Indian Hills Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ogallala, Nebraska.
- Location
- 1720 North Spruce, Ogallala, Nebraska 69153
- CMS Provider Number
- 285091
- Inspections on file
- 21
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Indian Hills Manor during CMS and state inspections, most recent first.
The facility failed to meet regulatory and policy timeframes for reporting an incident of resident-to-resident abuse and submitting the investigation results. An incident of abuse occurred between two residents, one with dementia, weight loss, unsteadiness, and type 2 DM, and another with COPD, pneumonia, bladder dysfunction, and heart failure. The DON and ADM were notified by phone the day of the incident, but the ADM did not notify the State Agency until days later, beyond the required 24 hours, and the written investigation report was also submitted after the 5-working-day deadline.
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training for the year, potentially affecting all residents. Record reviews showed that MA-D, NA-A, MA-G, and MA-F did not meet the training requirements, with some completing duplicate courses. The Administrator confirmed these deficiencies.
The facility failed to implement a water management program to prevent legionella, with zero chlorine levels found in tested areas despite flushing. Additionally, an LPN did not follow hand hygiene protocols during wound care for a resident, failing to sanitize hands between glove changes.
The facility did not ensure that five employees, including a cook, a dietary aide, the DON, and two nurse aides, completed their initial orientation training within two weeks of hire. This training was supposed to cover resident rights and emergency procedures, as required by regulations. The lack of training was confirmed through record reviews and an interview with the Administrator, potentially affecting all 27 residents in the facility.
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training, including dementia management and abuse prevention. Record reviews showed that staff had incomplete or duplicate training hours, potentially affecting all residents. The Administrator confirmed the shortfall in training hours.
A facility failed to protect the private health information of three residents during medication administration. An RN was observed leaving a computer screen open with residents' private health information visible while administering medications in the dining room. This action violated the facility's privacy policies, which emphasize the protection and confidentiality of personal and medical records.
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. Residents admitted with conditions such as palliative care needs, diabetes type 2, and dementia with a femur fracture did not have timely care plans. The facility's process did not include a separate baseline care plan, leading to delays in care plan initiation.
The facility failed to document and monitor three residents during acute illnesses, including influenza A and pneumonia. Resident 18 was transferred to the hospital without proper documentation of their condition or assessment. Resident 3 and Resident 8, both diagnosed with influenza A, were not consistently monitored every shift as required. The DON confirmed these deficiencies in care and documentation.
A facility failed to accurately update a resident's MDS, listing resolved fractures as active diagnoses. Despite the resident's fractures having resolved over a year ago, the MDS assessments continued to reflect them as active, contrary to the facility's policy and federal guidelines. The ADON and MDS Nurse confirmed the inaccuracies in the assessments.
A resident with severe cognitive impairment and dependent on staff for bathing did not receive necessary bathing services while in isolation for Influenza A. Staff were instructed not to give baths to isolated residents, but bed baths were not offered or documented, leading to a two-week period without bathing, contrary to the resident's care plan.
The facility failed to implement and revise nutritional interventions for residents experiencing significant weight loss. A resident with dementia and COPD lost 9.8% of their weight over five months due to inadequate meal assistance and documentation. Another resident with a cerebral infarction lost 5.9% of their weight in less than a month, with inconsistent meal monitoring and assistance. A third resident with dementia and Parkinson's disease lost 16.81% of their weight over six months, with frequent interruptions in feeding assistance and poor documentation of meal intakes.
The facility failed to resolve ongoing grievances and ensure residents could voice concerns without fear of retaliation. Issues included inaccessible call lights, unmade beds, and staff unavailability due to smoke breaks. Residents reported threats of room changes if they complained. Grievances were repeatedly documented but remained unresolved, indicating ineffective communication and follow-up between departments.
The facility failed to ensure the Dietary Manager had the necessary credentialing as required by the job description, which included completing a Dietary Manager certification course. The President of Operations and the facility Administrator confirmed the current DM did not meet these qualifications, potentially affecting all residents consuming food from the kitchen.
The facility staff failed to follow proper handwashing, gloving, and food storage practices, leading to potential cross-contamination risks. Observations revealed outdated and undated food items, disorganized kitchen utensils, and non-cleanable cooking equipment. A dietary cook was seen handling food without washing hands or using gloves, further compromising food safety.
The facility's QAPI program was found deficient as the QAA committee did not include the Infection Preventionist due to their night shift, and no performance improvement projects were conducted. The committee, which met monthly, failed to address significant issues like resident weight loss, potentially affecting all 34 residents.
A LTC facility failed to use required PPE for a resident on Enhanced Barrier Precautions, did not perform proper hand hygiene and gloving during a blood glucose test, and lacked measures to prevent Legionella growth. A resident with a pressure ulcer was not provided with proper signage for precautions, and a blood glucose test was conducted without hygiene protocols. The facility also did not conduct a water risk assessment for Legionella prevention.
The facility did not ensure that four NAs completed the required 12 hours of continuing education in 2023, including training in Dementia care and infection control. NA-M had only 0.5 hours of education, lacking both Dementia and infection control training. NA-N completed 4.25 hours without Dementia training, while NA-O and NA-P had 7.10 and 5.15 hours, respectively. The Administrator confirmed the deficiency, and the facility's policy mandates compliance with education requirements, which was not met.
A facility failed to provide timely assistance with activities of daily living (ADLs) for residents requiring help. One resident with dementia was left without repositioning or toileting for hours, resulting in saturated clothing and dried feces. Another resident with cerebral infarction was left unattended during meals, leading to uneaten food. A third resident with severe cognitive impairment was not toileted for extended periods. Staff interviews confirmed these deficiencies.
The facility failed to provide adequate staffing, resulting in insufficient feeding assistance, repositioning, and incontinence care for residents. A resident with dementia was left unable to reach their meal and went without repositioning or incontinence care for hours, while another resident requiring partial assistance with eating was left unattended with uneaten meals. Staffing shortages were confirmed by staff and the DON, with only one nurse aide available during meal times.
The facility failed to ensure call devices were within reach for two residents, both with cognitive impairments and mobility issues. Observations revealed that the call devices were not accessible, leading to distress for one resident. A nurse aide confirmed that call devices should be within reach, indicating a lapse in policy adherence.
A facility failed to accurately assess a resident's medication usage during the Admission MDS process. The resident, with Type 2 Diabetes Mellitus, had orders for glipizide, metformin, and Victoza, but the MDS inaccurately documented insulin usage. The MAR confirmed no insulin orders, and the resident, cognitively intact, reported taking Victoza for years. The facility's MDS policy was not followed, leading to this documentation error.
A resident with dementia was diagnosed and treated for a UTI, but the facility failed to update the care plan to reflect this change. Despite receiving antibiotics, the care plan did not include new interventions for the UTI, contrary to the facility's policy. The DON confirmed the care plan should have been revised.
A resident with paraplegia and a stage 4 pressure ulcer was not repositioned as required by their care plan and facility policy. Observations showed the resident remained in the same position for extended periods, both in bed and in a wheelchair. The air mattress was set incorrectly, and the head of the bed was elevated beyond recommended levels. The DON confirmed these discrepancies, leading to a deficiency in pressure ulcer care.
A facility failed to ensure physician review of Medication Regimen Reviews for a resident with multiple diagnoses, including Dementia and Parkinson's disease. Despite the pharmacist's concerns about medications like citalopram and risperidone, there was no documentation of physician review or response. The facility's policy requires adherence to CMS guidelines, which was not followed.
A facility failed to limit PRN orders for antipsychotic drugs to 14 days or document a stop date, as required by policy. A resident was prescribed Seroquel for insomnia without a stop date or re-evaluation, which the facility did not consider appropriate. The resident had a history of heart failure, insomnia, and moderate cognitive impairment.
Failure to Timely Report Resident-to-Resident Abuse and Investigation Results
Penalty
Summary
The facility failed to timely report an incident of resident-to-resident abuse to the State Agency and failed to submit the required investigation report within the regulatory timeframe. An untitled facility document showed that an incident of abuse between Resident 1 and Resident 2 occurred on 2/28/26 at 12:45 PM, and the Administrator was notified that same day at 1:15 PM. Resident 1 had unspecified dementia, weight loss, unsteadiness on feet, and type 2 diabetes mellitus, while Resident 2 had chronic obstructive pulmonary disease, pneumonia, bladder dysfunction, and heart failure. Despite the facility’s abuse prevention plan policy stating that alleged violations of abuse or neglect are to be reported to the Administrator and the State Agency immediately, the State Agency was not notified until 3/2/26 at 1:00 PM. Record review and interviews confirmed that the Director of Nursing was notified by telephone on 2/28/26 that an incident of abuse had occurred between the two residents and that the Director of Nursing then notified the Administrator by telephone the same day. The Administrator stated that the incident was reviewed on the next working day, 3/2/26, and only then reported to the State Agency, which was beyond the 24-hour requirement in regulation and facility policy. The same untitled document and the Administrator’s interview further confirmed that the results of the investigation were submitted to the State Agency on 3/6/26, which exceeded the required 5 working days for submission of the investigative report.
Deficiency in Staff Training Hours
Penalty
Summary
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training for the year, as mandated by the licensure reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and interviews, which revealed that the lack of training had the potential to affect all residents within the facility, which had a census of 27. The Facility Assessment Tool indicated that all training should be completed at least upon orientation, annually, and as needed, covering topics such as dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. Specific findings showed that MA-D had only 0.5 hours of ongoing training and no training on dementia or abuse/neglect. NA-A had completed 4.95 hours of training, with some courses being duplicates, resulting in a total of 4.7 hours. MA-G had completed 9 hours of training, while MA-F had 15.7 hours, but with 4 hours being duplicates, resulting in 11.7 hours of valid training. An interview with the Administrator confirmed these findings, acknowledging that the employees had not met the required training hours for the year.
Deficiencies in Water Management and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement a comprehensive water management program to monitor and prevent the potential for legionella and other waterborne pathogens, which could affect all residents. The facility's policy required the maintenance director to maintain documentation describing the water system and apply control measures at each control point. However, the facility did not have a description of its water systems, and chlorine levels in tested eyewash stations and selected resident rooms were consistently found to be zero on multiple dates, despite documentation indicating that these areas were flushed. This was confirmed by the Nursing Home Administrator, who acknowledged the lack of additional dates for these tasks. Additionally, the facility failed to adhere to proper hand hygiene protocols during wound care for a resident. The resident had a physician's order for daily wound care on the right gluteal fold. During an observation, an LPN removed a soiled dressing, changed gloves without performing hand hygiene, and applied a new dressing. The facility's policy required hand hygiene after removing gloves and before putting on new gloves, which was not followed. The LPN confirmed the failure to perform hand hygiene during an interview.
Failure to Complete Initial Orientation Training for Staff
Penalty
Summary
The facility failed to ensure that five sampled employees completed their initial orientation training within two weeks of beginning employment, as required by the licensure reference 175 NAC 12-006.04(B)(i). This training was supposed to include essential topics such as resident rights and emergency procedures. The deficiency was identified through record reviews and interviews, which revealed that none of the five employees had evidence of completing the required orientation training. The employees in question included a cook, a dietary aide, the Director of Nursing (DON), and two nurse aides. The facility's Facility Assessment Tool, dated February 26, 2025, indicated that training should be completed at orientation, annually, and as needed, covering topics like effective communication, resident rights, abuse/neglect, infection control, and culture change. However, personnel file reviews showed no evidence of initial orientation training for the cook and dietary aide, and no evidence of training on resident rights and emergency procedures for the DON and the two nurse aides. An interview with the Administrator confirmed the lack of initial orientation training for these employees, which had the potential to affect all residents in the facility, which had a census of 27.
Deficiency in Staff Training Hours
Penalty
Summary
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training within the year, which included essential topics such as dementia management and resident abuse prevention. This deficiency was identified through record reviews and interviews, revealing that the training shortfall had the potential to affect all residents in the facility, which had a census of 27. The facility's Facility Assessment Tool, dated February 26, 2025, stipulated that all training should be completed at least upon orientation, annually, and as needed, with a minimum of 12 hours per year covering various critical topics. Specific deficiencies were noted in the training records of the staff. Medication Aide (MA) D, hired in 2010, had only 0.5 hours of ongoing training and none in dementia or abuse/neglect. Nurse Aide (NA) A, hired in 2022, completed 4.95 hours of training, with some courses duplicated, resulting in only 4.7 hours of valid training. MA G, hired in 2013, completed 9 hours of training, while MA F, hired in 2022, completed 15.7 hours, but with 4 hours of duplicate courses, resulting in 11.7 hours of valid training. An interview with the Administrator confirmed these findings, acknowledging the failure to meet the required training hours for the year.
Failure to Protect Resident Health Information During Medication Administration
Penalty
Summary
The facility failed to protect the private health information of three residents during medication administration. A Registered Nurse (RN-J) was observed administering medications in the dining room using a laptop computer mounted on a mobile medication cart. During the process, RN-J left the computer screen open with the private health information of Residents 9, 23, and 32 visible to anyone in the vicinity while they walked to the residents' tables to administer medications. This occurred for each of the three residents, and RN-J confirmed this was their usual routine. The facility's policies, as reviewed, emphasize the importance of protecting the privacy of individual health information and ensuring confidentiality of personal and medical records. However, the actions observed during the medication administration process were in direct violation of these policies. RN-J acknowledged the oversight and confirmed that the private health information was left visible, which should not have happened according to the facility's privacy policies and procedures.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for three residents. The Baseline Care Plan Policy, dated 4/23/2019, requires that a baseline care plan be developed within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. However, for Resident 35, who was admitted for palliative care with diagnoses including atrial fibrillation, osteomyelitis, and neuralgia, the care plan was not initiated until several days after admission. The Social Services Director and Director of Nursing confirmed that the facility did not utilize a separate baseline care plan, and the nursing portion of the care plan was delayed due to late or incomplete admission assessments. Similarly, Resident 23, admitted with a primary diagnosis of diabetes type 2, did not have a baseline care plan developed within the required timeframe. The earliest entry in the care plan was made several days after admission. The Registered Nurse Clinical Coordinator and Director of Nursing confirmed the absence of a baseline care plan. For Resident 27, admitted with dementia and a femur fracture, the care plan was also not initiated within the required timeframe. The Director of Nursing confirmed the lack of a baseline care plan for this resident as well. These deficiencies indicate a systemic issue in the facility's process for developing timely baseline care plans.
Failure to Document and Monitor Residents During Acute Illnesses
Penalty
Summary
The facility failed to ensure proper documentation and monitoring during the course of acute illnesses for three residents, leading to deficiencies in care. Resident 18, who had a history of unspecified dementia, ventricular tachycardia, and cardiomyopathy, was admitted to the hospital with pneumonia after a recent diagnosis of influenza A. However, there was no documented evidence of Resident 18's transfer to the hospital or any nursing assessment prior to the transfer. The Director of Nursing (DON) confirmed that there should have been documentation of Resident 18's condition, assessment results, and subsequent transfer to the hospital. Resident 3, diagnosed with dementia and chronic obstructive pulmonary disease, tested positive for influenza A. Despite the care plan interventions to monitor for signs of dehydration and other symptoms, there was a lack of consistent documentation and assessment between specific dates. The DON confirmed that Resident 3 had not been monitored every shift during their acute illness, which was against the facility's expectations for monitoring during such conditions. Resident 8, with a history of congestive heart failure, diabetes, and vascular dementia, also tested positive for influenza A. Similar to Resident 3, there was insufficient documentation and assessment during the course of the illness. The DON acknowledged that Resident 8 had not been monitored every shift as required during acute illnesses. These lapses in documentation and monitoring reflect a failure to adhere to the facility's policies and procedures for managing changes in residents' conditions.
Inaccurate MDS Assessment for Resident's Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated comprehensive assessment tool. The deficiency was identified during a review of records and interviews, where it was found that the MDS did not accurately reflect the active diagnoses for one resident. Specifically, the resident had been admitted with a diagnosis of dementia and had a history of fractures, including a trochanteric fracture of the femur and fractures of the sixth and seventh cervical vertebrae. These fractures were incorrectly listed as active diagnoses in the resident's MDS assessments conducted on multiple occasions, despite having resolved over a year ago. The facility's policy, which was intended to ensure the timeliness and accuracy of all MDS assessments, was not followed. The Assistant Director of Nursing confirmed that the resident's fractures had resolved, and the MDS Nurse acknowledged that the MDS assessments were incorrectly coded. The incorrect coding persisted across several assessments, indicating a failure to update the resident's medical status accurately. This oversight resulted in the inclusion of resolved conditions as active diagnoses, contrary to the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.
Failure to Provide Bathing Services During Isolation
Penalty
Summary
The facility failed to provide adequate bathing services to a resident during isolation precautions. The resident, who was admitted with a diagnosis of dementia and had severe cognitive impairment, was dependent on staff for bathing assistance. The resident was placed in isolation after testing positive for Influenza A, and during this period, the facility did not provide the necessary bathing services as per the resident's care plan. The care plan indicated that the resident required extensive assistance with bathing, yet the records show that no baths were given from February 5, 2025, to February 19, 2025, while the resident was in isolation. Interviews with staff revealed that they were instructed not to give baths to residents in isolation to prevent the spread of influenza. However, it was noted that bed baths could have been offered and documented, which was not done in this case. The Assistant Director of Nursing confirmed that the resident did not receive a bath for two weeks while in isolation, which was against the facility's policy and the resident's care plan requirements. This oversight led to a deficiency in providing necessary care and assistance for activities of daily living, specifically bathing, to the resident during their isolation period.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility failed to implement, evaluate, and revise nutritional interventions for residents experiencing significant weight loss. Resident 4, diagnosed with chronic conditions such as dementia and COPD, experienced a 9.8% weight loss over five months. Despite having a care plan that included nutritional supplements and monitoring, the facility did not document weights consistently or provide adequate assistance during meals. Observations showed Resident 4 was unable to reach their meal due to improper wheelchair positioning, and staff assistance was insufficient, leading to minimal food intake. Resident 27, admitted with a cerebral infarction, also experienced a significant weight loss of 5.9% in less than a month. The resident's care plan required monitoring of meal intake and weight, but documentation was inconsistent, and the resident was often left unattended during meals. Observations revealed the resident frequently had their eyes closed during meal times, with food left uneaten and no staff intervention to assist or encourage eating. Resident 14, with a history of dementia and Parkinson's disease, showed a 16.81% weight loss over six months. The resident required assistance with feeding due to tremors and loose-fitting dentures, but staff frequently interrupted feeding assistance, resulting in the resident consuming less than 25% of meals. The facility failed to document meal intakes consistently, and the DON confirmed that aides were expected to assist with feeding according to the care plan, which was not adhered to.
Unresolved Grievances and Retaliation Concerns
Penalty
Summary
The facility failed to resolve ongoing grievance concerns and did not ensure that residents could voice concerns without fear of retaliation. The facility's grievance policy, revised in March 2019, was not effectively implemented. The policy required grievances reported during resident or family council meetings to be documented and investigated within 72 hours, but this process was not followed. Multiple unresolved issues were documented in Resident Council meetings from October 2023 to March 2024, including call lights not being answered promptly, staff not knocking before entering rooms, and beds not being made or stripped on bath days. Specific grievances included staff leaving call lights inaccessible, not changing bed linens regularly, and failing to provide snacks and fresh ice water. Residents also reported that staff threatened to move them if they complained too often and that staff were unavailable due to frequent smoke breaks. These issues were repeatedly brought up in Resident Council meetings but remained unresolved, indicating a lack of effective communication and follow-up between the Social Services Director, nursing department, and other responsible parties. Interviews with residents and staff confirmed these ongoing issues. Resident 26 reported that staff often left the call light clipped to the fitted sheet, making it inaccessible for Resident 25, who also experienced delays in receiving assistance. The Social Services Director and Director of Nursing acknowledged that grievance forms were not always returned with resolutions, and the nursing department was not consistently informed of unresolved concerns. This lack of resolution and communication contributed to the ongoing grievances and dissatisfaction among residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary credentialing to meet the requirements for the position, as outlined in the facility's job description for the role of Dietary Service Director dated 7/1/2018. The job description specified that the DM should have completed a Dietary Manager certification course. During an interview, the President of Operations and the facility Administrator confirmed that the current DM did not have the required training to fulfill the qualifications for the position. This deficiency had the potential to affect all residents consuming food from the kitchen, with the facility census being 34 and a total sample size of 19.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility staff failed to adhere to proper handwashing and gloving techniques, as well as appropriate food storage, preparation, and serving practices, which could potentially lead to cross-contamination and foodborne illnesses affecting all residents served meals from the kitchen. The facility's policy on date marking for food safety was not followed, as evidenced by the presence of outdated and undated food items in the walk-in refrigerator and freezer. Observations revealed pork chops, broccoli, egg salad, ham cubes, and mandarin oranges in the refrigerator, along with unlabeled and undated chicken products and French fries in the freezer. During a kitchen sanitation tour, several issues were identified, including a heavy layer of dust and grease on the stove hood, disorganized kitchen drawers with utensils stored in a manner that could contaminate food contact surfaces, and undated food items such as flour tortilla shells, cornstarch, and honey. Additionally, frying pans and cookie sheets were found with heavy carbon buildup, making them non-cleanable, and an ice machine was observed with makeshift containers to catch leaks. Personal items, such as a cell phone and charger, were improperly stored on the steam table, posing a contamination risk. A dietary cook was observed handling food without washing hands, using gloves, or employing tongs, directly touching prepared cheese and bacon sandwiches with bare hands. This action was confirmed by the facility's Administrator, Dietary Manager, and President of Operations, who acknowledged that kitchen staff were responsible for ensuring food items were labeled, dated, and discarded if outdated. They also confirmed that utensils should be stored to prevent contamination, the ice machine required maintenance, and personal items should not be stored in food service areas.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as required by their policy. The policy outlined that the Quality Assurance and Assessment (QAA) committee should include the Director of Nursing (DON), Medical Director (MD), Infection Preventionist (IP), and three other staff members, and that the committee should meet at least quarterly to address quality deficiencies. However, the facility's QAA committee did not include the IP due to their night shift schedule, and the facility had not conducted any performance improvement projects (PIPs) as mandated by their policy. Additionally, the committee had not addressed significant issues such as resident weight loss during their meetings. An interview with the Administrator revealed that the QAA committee met monthly, but the IP was not involved in these meetings. The Administrator stated that the DON was informed about infection control topics, and the committee occasionally discussed issues like infection surveillance, antibiotic stewardship, abuse, gradual dose reductions (GDRs), and medication regime reviews (MRR). Despite these discussions, the facility did not implement any PIPs, which are essential for addressing high-risk or problem-prone areas, as required by their QAPI policy. This lack of action had the potential to affect all 34 residents residing in the facility.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to utilize the required Personal Protective Equipment (PPE) when performing wound care for a resident on Enhanced Barrier Precautions. The resident, who was admitted with diagnoses including dementia, a history of Transient Ischemic Attack, hemiplegia, and an unstageable pressure ulcer, was observed without proper signage indicating the need for enhanced precautions. A Registered Nurse (RN) did not wear a gown, gloves, or mask while performing a dressing change, despite the presence of PPE outside the resident's room. The RN was unaware of the need for additional PPE, and it was later confirmed that the facility should have had signs posted to inform staff of the precautions. The facility also failed to complete hand hygiene and proper gloving during a blood glucose test for another resident. A Medication Aide (MA) did not use a barrier for the blood glucose monitor and supplies, did not perform hand hygiene, and did not wear gloves during the procedure. The MA also failed to clean and disinfect the blood glucose monitor before returning it to storage. These actions were confirmed as incorrect by the Vice President of Operations, who noted the lack of adherence to the facility's policies on hand hygiene and glove use. Additionally, the facility did not implement measures to prevent the growth of Legionella and other waterborne pathogens. The Administrator confirmed that no water risk assessment had been conducted, and there was no documented plan to prevent pathogen growth in the facility's water systems. The facility's policy on Legionella prevention was not followed, as there was no full-scale environmental investigation or decontamination of potential sources.
Deficiency in Nursing Assistant Continuing Education
Penalty
Summary
The facility failed to ensure that four Nursing Assistants (NAs) received the required 12 hours of continuing education in 2023, which includes training in Dementia care and infection control. A review of staff education records showed that NA-M had only 0.5 hours of continuing education and lacked both Dementia and infection control training. NA-N completed 4.25 hours of continuing education but did not receive Dementia training. NA-O had 7.10 hours, and NA-P had 5.15 hours of the required 12 hours of continuing education. An interview with the Administrator confirmed the deficiency in staff education. The facility's policy, effective October 2022, mandates compliance with State and Federal regulations for continuing education, including training in Dementia, infection control, and abuse/neglect. However, the facility did not adhere to these requirements, as evidenced by the incomplete training records of the nursing assistants.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide timely repositioning, feeding assistance, and toileting/incontinence management for several residents who required assistance with activities of daily living (ADLs). Resident 4, who had diagnoses including dementia and chronic obstructive pulmonary disease, required extensive assistance with various ADLs. Observations revealed that Resident 4 was left in a wheelchair for extended periods without repositioning or toileting assistance, resulting in the resident being found with saturated clothing and dried feces on their skin. The resident was also not provided adequate assistance during meal times, consuming only a few bites of food. Resident 27, admitted with a primary diagnosis of cerebral infarction, required partial assistance with eating. However, observations showed that the resident was left unattended with uneaten food in front of them for extended periods. Despite attempts to wake the resident, staff did not provide consistent assistance, resulting in the resident not consuming their meals. The Director of Nursing acknowledged that staff should have assisted the resident more, especially given the resident's recent stomach bug and decreased appetite. Resident 15, with severe cognitive impairment and frequent incontinence, required maximum assistance with toileting and personal hygiene. Observations indicated that the resident was not assisted with toileting for several hours, both before and after breakfast. Interviews with staff confirmed that the resident had not been toileted since before breakfast, highlighting a failure to provide necessary assistance in a timely manner.
Inadequate Staffing Leads to Insufficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, resulting in inadequate feeding assistance, repositioning, and incontinence care for several residents. Resident 4, who had multiple diagnoses including dementia and required extensive assistance with activities of daily living, was observed in a tilt-n-space wheelchair unable to reach their meal. Despite attempts to assist, the resident consumed only a few bites of food and was left without proper repositioning or incontinence care for extended periods, leading to saturated clothing and dried feces on the skin. Similarly, Resident 27, who required partial assistance with eating, was left unattended with uneaten meals in front of them. The resident was observed with eyes closed and food untouched for long durations, indicating a lack of staff intervention to ensure adequate nutrition. Despite being cued to eat, the resident's food intake was minimal, and they were often left without assistance, highlighting the facility's staffing inadequacies. Interviews with staff and the Director of Nursing confirmed the staffing shortages, with only one nurse aide available during meal times and insufficient staff to provide necessary care. The facility's staffing assignments revealed gaps in coverage, contributing to the inability to meet residents' needs for timely assistance with meals, repositioning, and incontinence management.
Failure to Ensure Call Device Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call devices were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident 14, who had severe cognitive impairment and required maximum assistance for toileting, hygiene, and dressing, was observed on two separate occasions with the call device hanging on the wall at the foot of the bed, out of reach. During one observation, Resident 14 was found lying in bed, whimpering and crying out for help, indicating distress and an inability to access assistance. Similarly, Resident 23, who had a self-care deficit related to dementia, impaired balance, and limited mobility, was observed twice without a call device within reach or viewable sight. The care plan for Resident 23 included an intervention to encourage the use of the call device for assistance, which was not adhered to. An interview with a nurse aide confirmed that call devices should be within reach for all residents, highlighting a lapse in the facility's adherence to its policy on call light accessibility.
Inaccurate Assessment of Resident's Medication Usage
Penalty
Summary
The facility failed to accurately assess a resident's medication usage during the completion of their Admission Minimum Data Set (MDS). The resident, who was admitted with a diagnosis of Type 2 Diabetes Mellitus, had physician's orders for glipizide, metformin, and Victoza, all intended to manage their diabetes. However, the Admission MDS inaccurately documented that the resident had received insulin injections during the lookback period, despite the Medication Administration Record (MAR) showing no orders for insulin and confirming the resident took their oral hypoglycemic medications as prescribed. An interview with the resident revealed that they had been taking Victoza, a noninsulin injectable medication, for 5 to 6 years. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. The facility's policy on MDS, which aims to ensure the timeliness and accuracy of assessments, was not adhered to, resulting in the inaccurate documentation of the resident's medication usage.
Failure to Update Care Plan for UTI Treatment
Penalty
Summary
The facility failed to update the care plan for a resident who was diagnosed and treated for a urinary tract infection (UTI). The resident, who was admitted with a primary diagnosis of unspecified dementia with psychotic disturbance, showed symptoms of a UTI, including blood in the urine and painful urination. A urinalysis was conducted, and the resident was treated with antibiotics Bactrim DS and Keflex for the UTI. Despite these developments, the resident's care plan was not updated to reflect the new diagnosis and treatment. The facility's policy requires care plans to be updated to reflect current care needs as changes occur. However, a review of the resident's care plan revealed no updates regarding the UTI or the antibiotics prescribed. The Director of Nursing confirmed that the care plan should have been revised to include new interventions following the diagnosis and treatment of the UTI.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement interventions per their policy and the resident's care plan for a resident with a stage 4 pressure ulcer. The resident, who was admitted with complete paraplegia and fecal incontinence, had a primary diagnosis of a stage 4 pressure ulcer on the right ischium. The facility's policy required repositioning every two hours for residents in bed and every hour for those in a wheelchair, but these measures were not consistently followed. Observations revealed that the resident was often left in the same position for extended periods, both in bed and in a wheelchair, contrary to the care plan's requirements. The resident's air mattress was incorrectly set at 250 pounds, despite the resident weighing 109 pounds, which was confirmed by the Director of Nursing (DON) as inappropriate. The resident was observed lying on their back or at a slight angle with the head of the bed elevated beyond the recommended degree, and repositioning was not done as frequently as required. Interviews with the DON confirmed that the resident was not repositioned as per the care plan and facility policy. The DON acknowledged that the air mattress setting was incorrect and that the head of the bed was elevated more than the policy allowed. These failures in following the care plan and facility policy contributed to the deficiency in providing appropriate pressure ulcer care and prevention for the resident.
Failure to Document Physician Review of Medication Regimen
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews were reviewed by the physician and that a rationale was provided when no action was taken for one of the sampled residents. Resident 14, who was admitted to the facility with multiple diagnoses including Dementia, Parkinson's disease, delusional disorder, Major Depressive Disorder, anxiety, heart failure, and Chronic Obstructive Pulmonary Disease, did not have documentation showing that the physician had completed the required monthly medication review. Specifically, a Consultation Report dated 9/24/2023 indicated that the pharmacist conducted a comprehensive medication review, but there was no documentation of a physician review. Further, a Consultation Report dated 11/15/2023 revealed that the pharmacist had concerns regarding Resident 14's use of citalopram and risperidone, yet there was no documentation that the physician reviewed or responded to these concerns. An interview with the President of Operations confirmed the lack of documentation for the physician's review of the Medication Regimen Reviews for the specified dates. Additionally, a Consultation Report with a recommendation date of 5/24/2023 showed a recommendation to trial discontinuation of melatonin, which the physician declined with a rationale of no change. The facility's policy, last revised on 8/17/2023, mandates adherence to CMS guidelines for pharmaceutical care, which was not followed in this instance.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days or had a stop date or duration documented by the prescriber. Specifically, for one resident, there was an order for Seroquel, an antipsychotic medication, to be administered as needed for insomnia, without a stop date, duration, or re-evaluation date. The facility's policy required that PRN orders for antipsychotic medications be limited to 14 days and not renewed unless the physician evaluated the resident for the appropriateness of the medication. The resident involved had a history of heart failure, insomnia, atrial fibrillation, osteoarthritis, and a recent urinary tract infection. The resident's cognition was moderately impaired, and they exhibited verbal behaviors directed at others, impacting their care. The Director of Nursing confirmed that the only diagnosis for the PRN Seroquel was insomnia, which the facility did not consider appropriate for the use of an antipsychotic medication. This oversight in medication management led to the deficiency noted in the report.
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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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