Newport House
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 6798 N 67th Plaza, Omaha, Nebraska 68152
- CMS Provider Number
- 285085
- Inspections on file
- 18
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Newport House during CMS and state inspections, most recent first.
Food items in the kitchen were found unlabeled, undated, and/or unsealed in the reach-in freezer, walk-in refrigerator, and walk-in freezer. Surveyors observed multiple bags of food, open sliced cheese, and a sheet pan item that were not properly labeled or sealed, and the Sous Chef and TLFNS confirmed the items should have been labeled or sealed.
Multiple infection control failures were observed during resident care and equipment handling. Staff used a Hoyer lift for transfers without disinfecting it, did EBP cares for a resident with an ileostomy and PEG tube without wearing gowns, left a nebulizer kit with residual liquid after use, failed to perform hand hygiene between glove changes during perineal care, and handled washcloths in ways that could cause cross contamination. Respiratory equipment for another resident was also left undated or stored improperly, including nebulizer tubing, an O2 humidification bottle, BiPAP tubing on the floor, and a BiPAP mask on a bedside table without a barrier.
A resident with a history of stroke, hemiplegia, moderate cognitive impairment, and chronic constipation repeatedly refused multiple ordered bowel medications over an extended period, as documented on the MAR and in nursing progress notes. RNs educated the resident several times about the importance of the bowel regimen while noting prolonged absence of BM and episodes of vomiting, but the refusals continued. Facility policy required notifying the physician when treatment needed to be significantly altered, using an SBAR tool for communication. Record review showed no evidence that the provider was notified of the ongoing medication refusals, and there were no documented parameters for notification in the orders or care plan; the RN team lead and DON confirmed that no SBAR or other provider notification was found.
A resident with CHF, delirium, depression, anxiety, and hospice services had PRN Lorazepam continued beyond the 14-day limit without a clear documented rationale on the pharmacist recommendation. The MAR and progress notes showed PRN doses were given for anxiety, but no behaviors or non-pharmacological interventions were documented, and the DON confirmed the rationale was anxiety.
Failure to implement a comprehensive nutrition care plan. A resident with severe cognitive impairment, extensive assistance needs, and about 50% meal intake had a baseline plan for a mechanical soft diet and eating assistance, but the comprehensive care plan did not include altered nutrition. The RD confirmed the nutrition care plan should have been in place earlier but was not implemented until later.
A resident with severe cognitive impairment and extensive feeding assistance needs experienced significant weight loss after poor PO intake, decreased fluids, and swallowing difficulty were documented. The hospital dietary consult recommended a soft diet and Ensure with meals, but no supplement orders were entered and no nutrition care plan was in place. Weights showed a loss of more than 6% within 30 days, and the RD confirmed the weight loss was not identified until later and interventions were not put into place until after the significant loss was noted.
Medication Administration Errors Exceeded Allowed Rate: The facility had an 8% med error rate, with 2 errors out of 25 opportunities. An RN gave riluzole to one resident while the resident was eating, even though the order required it to be given by PEG tube 1 hour before or 2 hours after meals, and another RN gave omeprazole to a second resident with breakfast instead of 60 minutes before the meal.
The facility failed to properly dispose of medications as observed during medication administration. An RN and an LPN were seen disposing of dropped medications in the trash can attached to the medication cart, contrary to facility policy. Both staff members confirmed their lack of knowledge regarding proper disposal procedures, as verified by the DON.
Food Storage Items Left Unlabeled and Unsealed
Penalty
Summary
Food stored in the kitchen was not labeled, dated, and/or sealed in accordance with the facility’s Food Storage General Guidelines policy and the FDA Food Code 2022. During observation of the large reach-in freezer, surveyors found multiple items that were not labeled or sealed, including a clear bag of small round brown substance, a clear bag of large flat tan/brown substance, two brown bags of yellow elongated substance identified by staff as French fries, and a brown bag of tan round substance identified by staff as tator tots. In the walk-in refrigerator, an open package of sliced cheese was observed that was not sealed. In the walk-in freezer, surveyors observed a large sheet pan with round, colorful, tan substance that was not labeled, dated, or sealed. During interview, the Sous Chef confirmed the unlabeled and unsealed items in the freezer should have been labeled or sealed, and identified the brown bag of yellow elongated substance as French fries and the brown bag of tan round substance as tator tots. The Team Lead Food Nutrition Services also confirmed the open sliced cheese in the walk-in refrigerator and the unlabeled, undated, and unsealed sheet pan item in the walk-in freezer should have been sealed and labeled.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during multiple resident care activities and equipment handling. The report states that Hoyer lifts were used for transfers without being disinfected before or after use. On one occasion, staff brought the lift into Resident 7’s room without disinfecting it, used it to transfer the resident from a wheelchair to bed, and then placed it back in the hallway without cleaning it. The same lift was later taken into another resident’s room and used again without disinfection. An RN and NA confirmed the lift had not been disinfected before or after use, and the DON confirmed staff should have disinfected it. The facility also failed to follow barrier precautions and hand hygiene expectations during care for a resident in EBP. Resident 14 had an ileostomy and PEG tube and was identified in the care plan as requiring gowns and gloves during high-contact care. During PEG tube care, an RN performed hand hygiene and gloved but did not wear a gown. During ileostomy care, an NA performed the task with gloves but without a gown. The RN confirmed the resident was in EBP and that both staff members should have worn gowns during those cares. Additional infection control failures involved respiratory equipment and linen handling. Resident 7’s nebulizer administration kit was observed multiple times with residual liquid remaining in it, and staff did not rinse the kit after use as required by facility policy. During incontinence and hygiene care for Resident 3, an NA removed soiled briefs, performed perineal care, removed gloves, and reapplied new gloves without hand hygiene. The same NA also placed washcloths on the bedside table without a barrier and squeezed washcloths against the sink basin before using them for facial and perineal care; both the NA and RN confirmed these actions could cause cross contamination. For Resident 9, respiratory equipment was observed stored and maintained without required labeling or proper placement. The resident had orders for oxygen, BiPAP with heated humidification, and nebulizer treatment. The nebulizer kit and tubing were undated, the disposable oxygen humidification bottle was undated, the BiPAP bleed-in tubing was stored on the floor, and the BiPAP mask was left on the bedside table without a barrier. The LPN and the ADON/Infection Preventionist confirmed these items should have been dated and stored in a manner to prevent cross-contamination.
Failure to Notify Provider of Ongoing Refusal of Bowel Regimen
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the medical practitioner of ongoing refusals of prescribed bowel medications for one resident. The facility’s policy, last reviewed on 08/27/2018, required notification of the physician or designee and the resident’s legal representative when there was a need to significantly alter treatment, including discontinuation of existing treatment due to ineffectiveness or adverse consequences, or initiation of new treatment. The policy specified use of an SBAR tool for non-emergent notifications, with documentation to be filed in the physician’s order section of the chart. Despite this policy, the facility did not notify the provider when the resident repeatedly refused bowel regimen medications over a series of days. The resident involved had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, difficulty walking, moderate cognitive impairment (BIMS score of 7), and constipation. The comprehensive care plan included monitoring for constipation, monitoring bowel and bladder patterns every shift, and ongoing education about bowel management, noting that the resident often stated it was normal to go a lengthy time between bowel movements and that the resident sometimes refused bowel protocol due to past work circumstances. Physician orders included multiple bowel regimen medications (prune products PRN, milk of magnesia PRN, senna, bisacodyl suppository PRN, Motegrity, Miralax, and an order to document bowel sounds and abdominal characteristics daily). Medication Administration Records showed that over a 10-day period the resident refused docusate sodium 15 of 20 scheduled doses, refused Motegrity and Miralax 8 of 10 scheduled doses, and refused senna on 2 occasions. Progress notes documented repeated refusals despite RN education on the importance of bowel medications and more frequent bowel movements, and noted the resident had gone 7 and then 8 days without a bowel movement while continuing to refuse bowel protocol, though bowel sounds were active in all quadrants at those times and the resident denied pain or discomfort. Additional notes documented vomiting episodes and changes in bowel sounds on one day. A physician dictation later acknowledged the resident had not been taking the bowel regimen because of dislike of the medications. However, review of progress notes, scanned documents, and the physical chart revealed no evidence that the medical practitioner had been notified of the repeated refusals, and there were no documented parameters for notification of medication refusals in the physician’s orders or care plan. The RN Team Lead and DON confirmed there was no evidence of SBAR communication or provider notification for these refusals during the period reviewed.
Missing documented rationale for continued PRN Lorazepam
Penalty
Summary
The facility failed to ensure a rational was documented to continue PRN Lorazepam beyond 14 days for one resident. Resident 7 had diagnoses of chronic diastolic CHF, delirium due to a known physiological condition, depression, and anxiety, and was noted on the MDS to have a BIMS score of 15, indicating cognitive awareness. The resident required varying levels of assistance with activities of daily living, had no behaviors, and was receiving hospice services. Resident 7 had standing orders for scheduled Lorazepam at bedtime and PRN Lorazepam concentrate every hour as needed for anxiety. The PRN Lorazepam was administered twice in January 2026, and the progress notes for those administrations documented anxiety but did not document behaviors or non-pharmacological interventions. A pharmacist recommendation dated 10/08/2025 noted CMS required a 14-day stop on PRN psychotropic medications unless the prescriber documented clinical rational for continued use and a new duration; the prescriber agreed to continue the medication for 6 months, but the response did not include a clear rational for continued PRN use. The DON confirmed that the rational documented for the continued PRN Lorazepam was anxiety and that, for a normal resident not on hospice, a rational should have been documented on the pharmacist recommendation.
Failure to Implement Comprehensive Nutrition Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan to prevent the potential for altered nutrition for Resident 3. The resident’s MDS dated 01-04-2026 showed admission to the facility, an admission weight of 173 lbs, a BIMS score of 0 indicating severe cognitive impairment, extensive assistance needed with eating, and total assistance needed with hygiene, dressing, bed mobility, transfers, toileting, and bathing. The baseline care plan dated 12-31-2025 noted a regular mechanical soft diet and assistance with eating. The Nutrition Assessment dated 01-04-2026 identified a goal to provide adequate nutrition and hydration and improve oral intake to 75% or greater at 2 meals daily, and documented that the resident had no edema, was averaging 50% meal intake, would be followed for possible oral nutritional supplements, and had no skin breakdown. The comprehensive care plan dated 01-05-2026 did not include a plan of care for altered nutrition, and the Registered Dietician confirmed on 01-28-2026 that a comprehensive care plan for altered nutrition should have been implemented on or before 01-20-2026 but was not implemented until 01-26-2026.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to evaluate, monitor, and implement interventions for Resident 3’s significant weight loss. Resident 3 was admitted with a weight of 173 pounds, had severe cognitive impairment with a BIMS score of 0, and required extensive to total assistance with eating and most activities of daily living. The hospital dietary consult noted poor oral intake, trouble with a regular diet, and family assistance with eating, and recommended a soft diet and Ensure three times daily. However, the resident’s order summary and MAR showed no orders for Ensure or other nutritional supplements, and the comprehensive care plan had no nutrition care plan. Resident 3’s weights showed a decline from 172.2 pounds to 166.0 pounds, then to 162.0 pounds, which was a 6.15% loss within 30 days and a significant weight loss, and later to 161.3 pounds, a 6.32% loss within 30 days of admission. The nutrition assessment documented average meal intake of 50% and noted the resident would be followed for possible oral nutritional supplements, but the record contained no evaluation or implementation of interventions when the significant weight loss was identified. Progress notes also documented decreased fluid intake, change in appetite, difficulty swallowing at times, and new orders to encourage fluids and monitor for decreased appetite, weight loss, and worsening kidney function. During observation, the resident ate only a few bites of breakfast while the daughter assisted.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with 2 medication errors identified out of 25 opportunities for error, resulting in an 8 percent medication error rate. The facility policy required medications and treatments to be stored and administered in a safe and effective manner and to follow the 6 rights of medication administration, including the right time and right documentation. During observation, RN E administered multiple medications to Resident 84 while the resident was eating breakfast, including riluzole 50 mg. The resident’s order required riluzole 50 mg to be given by PEG tube twice daily, 1 hour before or 2 hours after a meal, and RN E confirmed it was not given within that time frame. In a separate observation, RN D administered omeprazole 20 mg to Resident 52 while the resident was eating breakfast. The resident’s order required omeprazole 20 mg daily to be given 60 minutes before meals, and RN confirmed it was given with breakfast instead of before the meal.
Improper Medication Disposal by Nursing Staff
Penalty
Summary
The facility failed to dispose of medications in accordance with standard practice, as observed during a medication administration process. During an observation, a Registered Nurse (RN) dropped a Tylenol 500 mg tablet on the floor and subsequently disposed of it in the trash can attached to the medication cart. The RN confirmed in an interview that they were unaware of the proper procedure for disposing of medications. Similarly, a Licensed Practical Nurse (LPN) was observed placing several medications, including Atorvastatin, Sertraline, Amlodipine, Memantine, Aspirin, Carvedilol, and Donepezil, into a medication cup. While preparing to crush these medications, they fell on the floor. The LPN picked up the medications and disposed of them in the trash can attached to the medication cart. The LPN also confirmed in an interview that they did not know the correct disposal procedure. The Director of Nursing (DON) confirmed that both the RN and LPN did not follow the facility's policy for medication disposal.
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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