surfaces until after a stage 2 buttock ulcer developed, and later developed additional pressure ulcers without timely measurements or new care plan interventions; this resident’s air mattress was repeatedly set for a much higher weight than recorded, with no practitioner order for the mattress or its settings. Another resident, cognitively intact but with incontinence and decreased mobility, had a history of heel and foot ulcers and was care planned for weekly skin monitoring, yet went 11 days without a documented weekly skin evaluation before hospital transfer; hospital records then identified a full-thickness posterior thigh wound with purulent, malodorous drainage and additional pressure ulcers to the heel and top of the foot that were not fully captured in facility documentation. Staff interviews confirmed missed weekly skin evaluations, lack of identified causal factors for certain wounds, and uncertainty about whether treatments were in place prior to hospital transfer.
A resident with bilateral venous ulcers, cognitively intact but dependent for most ADLs, had a care plan and facility policy requiring initial and weekly wound measurements (length, width, depth) and ongoing documentation of wound status. However, over several months, the EHR contained no wound assessments or measurements, and progress notes lacked wound evaluations. The resident’s legs were observed wrapped in gauze, and the ADON and DON acknowledged that wound assessments were being done only at an outside vascular clinic and that the facility neither obtained wound descriptions or measurements from those visits nor performed its own weekly evaluations, despite the Director of Compliance confirming that weekly in-house monitoring was required.
Surveyors found that three residents receiving diuretic medications for conditions such as chronic kidney disease and congestive heart failure did not have appropriate monitoring in place. Despite care plans referencing the need for lab work and symptom monitoring, there were no orders or documentation of monitoring, and staff confirmed the absence of such orders. The DON indicated that pharmacy recommendations are made, but monitoring is only implemented if ordered by the provider.
Staff did not follow hand hygiene and gloving protocols during meal service, with a nurse aide delivering multiple meal trays to different rooms without removing gloves or performing hand hygiene between rooms. The aide also carried a tray of uncovered cinnamon apples into resident rooms, contrary to facility policy. This affected 44 residents who received food from the tray cart.
A resident with cognitive intactness and multiple medical conditions alleged being physically abused by staff, including being grabbed and forced to take a shot. The facility failed to notify the State Agency of this abuse allegation within the required timeframe, only reporting it after a significant delay.
Staff did not measure and record pulse rates before and after nebulizer treatments for a resident with heart and kidney conditions, despite facility procedures requiring this monitoring. Instead, the resident's pulse was only recorded once daily during the treatment period, and the DON confirmed the expected process was not followed.
Staff failed to perform hand hygiene before and after glove use during medication administration for two residents. A medication aide and an RN both administered medications without using hand sanitizer or washing hands as required by facility policy, despite being aware of the protocol.
A resident with Alzheimer's disease was not properly positioned in their wheelchair, leading to a fall and injury. The care plan required the resident to be in a tilt position except during meals, but observations showed the resident's legs were unsupported, causing them to dangle. Staff interviews revealed that wheelchair pedals were removed, contradicting the need for leg support.
Two residents were transferred using methods not aligned with their care plans, which specified the use of a Hoyer lift with two-person assistance. Despite the care plans, staff used alternative transfer methods, such as a gait belt and sit-to-stand lift, based on discretion and resident behavior. This discrepancy was confirmed by a Physical Therapy Assistant and acknowledged by the Director of Nursing.
Two instances of resident safety lapses were identified. Resident 48, with dementia and seizure disorder, fell and sustained a head injury requiring stitches during a bath due to an unsecured safety belt and insufficient supervision. Resident 94, with cognitive deficits and hemiplegia post-cerebral infarction, suffered a left femur fracture after a fall in the dining area. Despite a fall prevention care plan, interventions like non-slip socks and staff assistance were inconsistently applied, leading to multiple falls.
The facility failed to maintain proper hand hygiene during food preparation, ensure staff did not touch drinking surfaces while serving beverages, and maintain cleanliness in the main kitchen and Evergreen/Memory unit kitchen. Additionally, items in the Evergreen/Memory Care unit refrigerator and freezer were not labeled and dated as required.
The facility failed to ensure staff consistently wore masks correctly, performed hand hygiene, and followed proper infection control procedures. Multiple instances were observed where staff did not wear masks properly, did not perform hand hygiene between resident contacts, and did not follow proper procedures during medication administration and catheter care. These deficiencies were confirmed by staff interviews.
The facility staff failed to ensure the venting system was functional in four rooms, affecting seven residents, and did not maintain the Heating and Cooling unit in good repair, as evidenced by a missing front cover in one room. These issues were observed and confirmed by the Maintenance Director.
The facility staff failed to provide rationale for the continued use of an antianxiety medication for three residents and did not complete behavioral monitoring for one resident. Additionally, the facility did not document non-pharmacological interventions before administering Lorazepam to another resident and failed to document the rationale for extending PRN orders beyond 14 days.
The facility staff failed to ensure proper labeling and security of medications in the memory care unit. Unlabeled medications were found in a medication cart, and the medication refrigerator was unsecured. Additionally, a resident's blood pressure medication was left unsupervised on top of the medication cart, and the cart was found unlocked with Metoprolol tablets on top. Staff confirmed these actions did not meet facility expectations and posed a danger to residents.
The facility staff failed to protect four residents from abuse. One resident reported being verbally abused by an NA, causing significant distress. Another LPN reported that an NA was verbally inappropriate and rough with three residents. The facility did not take immediate protective actions, leaving the residents unprotected during the delay.
The facility failed to ensure competencies in insulin administration for five CMAs and three licensed nurses, affecting 13 residents. Interviews and record reviews revealed that these staff members had not been assessed for competency, despite facility policy requiring such assessments.
The facility failed to update the care plan for a resident with severe cognitive impairment and multiple diagnoses, including COPD, to reflect a new oxygen order. Despite a verbal order to increase oxygen to 5 l/m, the care plan still indicated 2 l/m continuously.
The facility staff failed to follow practitioners' orders for medication administration for a resident with multiple diagnoses, including Diabetes, and failed to implement treatment orders for another resident with skin impairment risks. Observations and interviews confirmed the deficiencies.
The facility failed to notify the provider when a resident's oxygen level dropped below the ordered parameter. The resident, with COPD and other respiratory issues, had multiple instances of oxygen saturation below 90%, but the provider was not informed until much later, resulting in a delayed adjustment of oxygen levels.
The facility staff failed to evaluate and implement interventions for a resident with PTSD. Observations and interviews revealed a lack of awareness and understanding of the resident's diagnosis and care plan, including the use of male caregivers despite the care plan's directive for female caregivers.
Failure to Provide Timely Pressure Ulcer Prevention, Assessment, and Wound Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and wound care for two residents, despite facility policy requiring comprehensive skin assessments, staging by licensed staff, and routine wound measurements documented on wound progress forms. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 states that all team members are responsible for preventing and treating altered skin integrity, that wounds must be measured in three dimensions upon identification and at admission, and that measurements must be completed routinely and documented for all impaired skin integrity issues. For Resident 3, who was admitted with intact skin, quadriplegia, multiple sclerosis, moderate cognitive impairment, total dependence for ADLs, and a Braden score of 13 indicating moderate risk, the baseline care plan identified risk for skin breakdown and called for repositioning, nutritional support, and notification of the PCP for skin changes, but did not initially include pressure-reducing surfaces for the bed or wheelchair. For Resident 3, the record showed no weekly skin evaluation between admission and 05-23-2025, a 14‑day gap, despite the resident’s identified risk. Interventions for pressure ulcer prevention, including a pressure reduction mattress and wheelchair cushion, were not implemented until 05-21-2025, after a stage 2 pressure ulcer to the left buttock had already developed. The initial wound evaluation for this ulcer was not conducted, and early documentation lacked wound measurements and descriptions. Progress notes later documented a stage 2 pressure ulcer to the left buttock and an additional pressure ulcer to the left heel, again without measurements. By late July, documentation showed a new stage 3 pressure ulcer to the right buttock with full-thickness skin loss and tunneling, with measurements recorded on 07-28-2025, but the comprehensive care plan contained no new interventions specific to this stage 3 ulcer. During observation of wound care, surveyors noted a right gluteal wound with tunneling and drainage, and the ADON acknowledged that causal factors for the right buttock ulcer had not been identified. The DON confirmed that Resident 3 had two separate pressure ulcers, one on each buttock. Additional deficiencies for Resident 3 involved the use and management of an air mattress. The Protekt Aire 4000DX/5000DX operating manual indicates that mattress settings should be adjusted according to the user’s weight or a health care professional’s suggestion. Resident 3’s most recent recorded weight was 178 lbs, but observations on multiple occasions showed the air mattress set at 240 lbs and later at 270 lbs. There was no physician order in the electronic health record for the air mattress or its settings. The DON confirmed that setting the mattress for a much higher weight would increase pressure for a lighter resident, and the Director of Compliance confirmed that air mattresses should be set according to the resident’s weight or practitioner-ordered settings. For Resident 1, who was cognitively intact, required assistance with mobility and ADLs, was always incontinent of bladder, frequently incontinent of bowel, at risk for pressure ulcers, and had a Braden score of 13, the comprehensive care plan identified risk for impaired skin integrity due to incontinence, decreased mobility, Braden risk, prior MASD, and excoriation to the buttocks. The care plan included interventions such as repositioning, nutrition and hydration support, keeping skin clean and dry, weekly monitoring and documentation of skin injuries with measurements, and use of pressure reduction mattress and wheelchair cushion. On 04-22-2025, an unstageable pressure ulcer to the right heel was documented, with treatment orders and a protective boot, and the care plan was updated to include heel protectors and treatment as ordered. Subsequent progress notes in December documented a stage 2 pressure ulcer to the right heel with serial measurements and a large fluid-filled blister on the top of the right foot, which later opened and increased in size. A weekly skin evaluation on 12-04-2025 noted a diabetic foot ulcer and buttock redness, but there was no weekly skin evaluation documented on or around 12-11-2025, resulting in an 11‑day gap between 12-04-2025 and the resident’s transfer to the hospital. Hospital records for Resident 1 revealed additional wounds that had not been fully documented in the facility’s records. The emergency department noted a wound to the right posterior thigh with surrounding redness, foul rotting fruit odor, mild drainage, and additional skin breakdown to the right posterior heel and a large fluid-filled blister on the lateral right foot. The hospital wound ostomy care consult described three wounds: a full-thickness wound of unknown etiology on the right posterior thigh with boggy center, dark purple/maroon discoloration, slough, eschar, indurated and reddened surrounding skin, and moderate purulent, malodorous exudate; a chronic stage 2 pressure ulcer on the right posterior heel; and a stage 2 pressure ulcer on the top of the right foot. A hospital progress note identified a soft tissue infection of the pressure ulcer to the hip, and an operative note documented surgical debridement of the right posterior thigh wound with removal of necrotic skin and exposure of thigh fascia. Facility staff interviews indicated that a NA was aware of a skin issue to the right thigh near the buttocks covered with a bandage before hospital transfer, and an RN knew the resident was starting to get a pressure ulcer to the thigh but could not recall whether a treatment was in place. The DON confirmed that a weekly skin evaluation should have been completed on 12-11-2025 and that it was not, and the ADON acknowledged that causal factors for the wound on the top of the right foot had not been identified. The Director of Compliance confirmed that weekly skin evaluations were required and that the facility could not provide additional information regarding the wounds for either resident prior to survey exit.
Failure to Monitor and Document Venous Ulcers Between Vascular Clinic Visits
Penalty
Summary
The facility failed to monitor and document vascular wounds for a resident with venous ulcers to both lower extremities, contrary to its own wound care policy and the resident’s comprehensive care plan. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy required that wounds be measured in three dimensions (length, width, depth) upon identification and routinely thereafter, with documentation on a wound progress assessment form for all impaired skin integrity issues. The resident’s MDS showed the resident was cognitively intact, dependent for most ADLs, and had two venous and/or arterial wounds. The comprehensive care plan identified venous ulcers on both lower extremities, with the right worse than the left, and included interventions to monitor and document the location, size, and treatment of any skin injury or change when noted and then weekly until healed, and to report abnormalities or failure to heal to the physician. Despite these requirements, record review of the resident’s EHR assessments and progress notes over several months revealed no wound evaluations with descriptions or measurements of the venous ulcers. Documents from the vascular clinic visits contained treatment orders and follow-up dates but did not include wound descriptions or measurements. The resident reported going to a vascular clinic for management of venous ulcers, and observation showed both lower legs wrapped with gauze bandages from ankles to knees. The ADON stated the resident’s venous ulcers were measured and assessed at the vascular clinic and confirmed that this was why there were no wound evaluations in the facility’s EHR. The DON confirmed the facility had not obtained wound descriptions or measurements from the vascular clinic visits, and the Director of Compliance confirmed the venous ulcers should have been evaluated weekly and monitored between clinic appointments, but staff were unable to provide additional wound information before survey exit.
Failure to Monitor Residents on Diuretic Therapy
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate monitoring for residents receiving diuretic medications. For one resident with chronic kidney disease and an order for Furosemide, there were no laboratory orders or care plan interventions in place to monitor the effects of the medication. This was confirmed by a registered nurse who acknowledged the absence of monitoring orders. Another resident with chronic kidney disease and congestive heart failure was prescribed Torsemide, but there were no orders or documentation for monitoring the medication's effects, and the resident reported not having any blood tests while in the facility. The care plan referenced monitoring lab work and symptoms of hypokalemia, but no pharmacy recommendations or orders for monitoring were present. A third resident with congestive heart failure was prescribed Spironolactone, and while the care plan included interventions to monitor for hypokalemia and other lab values, there was no documentation in the medication administration record indicating that monitoring occurred. The registered nurse confirmed the lack of monitoring orders. The Director of Nursing stated that pharmacy recommendations for monitoring are made to the primary care provider, but it is ultimately up to the provider to order such monitoring. These findings demonstrate a lack of consistent monitoring for residents on diuretic therapy, as required by facility policy and regulatory standards.
Failure to Follow Hand Hygiene and Food Handling Protocols During Meal Service
Penalty
Summary
Facility staff failed to follow proper hand hygiene and gloving procedures during meal service, as observed during continuous monitoring in the assisted dining room and Evergreen Hall. Specifically, a nurse aide (NA-K) was seen delivering meal trays to multiple resident rooms without removing gloves or performing hand hygiene between rooms, contrary to facility policy. NA-K also handled a tray of sliced cinnamon apples, some of which were uncovered, and carried the entire tray into resident rooms, increasing the risk of potential contamination. These actions were confirmed by NA-K during an interview, acknowledging the failure to doff gloves and perform hand hygiene as required. Record review of the facility's policy on meal tray delivery and infection control outlined the necessity for staff to apply hand sanitizer after each tray delivery and to repeat handwashing procedures upon returning to the kitchen. Despite these policies, the observed practices did not align with the established protocols. The Clinical Care Coordinator confirmed that 44 residents received food from the affected tray cart during the period in question. The facility census at the time was 103 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe for one resident. According to facility policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported to the appropriate agencies not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, a resident with a history of fibromyalgia, depressive episodes, cognitive deficits following a stroke, and insomnia, who was assessed as cognitively intact, reported being grabbed, held down, and forced to take a shot at the end of March. The resident also reported to police that she had been beaten by a nurse, tied up, and had blood drawn. Facility documentation showed that the Administrator or DON were notified of the allegation on April 1, but there was no evidence that the State Agency was notified at that time. The surveyor was made aware of the allegation during an interview with the resident, who displayed a purple discolored area on her right upper arm. The facility staff did not report the allegation to the State Agency until April 16, well after the required reporting timeframe. The delay in reporting was confirmed by the Administrator, who acknowledged that the allegation was not reported as required when it was initially made by the resident.
Failure to Record Pulse Before and After Nebulizer Treatments
Penalty
Summary
Facility staff failed to measure and record pulse rates before and after administering nebulizer treatments for a resident with diagnoses including congestive heart failure, atrial fibrillation, and chronic kidney disease. The facility's Nebulizer Competency procedure required staff to take the resident's pulse prior to and at the completion of each nebulizer treatment. However, record review showed that the resident's pulse was only measured and recorded once daily, rather than before and after each treatment, during the period the resident was receiving albuterol sulfate inhalation nebulization. The DON confirmed that there was no facility policy for nebulized medication administration and that staff were expected to follow the Nebulizer Competency, which was not done in this case.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration for two residents. In one instance, a medication aide donned gloves to assist a resident with sitting up, administered medication and nasal spray, applied powder, and assisted the resident to lie down. The aide then removed gloves and exited the room without performing hand hygiene before donning gloves, after removing them, or upon leaving the room. The aide later confirmed awareness of the hand hygiene requirement but stated they forgot to perform it. In another instance, a registered nurse donned gloves to administer eye drops to a resident without performing hand hygiene beforehand. The nurse also confirmed knowledge of the hand hygiene protocol but did not follow it. Review of the facility's hand hygiene policy indicated that staff are required to use hand sanitizer or wash hands before and after glove use, and immediately before and after patient contact.
Failure to Ensure Proper Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure proper positioning to maintain body alignment for a resident diagnosed with Alzheimer's disease, who was at risk for falls. The resident's care plan included an intervention for staff to ensure the resident was in a tilt position in their wheelchair at all times, except during meals. However, observations revealed that the resident was often seated in a wheelchair without leg rests or foot pedals, causing their legs to dangle unsupported. This improper positioning was noted during various times of the day, both in the dining room and common areas. The deficiency was highlighted by an incident where the resident fell out of their wheelchair after putting their feet down and leaning forward, resulting in a nose fracture. Interviews with staff confirmed that the resident's wheelchair pedals had been removed to prevent the resident from scooting back, but this removal contradicted the need for leg support when the wheelchair was tilted or being pushed. The occupational therapist acknowledged that leg rests or foot pedals should be used, and the Director of Nursing confirmed the necessity of using wheelchair pedals when transporting the resident.
Failure to Adhere to Resident Transfer Care Plans
Penalty
Summary
The facility failed to ensure that residents were transferred in accordance with their care plans, leading to deficiencies in the care of two residents. Resident 3, who was admitted with Parkinson's Disease and unspecified dementia, was observed being transferred using a gait belt and pivot transfer by the Director of Nursing and Nurse Aide A, despite the care plan indicating the need for a Hoyer lift with two-person assistance. This discrepancy was confirmed by a Physical Therapy Assistant who noted that Resident 3's transfer status had been downgraded to a Hoyer lift due to decreased weight-bearing ability and safety concerns. The Director of Nursing acknowledged awareness of the transfer status change but allowed staff discretion in transfer decisions. Similarly, Resident 1, diagnosed with Alzheimer's disease, was observed being transferred using a sit-to-stand lift by Nurse Aide A and Nurse Aide F, contrary to the care plan requirement for a Hoyer lift with two-person assistance. The Physical Therapy Assistant confirmed that Resident 1's transfer status remained as a Hoyer lift with two-person assistance, and the Director of Nursing indicated that the transfer method could vary based on the resident's behavior. These actions demonstrate a failure to adhere to the prescribed care plans, potentially compromising resident safety.
Resident Safety Incidents Highlighted in Deficiency Report
Penalty
Summary
The report highlighted two instances where the facility failed to ensure resident safety, resulting in deficiencies. In the case of Resident 48, who had a complex medical history including dementia and seizure disorder, the facility did not secure the safety belt during the bathing process, leading to a fall that resulted in the resident hitting their head and requiring stitches. Despite being on hospice care and requiring a 2-person assist for activities of daily living, the resident fell while being bathed, indicating a lack of proper supervision and adherence to safety protocols. On the other hand, Resident 94, who had diagnoses of cognitive deficits and hemiplegia following a cerebral infarction, experienced a fall in the dining area that resulted in a left femur fracture. The facility's care plan for fall prevention included interventions such as X-rays and evaluations after falls, but key interventions like non-slip socks and staff assistance to the bathroom were not consistently implemented. Despite being identified as high risk for falls, Resident 94 experienced multiple falls, including one that led to a significant injury, indicating gaps in supervision and intervention implementation.
Failure to Maintain Proper Hygiene and Cleanliness in Food Preparation Areas
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during food preparation, as observed on multiple occasions. The Chef did not wash hands after returning from the dry storage area, walk-in refrigerator, and freezer, and after touching potentially contaminated items such as boxes and bags. The Chef also used bare hands to insert the blade into the blender, which is a violation of sanitary practices. These actions were confirmed by the Dietary Manager (DM) during an interview, who acknowledged that the Chef should have performed hand hygiene at various stages of the food preparation process. Additionally, the facility did not ensure that staff avoided touching the drinking surfaces of cups and straws while serving beverages to residents. A Dietary Aide (DA) was observed delivering beverages by touching the drinking surfaces of the cups and the straw for one resident. This was confirmed by the Registered Dietician (RD), who stated that the DA should not have touched the drinking surfaces. The facility also failed to maintain cleanliness in the main kitchen and the Evergreen/Memory unit kitchen. Observations revealed scattered food debris, sticky substances, and crusty residues on various surfaces, including floors, refrigerators, ovens, and other kitchen equipment. The DM confirmed these observations and acknowledged that the items should have been cleaned but were not. Furthermore, the facility did not label and date all items in the Evergreen/Memory Care unit refrigerator and freezer, as required by their Proper Food Storage policy. This was also confirmed by the DM during an interview.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that staff consistently wore surgical masks correctly, performed hand hygiene, and followed proper infection control procedures. Observations revealed multiple instances where staff members, including medication aides, registered nurses, and administrative assistants, wore masks below the nose or mouth while in close proximity to residents. This was confirmed by the Regional Nurse Consultant, who stated that all staff should have worn masks properly at all times due to the presence of COVID-19 positive residents in the facility. Additionally, staff failed to perform hand hygiene between resident contacts and glove changes. For example, a nursing assistant was observed assisting two residents with meals without changing gloves or performing hand hygiene between contacts. Similarly, the Activities Director was seen assisting multiple residents with meals and adjusting their clothing without performing hand hygiene. These actions were confirmed by the Registered Dietician and the Regional Nurse Consultant, who acknowledged that hand hygiene should have been performed between resident contacts. Further deficiencies were noted in the administration of medication and catheter care. A Certified Medication Assistant did not perform hand hygiene before and after glove changes while administering insulin and performing blood glucose testing for a resident. Another instance involved improper hand hygiene and glove use during wound care and catheter care for multiple residents. Staff members were observed not changing gloves or performing hand hygiene between different tasks, leading to potential cross-contamination. These observations were confirmed by interviews with the staff involved, who acknowledged the lapses in proper infection control procedures.
Non-Functional Venting System and PTAC Maintenance Issues
Penalty
Summary
The facility staff failed to ensure the venting system was functional in four rooms (B-004, C-010, C-015, and C-017), affecting seven residents who resided in those rooms. Additionally, the Heating and Cooling unit (commonly called PTAC) was not maintained in good repair, as evidenced by the missing front cover in room C-011. These deficiencies were observed during a survey on 04/01/2024 and confirmed by the Maintenance Director on 04/04/2024. The facility had a census of 92 residents at the time of the survey.
Failure to Document Rationale and Behavioral Monitoring for Psychotropic Medications
Penalty
Summary
The facility staff failed to provide rationale for the continued use of an antianxiety medication for three residents and did not complete behavioral monitoring for one resident. Specifically, Resident 21, who is severely cognitively impaired, was prescribed Lorazepam without documented rationale for its continued use. The Director of Nursing (DON) confirmed the absence of documentation from the pharmacy or physician regarding the PRN Lorazepam order for 365 days. Additionally, the facility's Medication Regimen Review Policy requires the duration of therapy to be indicated and appropriate for the resident, which was not adhered to in this case. Resident 57, who has a history of depression and other mood disorders, was on Mirtazapine for a mood disorder. However, the facility failed to specify the target behaviors for monitoring the effectiveness of the antidepressant. Interviews with nursing staff revealed uncertainty about the target behaviors related to the resident's depression. The DON confirmed that the provider's documentation was not specific about the reason for ordering Mirtazapine or the behaviors being exhibited by the resident, which should have been clearly documented. Resident 25 had orders for Lorazepam as needed for anxiety but the facility did not document the non-pharmacological interventions attempted before administering the medication. The resident's care plan included various interventions to manage anxiety and behavioral issues, but the facility did not consistently implement these interventions before resorting to medication. Additionally, Resident 1 had an order for Lorazepam extended beyond 14 days without documented rationale, and there was no documentation to support the increase in dosage of Sertraline for this resident. The DON confirmed the lack of documentation for both the extended use of Lorazepam and the increased dosage of Sertraline.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility staff failed to ensure proper labeling and security of medications in the memory care unit. During an observation, an undated and unlabeled generic bottle of Cough DM and a bottle of Neomycin and Polymyxin B Sulfates and Dexamethasone Ophthalmic Suspension were found in the medication cart on hall E. The Certified Medication Assistant (CMA) interviewed did not know who the medications belonged to or how long they had been in the cart. Additionally, the medication refrigerator in the memory care unit was found to be unsecured, and the Registered Nurse (RN) confirmed that the office door and refrigerator should be locked at all times due to the presence of ambulatory residents in the unit. The Regional Nurse Consultant (RNC) also confirmed that the presence of undated and unlabeled medications in the cart and an unlocked medication refrigerator did not meet the facility's expectations and posed a danger to residents. Further observations revealed that a Licensed Practical Nurse (LPN) left a resident's blood pressure medication unsecured and unsupervised on top of the medication cart in the memory care unit. Another observation found the medication cart unlocked and unsupervised, with Metoprolol tablets left on top of the cart. The LPN confirmed that the cart should not have been left unlocked and the medication should not have been left on top of the cart. The facility's policy states that medication carts should be kept closed and locked when out of sight of the medication team member, and no medications should be left on top of the cart or in the medication cabinet without supervision.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility staff failed to protect four residents (Resident 32, 92, 342, and 33) from abuse. Resident 32 reported being verbally abused by Nursing Assistant (NA)-EE, who made derogatory comments about Resident 32's marital status and family situation. This incident caused Resident 32 significant distress, affecting their ability to sleep. Resident 32 did not report the incident immediately due to not knowing whom to tell and feeling fearful of NA-EE's strong personality. The facility Administrator was informed of the incident but did not take immediate action to address the situation. Additionally, Licensed Practical Nurse (LPN) QQ reported that NA-PP was verbally inappropriate and rough with Residents 92, 33, and 342. The Director of Nursing/Administrator was notified approximately nine hours after the initial report. There was no documentation of immediate protective actions taken for Residents 92, 33, and 342. The facility's policy requires immediate removal of the accused team member from resident care and initiation of an investigation, but these steps were not followed promptly, leaving the residents unprotected during the delay.
Failure to Ensure Competency in Insulin Administration
Penalty
Summary
The facility staff failed to ensure competencies in insulin administration were completed for five Certified Medication Assistants (CMAs) and three licensed nurses. This deficiency was identified during interviews and record reviews, revealing that the CMAs and nurses had not been assessed for competency in administering insulin. The Director of Nursing (DON) and the facility Administrator confirmed that competency assessments were required but had not been completed for these staff members. The facility's policy stated that only licensed nurses or certified personnel could administer injections, with insulin administration by competent medication techs using insulin pens only. However, the competency assessments for insulin administration were missing for several staff members, including those from staffing agencies, affecting 13 residents who receive insulin in the facility, which had a census of 92 residents. Interviews with the CMAs and nurses confirmed that they had administered insulin without being assessed for competency. The facility Administrator was unable to provide evidence of completed competency assessments for these employees. The record review of the facility's CMA and nurse competency checklists further confirmed the lack of insulin administration competency assessments. This deficiency had the potential to impact the well-being of the residents receiving insulin, as the staff administering the medication had not been properly evaluated for their competency in this critical task.
Failure to Update Care Plan for Oxygen Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident (Resident 77) who had a change in their oxygen order. The resident, who was admitted on 02/17/2024, had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, and Dependence on Supplemental Oxygen. The resident's Minimum Data Set (MDS) dated 02/23/2024 indicated severe cognitive impairment and dependence on staff for various activities of daily living. Observations on 04/01/2024 revealed the resident was using an oxygen concentrator set at 5 liters per minute (l/m), despite the care plan indicating an oxygen setting of 2 l/m continuously. A review of the Order Summary Report and Medication Administration Record (MAR) confirmed the resident had an order for oxygen at 2 l/m, but a verbal order on 03/22/2024 had increased the oxygen to 5 l/m due to low oxygen levels. This change was not reflected in the care plan, which still showed the outdated intervention of 2 l/m continuously. In an interview on 04/02/2024, the Regional Nurse Consultant (RNC-A) confirmed that the care plan had not been updated to reflect the new oxygen order from 03/22/2024. The facility's Comprehensive Care Planning policy stated that care plans should be revised as information about the resident's condition changes, but this was not followed in the case of Resident 77. The failure to update the care plan to reflect the new oxygen order constitutes a deficiency in the facility's care planning process.
Failure to Follow Medication and Treatment Orders
Penalty
Summary
The facility staff failed to follow practitioners' orders for medication administration for Resident 93 and failed to implement treatment orders for Resident 25. Resident 93, diagnosed with Dementia, Diabetes, Hypertension, Major Depressive Disorder, and Functional Quadriplegia, had an order to hold insulin if meals were not eaten. However, on 3/16/2024, RN-SS administered insulin without documentation of food intake, resulting in a morning blood glucose level of 58 on 3/17/2024. The Director of Nursing confirmed the failure to follow the practitioner's orders during an interview on 04/04/2024. Resident 25, diagnosed with Dementia, Heart Failure, Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Peripheral Vascular Disease, had a comprehensive care plan to maintain clean, intact skin. The treatment orders included wound care for both legs and the use of Geri Sleeves/Tubi Grip for protection. However, the treatment was not documented as completed on multiple dates in March 2024, and observations on 4/01/2024 and 4/02/2024 revealed outdated dressings and the absence of Geri Sleeves. Interviews with the Regional Nurse Consultant confirmed the lack of completed treatments and the absence of Geri Sleeves, contrary to the care plan and facility policy.
Failure to Notify Provider of Low Oxygen Levels
Penalty
Summary
The facility failed to ensure the provider was notified when a resident's oxygen level dropped below the ordered parameter. Resident 77, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, and dependence on supplemental oxygen, was observed with an oxygen concentrator set at 5 liters per minute (l/m) despite an order for 2 l/m. The resident's care plan specified oxygen at 2 l/m continuously, with instructions to notify the physician if oxygen saturation fell below 90%. However, records revealed multiple instances where the resident's oxygen saturation dropped below 90%, and the provider was not notified until much later, on 03/22/2024, when the oxygen was increased to 5 l/m by a verbal order from the Nurse Practitioner. The Medication Administration Record and Treatment Administration Record (MAR & TAR) showed that the resident's oxygen saturation was below 90% on several occasions, including 85% on 02/20/2024, 88% on 02/23/2024, and 76% on 03/22/2024, among others. Despite these low readings, there was no documentation in the Electronic Medical Record or Progress Notes indicating that the provider was notified of these critical values. It was only on 03/22/2024 that the Nurse Practitioner was contacted, and a new order was given to adjust the oxygen levels to maintain saturations above 88%.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility staff failed to evaluate and implement interventions to manage triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident's Minimum Data Set (MDS) indicated an active diagnosis of PTSD, and the care plan included interventions such as providing reassurance, encouraging expression of needs, and ensuring female caregivers for toileting and bathing. However, observations revealed that the resident frequently packed their belongings and placed them in the hallway, indicating distress. Interviews with staff members, including Nursing Assistants, the Director of Nursing, Social Services, and the Administrator in Training, revealed a lack of awareness and understanding of the resident's PTSD diagnosis and the specific care plan interventions. Additionally, the Director of Nursing confirmed that a Trauma Informed Care Assessment had not been completed for the resident. Further interviews with staff members indicated that some were unaware of the resident's PTSD diagnosis, while others were unsure of the specific interventions required. Despite the care plan's directive to provide female caregivers for toileting and bathing, it was reported that the resident had male caregivers. This lack of awareness and implementation of the care plan interventions highlights a significant deficiency in providing trauma-informed and culturally competent care for the resident with PTSD.
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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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