Old Mill Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 1131 Papillion Parkway, Omaha, Nebraska 68154
- CMS Provider Number
- 285289
- Inspections on file
- 26
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Old Mill Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure the Dietary Manager met regulatory qualifications. Record review showed the DM had no formal education in food or nutrition and no DM certification. The Administrator confirmed the DM was not certified, the RD did not work full time, and no other DM was overseeing the kitchen while the DM awaited a course start date. The DON stated that all 36 residents ate food prepared in the facility kitchen.
Kitchen ventilation covers and walk-in cooler circulation fans were observed with visible dust-like buildup. Four ceiling vent covers over food prep areas had grey fuzzy specks, and two cooler fans had a heavy black fuzzy coating while blowing toward food on shelves. The DM confirmed the buildup and stated dust could fall into the food, and the DON confirmed all residents ate food prepared in the kitchen.
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic meds, failed to monitor for EPS/tardive dyskinesia with antipsychotic use, and used an inappropriate diagnosis for risperidone in one resident. One resident had intact cognition with depression, anxiety, hemiplegia, and seizure disorder, while the other had moderate cognitive impairment with dementia and depression; records and the DON confirmed that the CCP, orders, MAR, and EMR did not include resident-specific behavior monitoring or EPS assessments.
Failure to Include Ordered Fluid Restrictions in Care Plans: Two residents had physician-ordered fluid restrictions that were not included in their CCPs. One resident had a 1.5 L daily fluid restriction, and another resident with HTN, a BIMS score of 11, and supervision needs had an order for a fluid restriction related to HTN, but neither care plan addressed the nutritional intervention. The MDS Coordinator confirmed the omissions.
Surveyors found that ventilation covers in several resident bathrooms were coated with dust due to insufficient cleaning frequency and unclear documentation practices. The facility's cleaning assignments and policy did not specify how often or how to document the cleaning of these covers, leading to inconsistent maintenance.
The facility did not maintain operational ventilation systems in 11 resident bathrooms on one hallway, as observed when the ventilation failed to draw a single ply of toilet paper to the vent cover. The Maintenance Director confirmed that routine checks were not performed as required, and documentation showed the last facility-wide check occurred several months prior.
A resident with hypertension received Hydralazine outside of physician-ordered blood pressure parameters on several occasions, and the physician and resident representative were not notified as required. The MAR showed medication was given when the resident's systolic blood pressure was below the ordered threshold, and in some cases, blood pressure readings were not documented. Facility policy required notification and documentation, but these actions were not taken.
Two residents with orders for oxygen therapy and respiratory treatments did not have their respiratory care needs addressed in their comprehensive care plans, despite facility policy and physician orders requiring such documentation. Observations confirmed the use of oxygen and nebulizer equipment, and staff interviews acknowledged the omission of these needs from the care plans.
A resident with a history of repeated falls and osteoarthritis, who required two-person assistance for transfers per care plan, was transferred with only one staff member on multiple occasions. The resident reported a recent fall and pain, and staff interviews confirmed that the two-person transfer protocol was not followed.
A nurse aide was rehired without the facility completing the required criminal background, APS, or CPS checks as mandated by policy and state regulations. The administrator confirmed that these screenings, which had been done at initial hire, were not repeated at rehire.
A facility failed to ensure timely response to residents' call lights, with multiple instances of delays exceeding 20 minutes. Residents with varying medical needs and cognitive abilities experienced significant delays, leading to accidents and unmet care needs. The facility's policy lacked a specific timeframe for call light response, contributing to the deficiency.
A resident with gastrointestinal issues did not receive Dulcolax as ordered due to an entry error marking it as PRN instead of BID. Additionally, despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once, even though the resident experienced frequent diarrhea. The RN and DON confirmed these oversights, leading to a deficiency in care.
A resident with a history of heart and respiratory issues experienced a significant medication error when warfarin was administered despite an APRN's order to hold the medication due to a high INR. The resident received doses on two consecutive days, leading to an increased INR, which was confirmed by the DON and an LPN as a significant error.
The facility failed to complete tracking/discharge MDS for 17 residents. A review of discharge Electronic Health Records revealed the missing MDS. The newly hired MDS Coordinator confirmed the requirement to complete the MDS within 3 days of discharge. The facility Administrator was unaware of the incomplete MDS and acknowledged the oversight.
A facility failed to have a physician's order for CPAP for a resident with COPD, Obstructive Sleep Apnea, heart failure, and hypertension. The resident's care plan indicated CPAP use, but no order was found in the records. The resident confirmed nightly use of the CPAP with nursing staff assistance, and an LPN confirmed the absence of an order.
The facility failed to provide written notification and a reason for discharge to a resident or the resident's representative, despite the resident being transferred to the hospital due to urgent medical needs. This deficiency was confirmed through interviews with the facility Administrator.
The facility staff failed to notify the practitioner or responsible party of falls for two residents. One resident experienced a fall with injuries, and the family was not informed. Another resident fell multiple times, and neither the family nor the physician was notified. This was confirmed through record reviews and interviews with the facility administrator.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager was qualified under regulations. Record review of the Dietary Manager’s employee file showed a hire date of 3/27/26, with no formal education in food or nutrition and no certification as a Dietary Manager. During interview on 03/30/2026 at 10:55 AM, the Administrator confirmed that the Dietary Manager was not currently certified and was enrolled in a class scheduled to start 05/01/2026. The Administrator also confirmed that the Registered Dietician did not work full time in the facility and that no other Dietary Manager was currently working with the existing Dietary Manager to oversee the facility until the dietary management course could be completed. During interview on 04/01/2026 at 2:37 PM, the DON stated that all 36 residents in the facility ate foods prepared in the facility kitchen.
Kitchen Ventilation and Cooler Fans Not Kept Clean
Penalty
Summary
The facility failed to ensure the cleanliness of ceiling ventilation system covers in the kitchen and ventilation fans in the walk-in cooler. During observation with the Dietary Manager, specks of a grey fuzzy substance resembling dust were seen on the exterior of 4 ceiling ventilation covers located directly over food preparation areas in the kitchen. In the walk-in cooler, 2 circulation fans had a heavy coating of a black fuzzy substance and were turned on, blowing toward food stored on shelves. The Dietary Manager confirmed the presence of the dust-like substance on the ventilation covers and fans and stated there was a potential for the dust to fall into the food, but was unable to confirm when the covers and fans were last cleaned. The Director of Nursing confirmed that all 36 residents in the facility ate food prepared in the kitchen.
Failure to Monitor Psychotropic Medication Use and Resident-Specific Behaviors
Penalty
Summary
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic medications, failed to monitor for tardive dyskinesia/extrapyramidal symptoms for both residents, and failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for one resident. Resident 48 was admitted with a BIMS score of 15/15 and diagnoses including depression, anxiety disorder, hemiplegia/hemiparesis, and seizure disorder. The record showed an order for risperidone, but the DON confirmed that generalized anxiety disorder was not an appropriate diagnosis for risperidone. The resident’s EMR contained no assessment to monitor extrapyramidal symptoms, and the DON confirmed that no such assessment had been completed. The order to monitor anxiety used a generalized standing order rather than resident-specific behaviors. Resident 5 was admitted with diagnoses including major depressive disorder, unspecified dementia, and anxiety, and had a 5-day MDS BIMS score of 10, indicating moderate cognitive impairment. The resident’s CCP listed psychotropic medications including quetiapine for dementia and desvenlafaxine for major depressive disorder, but the CCP did not include resident-specific target behaviors for continued use of either medication. Physician orders and the MAR also did not identify or monitor resident-specific target behaviors for quetiapine or desvenlafaxine. The EMR showed no monitoring for extrapyramidal symptoms related to quetiapine, and the DON confirmed that resident-specific target behaviors should have been identified and documented daily on the MAR and that no assessment for extrapyramidal symptoms had been completed.
Failure to Include Ordered Fluid Restrictions in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans related to physician-ordered fluid restrictions for 2 residents. Resident 44 had a comprehensive care plan that did not address the ordered 1500 cc daily fluid restriction. The record included an order summary dated 3/31/26 showing a 1.5 L fluid restriction and a dietary progress note dated 4/1/26 identifying a 1500 ml/day fluid restriction. During interview, the MDS Coordinator confirmed that the fluid restriction should have been included in the care plan in the nutritional section. Resident 9 was admitted on 03/16/26 with diagnoses including fracture of the right femur and hypertension. The admission MDS showed a BIMS score of 11, indicating moderately impaired cognition, and identified that the resident required supervision with activities of daily living and had no special nutritional approaches. The order summary dated 04/01/2026 showed an order for a 2000 Liter fluid restriction two times per day related to hypertension, starting on 03/26/26, but the resident's care plan dated 02/24/2026 did not include any specific information about the ordered fluid restriction. The MDS Coordinator confirmed that the fluid restriction had not been identified on the care plan and should have been included in the nutritional section.
Failure to Maintain Clean Ventilation Covers in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain the cleanliness of interior and exterior ventilation covers in eight occupied resident rooms along the south hallway. During a walkthrough with the Administrator and Maintenance Director, it was noted that the ventilation covers in resident bathrooms were coated with a white and gray fuzzy substance resembling dust. The Administrator confirmed the presence of this buildup and acknowledged that the current practice was to clean the covers monthly or upon resident discharge, which was not sufficient to prevent dust accumulation. A review of facility cleaning documentation revealed inconsistencies, with some records undated and lacking clear evidence of when cleaning was completed. The facility's cleaning assignments included a general note to check and wipe vents, but did not specify the frequency or documentation requirements for cleaning ventilation covers. Additionally, the facility's policy on routine cleaning and disinfection did not address the cleaning of ventilation covers in resident bathrooms. The Administrator confirmed that both the cleaning assignments and policy lacked necessary specificity regarding these tasks.
Failure to Maintain Operational Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation systems in resident bathrooms were operational in 11 out of 21 occupied bathrooms located on the south hallway. During an observation conducted with the Administrator and Maintenance Director, it was found that the ventilation system in these bathrooms was not functional, as evidenced by the inability of the system to draw a single ply of toilet paper to the surface of the ventilation cover. The Maintenance Director confirmed that the ventilation systems had not been routinely checked for proper function in these areas and that only one check had been performed since the Maintenance Director began employment in October 2024. Further review of facility records revealed that the last documented check of the ventilation systems facility-wide was on 11/24/25, with no other documentation available regarding ongoing checks. The facility's policy requires the Maintenance Director to maintain documentation of all inspections, tests, and maintenance of the HVAC system. The Administrator confirmed that staff should have been checking the ventilation system at least monthly, and ideally weekly, to ensure proper operation, but this was not done.
Failure to Notify Physician and Representative of Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to notify the physician and resident representative when a resident received Hydralazine outside of the physician-ordered blood pressure parameters. The resident, who was cognitively intact with a BIMS score of 14, had an order for Hydralazine to be held if the systolic blood pressure (SBP) was less than 150. Despite this, the medication was administered multiple times when the resident's SBP was below the ordered threshold, as documented in the Medication Administration Record (MAR). In some instances, blood pressure readings were not recorded on the MAR at all. Interviews confirmed that the family member was concerned about the administration of blood pressure medication outside of prescribed parameters, and the Director of Nursing acknowledged that the physician should have been notified when the medication was given outside of parameters. Facility policy required staff to obtain and record vital signs, hold medications outside of parameters, and notify the physician in the event of a medication error, but these steps were not followed in this case.
Failure to Develop Comprehensive Care Plans for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CCPs) that addressed the respiratory care and oxygen needs for two residents who required such services. Facility policy required that CCPs include specific interventions for oxygen therapy, such as the type of delivery system, administration schedule, flow rates, monitoring requirements, and potential complications. However, for both residents sampled, the CCPs did not contain any information related to their respiratory care or oxygen use, despite physician orders and assessments indicating the need for continuous or as-needed oxygen therapy. One resident was observed using an oxygen concentrator set at 3 liters per minute and had diagnoses of chronic respiratory failure with hypoxia and acute pulmonary edema. The resident's Minimum Data Set (MDS) and physician orders documented the need for continuous oxygen and specific parameters for administration, yet the CCP lacked any mention of these needs. Interviews with the MDS coordinator and Director of Nursing confirmed that the care plan did not address the resident's respiratory care or oxygen use, and that this was not in accordance with facility policy. Another resident had physician orders for nebulizer treatments and as-needed oxygen to maintain saturation above 90%, with the MDS also indicating continuous oxygen use. Observations confirmed the presence of oxygen and nebulizer equipment in the resident's room, but the CCP did not reflect any respiratory care needs. Additionally, an LPN was unaware of the current nebulizer orders, and the MDS coordinator confirmed the omission of respiratory care needs from the care plan.
Failure to Implement Two-Person Transfer Protocol for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with a history of repeated falls, primary osteoarthritis, and a recent urinary tract infection. The resident's care plan specified the need for assistance from two staff members (Ax2) for all transfers and use of a wheelchair for mobility. Despite this, documentation and interviews revealed that the resident was transferred with only one staff member assisting on at least one occasion, contrary to the care plan requirements. The provider was notified of an incident where the resident was transferred with only one staff member, and the resident reported experiencing a fall in the bathroom a couple of days prior, resulting in pain in the right arm and shoulder. Observation further confirmed that the resident was transferred from the bed to a chair with only one staff member assisting, despite the presence of both an occupational therapist and a nursing assistant in the room. Interviews with staff confirmed that the resident should have been transferred with two staff members, and that this protocol was not followed during the observed transfer. These actions demonstrate a failure to provide adequate supervision and implement fall prevention interventions as assessed and documented in the resident's care plan.
Failure to Complete Required Background Checks at Rehire
Penalty
Summary
The facility failed to complete required criminal background checks (CBG), Adult Protective Services (APS) checks, and Child Protective Services (CPS) checks at the time of rehire for one nurse aide. According to the facility's abuse prohibition policy, all potential employees, including rehires, must undergo background, reference, and credential checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. Documentation of these screenings is required to be maintained by the facility. Record review showed that the nurse aide in question had previously worked at the facility, with all required checks completed at the time of initial hire. However, upon rehire, there was no documentation that the necessary CBG, APS, or CPS checks were repeated. The facility administrator confirmed during an interview that these checks were not completed at the time of rehire, as required by facility policy and state regulations.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure that residents' call lights were answered within 20 minutes, as expected, for four sampled residents. The facility's policy on call light response did not specify a timeframe for answering call lights, which contributed to the deficiency. The facility's Patient Concern Forms revealed multiple complaints about long call light response times from residents and their families. Resident 1, who was cognitively intact and had specific medical conditions requiring prompt assistance, experienced multiple instances where call lights were not answered within 20 minutes. The resident's family reported incidents where the resident had to wait for assistance after vomiting and during a diarrhea episode, leading to significant delays in care. The Past Calls log documented numerous instances of call lights running for over 20 minutes, with some exceeding 30 minutes. Resident 4, also cognitively intact, required substantial assistance with daily activities and experienced similar delays in call light responses, with some instances exceeding 40 minutes. The resident confirmed having accidents while waiting for assistance. Residents 2 and 3, with varying levels of cognitive impairment and assistance needs, also experienced prolonged call light response times, with logs showing multiple instances of delays over 20 minutes. The Director of Nursing confirmed that the facility's goal was to answer call lights within 6-7 minutes, but the expectation was within 20 minutes.
Failure to Administer Medications as Ordered for Gastrointestinal Issues
Penalty
Summary
The facility failed to administer Dulcolax as per the provider's orders for a resident with a suspected bowel obstruction. The resident, who was cognitively intact and required assistance with daily activities, had a medical history of partial intestinal obstruction and other gastrointestinal issues. A verbal order for Dulcolax suppository twice daily was given by an APRN and documented by an RN, but the medication was only administered once due to an error in entering the order as PRN instead of BID. This oversight was confirmed by the RN and the Director of Nursing (DON) upon review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Additionally, the facility did not adequately address the resident's recurrent diarrhea. Despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once during a period when the resident experienced loose stools almost daily. The RN acknowledged being informed by nursing assistants about the resident's condition but did not assess the resident or administer the medication, citing instructions from the APRN not to administer it starting on a specific date. However, the order for Loperamide remained active and was not placed on hold. The DON confirmed the resident's frequent loose stools and the lack of consistent administration of the PRN Loperamide, which should have been offered to the resident even if not requested. The failure to follow the provider's orders for both Dulcolax and Loperamide resulted in a deficiency in the facility's care for the resident's gastrointestinal issues.
Significant Medication Error with Warfarin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of warfarin, an anticoagulant medication. The resident, who had a history of respiratory failure, heart failure, atrial fibrillation, venous insufficiency, and a pacemaker, was prescribed warfarin with specific dosing instructions. Despite an order from the Advance Practice Registered Nurse (APRN) to hold the medication due to a high International Normalized Ratio (INR) of 5, indicating an increased risk of bleeding, the resident received doses of warfarin on two consecutive days. This administration occurred on 07/19/2024 and 07/20/2024, contrary to the APRN's directive to hold the medication and recheck the INR on 07/21/2024. The error was confirmed through interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged that the warfarin should not have been administered given the elevated INR levels. The INR further increased to 8.0 by 07/21/2024, exacerbating the risk of bleeding. The facility's policy on medication errors defines a significant error as one that jeopardizes the resident's health and safety, which was the case here due to the failure to adhere to the physician's orders and the subsequent increase in the resident's INR levels.
Failure to Complete Tracking/Discharge MDS for 17 Residents
Penalty
Summary
The facility failed to complete tracking/discharge Minimum Data Sets (MDS) for 17 residents (2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42, and 44). A record review of the sampled residents' discharge Electronic Health Records revealed that these residents did not have a tracking discharge MDS completed. During an interview, the newly hired MDS Coordinator confirmed that a tracking discharge MDS should be completed within 3 days of a resident's discharge from the facility. The MDS Coordinator had started their position on 04/08/2024. Additionally, the facility Administrator confirmed they were unaware that the tracking discharge MDS were not completed for the mentioned residents and acknowledged that they should have been completed after the residents' discharge from the facility.
Lack of Physician's Order for CPAP
Penalty
Summary
The facility failed to have a physician's order for Continuous Positive Airway Pressure (CPAP) for one resident. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, unspecified diastolic heart failure, and essential hypertension, was admitted on a specified date. The resident's care plan indicated the use of a CPAP machine due to sleep apnea, but no order for the CPAP was found in the resident's Order Summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). An observation confirmed the presence of a CPAP machine in the resident's room, and the resident confirmed its nightly use with assistance from nursing staff. An interview with an LPN confirmed the absence of an order for the CPAP or the oxygen bled into the CPAP.
Failure to Provide Written Notification of Discharge
Penalty
Summary
The facility failed to provide written notification of discharge to Resident 50 or to the resident's representative, and did not provide a written reason for the discharge. Resident 50 was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, sepsis, lymphocytosis, major depressive disorder, and mixed hyperlipidemia. On the day of the incident, the resident's oxygen saturation levels were critically low, and the night nurse found the resident visibly struggling to breathe. The resident's provider was notified, and an order was given to transfer the resident to the hospital. The resident's daughter was informed of the transfer, and the resident was taken to the hospital by rescue squad. However, no written notice or reason for the discharge was provided to the resident or the resident's representative as required by the facility's policy and regulatory guidelines. The facility's Transfer and Discharge policy mandates that notice must be provided at least 30 days prior to a facility-initiated transfer or discharge, with exceptions for urgent medical needs. In such cases, notice must be provided as soon as practicable. Despite these guidelines, the facility did not send a written reason for discharge or a notice of discharge to Resident 50 or the resident's representative. This deficiency was confirmed through interviews with the facility Administrator, who acknowledged the failure to provide the required documentation.
Failure to Notify Practitioner or Family of Resident Falls
Penalty
Summary
The facility staff failed to notify the practitioner or responsible party of falls for two residents. Resident 1, admitted with multiple diagnoses including Respiratory Syncytial Virus Pneumonia and Diabetes Type II, experienced a fall on 2/12/24. The incident report indicated that Resident 1 was found on the floor with injuries including skin tears and a bump on the left temple. However, the facility did not notify Resident 1's family about the fall, as confirmed by both the resident's emergency contact and the facility administrator during interviews conducted on 3/5/24. Resident 3, admitted with conditions such as Acute Respiratory Failure and a history of stroke, fell multiple times between 11/05/2023 and 12/19/2023. The facility's records revealed that neither the resident's family nor the physician was notified of these falls. This was confirmed through a review of progress notes and an interview with the facility administrator. The facility's policies on fall prevention and notification of changes were not adhered to, leading to a failure in communication regarding the residents' falls and injuries.
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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