Holdrege Memorial Homes, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Holdrege, Nebraska.
- Location
- 1320 11th Avenue, Holdrege, Nebraska 68949
- CMS Provider Number
- 285067
- Inspections on file
- 18
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Holdrege Memorial Homes, Inc during CMS and state inspections, most recent first.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent reporting, and unclear protocols, leaving residents unprotected from these risks.
The facility did not include the actual hours worked by RNs, LPNs, or nurse aides on its daily posted nurse staffing reports, as required by policy. The posted reports only listed the number of staff per shift and the resident census, and this omission was confirmed by the DON.
The facility failed to complete required pre-employment health screenings for a re-hired nurse aide, did not enforce hand hygiene or personal grooming standards among dietary staff during meal service, and did not maintain sanitary storage or proper documentation for oxygen and nebulizer equipment for two residents. Additionally, enhanced barrier precautions and PPE availability were not consistently implemented for residents at risk for MDROs, with staff lacking awareness of protocols.
The facility did not submit MDS assessments for several residents within the required 14-day period after completion. Due to the MDSC's frequent absences and lack of backup, assessments were either finalized but not transmitted or submitted but not reviewed and accepted on time, affecting all sampled residents.
The facility did not ensure that care plans were individualized, person-centered, or included measurable goals and interventions for residents with complex needs such as respiratory infections, diabetes, nutrition, UTIs, and fluid restrictions. For example, a resident with ongoing respiratory issues had a care plan that only addressed antibiotics and oxygen, while another with diabetes and significant weight gain had no care plan interventions for nutrition or education. Staff interviews confirmed that care plans were not consistently updated to reflect residents' current needs or preferences.
The facility did not provide or document risk versus benefit information for psychotropic medications to two residents and their representatives. Despite multiple medication changes and the use of high-risk drugs, there was no evidence that risks, benefits, options, or alternatives were discussed or acknowledged. Staff confirmed that the facility did not have a process for reviewing or documenting this information.
A resident was discharged without the required notification to the state LTC Ombudsman. Review of records and interviews with the Social Services Director revealed that the facility's process only included ombudsman notification for hospital transfers, not discharges, resulting in the omission of the discharge notice for this resident.
A resident with multiple sclerosis and a denuded area on the left buttock did not receive comprehensive wound assessments or have treatment orders in place. Documentation was incomplete and did not follow best practice guidelines or facility policy, and staff confirmed that the wound was not fully assessed or managed according to protocol.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
The facility failed to report incidents of serious bodily injury within the required timeframe for two residents. One resident with a fractured fibula and another with a fractured femur experienced delays in reporting to APS, exceeding the two-hour requirement. The Director of Nursing confirmed these delays during an interview.
The facility failed to properly store oxygen tubing and CPAP mask/tubing for several residents, leading to potential cross-contamination. Observations showed that oxygen and CPAP supplies were not stored in bags as required by facility policy. The Director of Nursing confirmed the expectation for proper storage, but it was not followed, indicating a lapse in infection prevention and control practices.
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by licensure regulations. Interviews revealed a lack of awareness among staff regarding the required hours, and the Director of Nursing confirmed the oversight in monitoring education hours. The absence of a Staff Development Coordinator contributed to the deficiency, with the Payroll Coordinator responsible for auditing and notifying supervisors about incomplete education hours.
A resident with asthma did not have their nebulizer cleaned after each use, contrary to facility policy, leading to potential cross-contamination. Observations showed liquid residue in the nebulizer chamber, and interviews with the resident, an LPN, and the DON confirmed the failure to rinse the nebulizer as required.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the required systems to safeguard residents from these incidents were either not in place or not adequately enforced. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training, inconsistent reporting mechanisms, and a lack of clear protocols for identifying and responding to potential abuse, neglect, or theft events. As a result, residents were left vulnerable due to the absence of comprehensive preventive measures and oversight, as directly evidenced by the survey findings.
Failure to Post Actual Nurse Staffing Hours on Daily Reports
Penalty
Summary
The facility failed to ensure that the required daily posting of nurse staffing information included the actual hours worked for each staff category. Observations on multiple dates revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted in a common area, and while the reports listed the number of RNs, LPNs, and nurse aides assigned to each shift, they did not include the actual hours worked by each staff category as required by facility policy. The posted reports only indicated the number of staff per shift and the resident census, omitting the specific work hours for each staff type. Record review of the facility's policy confirmed that the daily posting should include the actual time worked during each shift for every category and type of nursing staff. During an interview, the Director of Nursing acknowledged that the posted reports did not contain the required information regarding actual hours worked. No information was provided about any residents' medical history or condition in relation to this deficiency.
Multiple Infection Control Failures in Staff Screening, Hand Hygiene, and Equipment Storage
Penalty
Summary
The facility failed to ensure that pre-employment health screenings were completed for a newly re-hired nurse aide. Although the facility's policy required all new hires to complete a health screening and tuberculosis test during general orientation, the personnel and medical files for the nurse aide did not contain documentation of a health screening for the current hire date. The business office and infection preventionist confirmed that the health screen was not repeated upon re-hire, despite a gap in employment. Dietary staff were observed not adhering to hand hygiene and personal grooming standards during meal service. A dietary aide with long artificial nails, which is prohibited by facility policy, was seen serving food and drinks to residents without performing hand hygiene between tasks or wearing gloves. The dietary manager was aware of the artificial nails but did not consider them a concern, and the infection preventionist confirmed that artificial nails should not be worn in the dietary department. The aide's competency review indicated requirements for short, unpolished, and clean nails, as well as proper handwashing, which were not followed during the observed meal service. The facility also failed to maintain sanitary storage and documentation for oxygen delivery devices and nebulizer equipment for two residents. Observations revealed that oxygen tubing was stored on the floor or in bags with outdated or missing labels, and there were no clear directions in the administration records for changing the equipment as required by policy. Additionally, enhanced barrier precautions (EBP) were not properly implemented for residents with wounds or at risk for multidrug-resistant organisms. PPE was not available near or outside resident rooms as required, and staff were not consistently aware of EBP protocols. These failures affected multiple residents, including those with chronic wounds, respiratory conditions, and those requiring supplemental oxygen.
Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that all Minimum Data Set (MDS) assessments for residents were submitted to the State within the required 14-day period after completion. This deficiency affected all seven residents sampled, as their MDS data was either finalized but not transmitted or submitted but not reviewed and accepted within the mandated timeframe. The facility's policy requires timely and accurate completion and submission of MDS assessments in compliance with federal and state regulations, with oversight by the MDS Coordinator and the interdisciplinary team. However, due to the MDS Coordinator's frequent absences and being the sole individual responsible for MDS data, the submission process was delayed, and no other staff monitored or managed the workload in the Coordinator's absence. Record reviews confirmed that for each of the seven residents sampled, the MDS data was either finalized but not sent or was in a production batch that had not been reviewed and accepted within the required period. Interviews with the MDS Coordinator corroborated that the assessments were not submitted on time, and there was no backup process in place to ensure timely submission during the Coordinator's absence. The facility census at the time was 73 residents, and the deficiency was identified through both record review and staff interviews.
Failure to Develop and Implement Individualized, Measurable Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, individualized care plans were developed and implemented for several residents, as required by both federal and state regulations. Specifically, care plans lacked person-centered goals, measurable objectives, and appropriate interventions for conditions such as respiratory infections, diabetes, nutrition, urinary tract infections, fluid restrictions, and resident choices. For example, one resident with a complex medical history including pneumonia, heart failure, and chronic kidney disease experienced multiple medication changes and ongoing respiratory symptoms, yet the care plan only addressed antibiotic use and oxygen therapy, omitting other relevant interventions for respiratory status and chronic cough. Another resident with diabetes, bilateral lower extremity amputations, and significant weight gain had a care plan that did not address nutritional choices, diabetic education, or set measurable weight goals, despite the resident keeping high-sugar snacks at the bedside and expressing knowledge of the risks. Similarly, a resident with a history of recurrent urinary tract and yeast infections had a care plan that only addressed a single episode of UTI and did not reflect the resident's infection history or all relevant interventions. Observations and interviews confirmed that care plans were not updated to reflect ongoing or recurrent issues, and that interventions were not tailored to the residents' individual needs and preferences. Additionally, a resident with chronic kidney disease and a physician-ordered fluid restriction was known by staff and family to be noncompliant with the restriction, but this was not reflected in the care plan. Interviews with staff, including the MDS Coordinator and DON, confirmed that care plans were often not personalized, and that acute issues were removed from care plans once resolved, without maintaining a history of significant conditions. The facility's own policy required individualized, comprehensive care plans, but in practice, care plans were not consistently updated or detailed to guide staff in providing individualized care.
Failure to Inform Residents and Representatives of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents and their representatives were fully informed about the risks, benefits, options, and alternatives of psychotropic medications prior to starting or changing such medications. For two of five sampled residents, documentation and interviews revealed that no risk versus benefit information was provided or discussed in plain language, and there was no evidence that residents or their representatives signed or received any such information. Instead, the facility only documented that family members were notified of medication changes in the progress notes, without specifying the content of those discussions. One resident, who was cognitively intact and had multiple complex diagnoses including breast cancer, diabetes, hypertension, and coronary artery disease, received several psychotropic medications for anxiety and depression. The medical record showed multiple medication changes, including new orders for Buspar, Ativan, and Hydroxyzine, but there was no documentation of any risk and benefit discussion or signed acknowledgment by the resident or representative. The MDS Coordinator and DON both confirmed that the facility did not have a process for reviewing or documenting the risks and benefits of psychotropic medications with residents or their representatives. Another resident, with diagnoses including Alzheimer's disease, insomnia, nightmare disorder, depression, unspecified dementia with agitation, and convulsions, was prescribed multiple high-risk medications such as antipsychotics, antidepressants, anticonvulsants, and diuretics. The care plan included non-pharmacological interventions and monitoring for side effects, but there was no available documentation of risk versus benefit information being provided to the resident or representative. The DON confirmed that the facility had never reviewed or documented such information with residents or their representatives.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman of a resident's discharge, as required by both facility policy and regulatory requirements. Record review showed that a resident was admitted and subsequently discharged, but there was no documentation in the medical record indicating that a discharge notice was provided to the ombudsman. The facility's policy specifies that a copy of all discharge notices must be sent to the ombudsman and relevant state agencies, with documentation of the date this was completed in the resident's record. Interviews with the Social Services Director (SSD) revealed that the SSD was unaware of the requirement to notify the ombudsman of resident discharges, and only notified the ombudsman of hospital transfers. Review of the facility's monthly notification email and the Emergency Transfers From Facility form confirmed that the resident's discharge was not included in the ombudsman notification. The SSD confirmed that the omission was due to a lack of awareness of the requirement.
Failure to Routinely Assess and Obtain Treatment Orders for Resident Wound
Penalty
Summary
The facility failed to ensure that wounds were comprehensively assessed on a routine basis and did not obtain treatment orders for a wound for one resident. The resident, who had multiple sclerosis and was admitted with a denuded area on the left buttock, was identified as having a potential for skin breakdown. The care plan included weekly skin assessments but did not list any treatment interventions for the wound. Documentation in the resident's records showed inconsistent and incomplete wound assessments, with missing details such as anatomical location, wound characteristics, and pain or symptom reporting. Progress notes and skin condition records indicated the presence of an open area on the left buttock, but assessments lacked comprehensive information as outlined in best practice guidelines and facility policy. Despite ongoing documentation of the wound, there were no physician orders for wound care in the resident's medical record during the review period. Interviews with nursing staff and the DON confirmed that the wound was not fully assessed or documented on a routine or weekly basis, and that no treatment orders were obtained for the area. This failure to follow established protocols and obtain necessary physician orders resulted in a deficiency related to the comprehensive assessment and management of wounds.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Delayed Reporting of Serious Bodily Injuries
Penalty
Summary
The facility failed to report incidents resulting in serious bodily injury within the required timeframe for two residents. Resident 2, who had a history of a fractured right fibula, dizziness, type 2 diabetes mellitus, and dementia, experienced a fall on 10/19/2024. Initially, the resident denied injury, but later notes indicated bruising and pain to the right ankle, which was eventually diagnosed as a fracture on 10/21/2024. The incident was reported to Adult Protective Services (APS) on 10/22/2024, more than two hours after the suspicion of serious bodily injury was formed, and the investigative report was submitted to the state agency after more than five calendar days. Resident 6, with diagnoses including a fractured right femur, irregular heartbeat, heart failure, dementia, high blood pressure, and a history of a heart attack, was found on the floor on 08/16/2024 with pain and inability to move the right leg. The resident was transported to the emergency room and diagnosed with a right femur fracture. The incident was reported to APS on 08/19/2024, again exceeding the two-hour reporting requirement. The Director of Nursing confirmed these reporting delays during an interview on 12/16/2024.
Improper Storage of Oxygen and CPAP Supplies
Penalty
Summary
The facility failed to properly store oxygen tubing and CPAP mask/tubing to prevent potential cross-contamination for several residents. Observations revealed that Resident 7's oxygen tubing was not stored in the attached bag on the concentrator when not in use, despite the facility policy requiring such storage. Similarly, Resident 23's CPAP mask and tubing were found draped over the CPAP machine without a storage bag, and the oxygen tubing was also improperly stored. The Director of Nursing confirmed that the facility's expectation was to store these supplies in a bag to prevent cross-contamination, but this was not adhered to. Resident 59's oxygen tubing was observed to be under the handle of the concentrator and not stored in a bag, as required by the facility's policy. The Director of Nursing acknowledged that the staff had been educated on the proper storage practices, yet the tubing was still not stored according to policy. Additionally, Resident 53's oxygen tubing was found coiled and tucked under the concentrator handle without being stored in a bag, and the nasal prongs were not properly positioned in the resident's nostrils during use. Resident 42's oxygen tubing was observed to be improperly stored, with the nasal cannula touching the wheelchair tire and the tubing wrapped around the flow meter of a portable oxygen tank. The facility's policy did not address the storage of oxygen tubing with portable tanks, and the Director of Nursing confirmed that the expectation was for the tubing to be stored in a bag when not in use. These observations indicate a failure to adhere to infection prevention and control practices, as outlined in the facility's policy.
Deficiency in Nursing Assistant Continuing Education Compliance
Penalty
Summary
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by the licensure reference number 175 NAC 12.006.4(B)(ii)(1). Specifically, NA-A, NA-C, and NA-D did not meet the continuing education requirements, with NA-A completing zero hours, NA-C completing 11.75 hours, and NA-D completing 9.25 hours within their respective annual periods. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adequately monitor or enforce the completion of these education hours. Interviews with nursing assistants NA-F and NA-G indicated a lack of awareness regarding the exact number of required continuing education hours, with incorrect estimates of 72 and 40 hours, respectively. The Director of Nursing confirmed the oversight in monitoring the education hours and acknowledged that staff continued to work without completing the required training. Additionally, the Business Office Manager confirmed the absence of a Staff Development Coordinator, with the Payroll Coordinator responsible for auditing education hours and notifying supervisors. However, the facility's policy of withholding annual pay increases until education hours are completed was not sufficient to ensure compliance with the training requirements.
Failure to Clean Nebulizer After Use
Penalty
Summary
The facility failed to ensure proper cleaning of a Metered Dose Inhaler (Nebulizer) after each use, which is necessary to prevent potential cross-contamination. This deficiency was identified for one resident, who was diagnosed with asthma and had a prescribed order for Ipratropium-Albuterol solution to be administered via nebulization three times a day. The facility's policy on administering medications through a nebulizer requires that the equipment be rinsed in warm water after each use to ensure safe administration of inhaled medications. Observations and interviews revealed that the nebulizer used by the resident was not being rinsed after treatments. On two separate occasions, a clear liquid was observed in the nebulizer chamber, indicating it had not been cleaned. Interviews with the resident and a Licensed Practical Nurse (LPN) confirmed that the nebulizer was not rinsed after each use. The Director of Nursing also confirmed that the facility's expectation, as per policy, was for staff to rinse the nebulizer after medication administration, which was not being followed in this case.
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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