St. Joseph's Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norfolk, Nebraska.
- Location
- 401 North 18th Street, Norfolk, Nebraska 68701
- CMS Provider Number
- 285160
- Inspections on file
- 21
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at St. Joseph's Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to report an unexpected, untoward death of a resident to the State Agency within required timeframes, as mandated by its abuse prevention policy and state licensure rules. The resident had multiple serious conditions, including end-stage kidney disease requiring hemodialysis, chronic respiratory failure, heart failure, diabetes, and COPD, with moderately impaired cognition and a care plan addressing dialysis needs and fistula monitoring. Nursing notes documented the resident was found nonresponsive in bed with no pulse or respirations, blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no trauma or sharp objects present. The DON acknowledged the death was unanticipated and that, although an internal investigation was completed, the facility did not submit the incident or investigation results to the State Agency as required.
A dietary staff member failed to change gloves and wash hands after handling food, leading to potential cross-contamination. The staff member touched various kitchen items without following proper hygiene protocols, as confirmed by the Dietary Manager.
The facility failed to implement and revise fall prevention measures for three residents with cognitive impairments and high fall risks. One resident lacked required grip strips in their room, another experienced multiple falls without new interventions, and a third had no additional fall measures despite confusion and a fall incident. The DON confirmed these deficiencies.
The facility failed to adhere to hand hygiene protocols and proper use of PPE during care for residents on Enhanced Barrier Precautions, as observed in the care of several residents. Staff did not perform hand hygiene before and after glove use, and gowns were not worn during high-contact care activities. Additionally, the facility did not implement measures to prevent the growth of Legionella in the water system, as confirmed by the Administrator and Maintenance Supervisor.
The facility failed to offer and educate three residents on pneumococcal and influenza vaccines, as required by its policy. The residents' medical records lacked evidence of screening for vaccination status, education on risks and benefits, or offering the vaccines. The DON confirmed the absence of a process and responsible staff for screening immunization status at admission.
The facility failed to offer the COVID-19 vaccine and provide education about its risks and benefits to three residents. The facility's policy required screening and education at admission, but records showed no evidence of these actions. The DON confirmed the absence of a process for screening immunization status and lack of staff responsibility for this task.
The facility failed to notify the PCP about significant lapses in medication and treatment for two residents. One resident did not receive Memantine and CPAP treatment as ordered, and was not assisted with walking as prescribed. Another resident did not receive Prednisone, leading to hospitalization. The DON confirmed the PCP was not informed of these issues.
Two residents in an LTC facility did not receive prescribed medications and treatments due to unavailability and staff oversight. One resident missed Memantine doses and CPAP use, while another did not receive Prednisone, leading to hospitalization. The DON confirmed these deficiencies.
The facility failed to document the duration of antibiotic use for two residents, despite its Antibiotic Stewardship Program requiring such documentation. Both residents, with moderate cognitive impairment and various diagnoses, received continuous antibiotic therapy without specified stop dates. Interviews confirmed that staff had attempted to educate providers on the need for stop dates, but the antibiotics were continued without them.
Failure to Report Unexpected Resident Death to State Agency
Penalty
Summary
The facility failed to report an unexpected resident death, considered an adverse event, to the State Agency within required timeframes as outlined in its own abuse prevention policy and state licensure requirements. The facility’s Abuse: Prevention of and Prohibition Against Policy dated 4/25 stated that all allegations of potential abuse, neglect, exploitation, misappropriation, and adverse events were to be reported immediately to the administrator, with notification to law enforcement in the event of a potential crime, and to Adult Protective Services within 2 to 24 hours depending on the case. The policy further required that a written report be submitted to the State Agency within 5 business days of the allegation. Despite these requirements, review of the facility’s 2026 Facility Reported Incidents showed no evidence that the unexpected death of a resident was reported to the State Agency. The resident involved had multiple serious medical conditions, including metabolic encephalopathy, end-stage kidney disease, chronic respiratory failure, anemia, heart failure, diabetes, and COPD, and required hemodialysis. The resident’s cognition was moderately impaired, and the resident did not have a condition or chronic disease documented as likely to result in a life expectancy of less than six months. The care plan noted the need for hemodialysis, occasional refusals of dialysis and medications, and interventions such as daily assessment of the left arm fistula for bruit and thrill, encouragement to attend dialysis, and monitoring for signs of infection. Nursing progress notes documented that the resident was found nonresponsive in bed with no pulse or respirations, with blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no signs of trauma or sharp objects nearby. During interview, the DON confirmed the death was unanticipated and untoward and that an internal investigation was completed to ensure no neglect was involved, but acknowledged the facility did not report the unexpected death or submit the investigation results to the State Agency within the required timeframe.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene and glove use during a meal service, leading to a potential for cross-contamination. During the noon meal service, a dietary staff member, identified as DC-P, was observed handling food with gloved hands. After placing a piece of pork loin on a dinner plate and cutting it into small pieces, DC-P did not change gloves or wash hands before touching various kitchen items, including resident cards, dishes, and serving utensils. This action was contrary to the Drug Administration Food Code, which mandates that food employees wash their hands and change gloves to prevent cross-contamination. An interview with the Dietary Manager confirmed that the staff should have removed gloves, washed hands, and donned a new pair of gloves before handling other kitchen items.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately review, revise, and implement care plan interventions to prevent falls for three residents, leading to deficiencies in fall management. Resident 16, who had moderate cognitive impairment and was a high fall risk, did not have grip strips present on the floor in front of their recliner as required by their care plan. Despite multiple observations over several days, the grip strips were consistently missing, which was confirmed by the Director of Nursing (DON). Resident 19, also with moderate cognitive impairment and a high fall risk, experienced multiple falls without any new immediate interventions being implemented. The resident's care plan included various fall prevention measures, but after falls on two separate occasions, no additional interventions were put in place to prevent future incidents. The DON confirmed the lack of new interventions following these falls. Resident 7, who had a diagnosis of anemia, non-Alzheimer dementia, seizure disorder, and depression, experienced a fall while sitting on a floor mat next to the bed. The resident was confused and unaware of their limitations. Although an SBAR was completed and a urinalysis was ordered, no other fall interventions were implemented. The DON confirmed the timeline of the urinalysis and culture results, but no treatment was ordered, and no further fall prevention measures were taken.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, as observed in the care of Residents 17, 11, and 7. For Resident 17, a nurse aide did not perform hand hygiene before and after glove use during multiple care activities, including assisting the resident with dressing and personal hygiene. Similarly, for Resident 11, a nurse aide did not wash hands or use hand sanitizer before and after glove changes while providing toileting and incontinence care. These actions were confirmed by interviews with the Director of Nursing and the staff involved, who acknowledged the lapses in following the facility's hand hygiene policy. The facility also failed to utilize appropriate Personal Protective Equipment (PPE) during the care of Residents 34 and 7, who were on Enhanced Barrier Precautions (EBP). For Resident 7, staff did not wear gowns during high-contact care activities, such as toileting and incontinence care, despite the resident having a stage 4 pressure ulcer and being on EBP. This was confirmed by interviews with the staff involved and the Director of Nursing, who acknowledged that gowns should have been worn. Similarly, for Resident 34, a nurse aide did not wear a gown while assisting with wound care and other high-contact activities, which was confirmed by the staff and the Infection Preventionist. Additionally, the facility failed to develop and implement measures to prevent the growth of potential waterborne illnesses, such as Legionella. The facility did not conduct a risk assessment to identify potential sources and areas of risk for Legionella growth in the water system. This was confirmed by the Administrator and the Maintenance Supervisor, who acknowledged that no measures had been implemented to prevent the growth of Legionella in the facility's water systems.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that three of five sampled residents were offered the pneumococcal and influenza vaccines and were educated about the associated risks and benefits. The facility's policy, revised on October 24, emphasized the importance of vaccinations for the health and well-being of long-term care residents, with procedures in place for screening residents at admission and annually for influenza. However, the facility did not adhere to these procedures, as evidenced by the lack of documentation in the electronic medical records of Residents 31, 197, and 244. These records showed no evidence of screening for vaccination status, education on the risks and benefits, or offering and administering the vaccines. During an interview, the Director of Nursing confirmed that the facility lacked a process and responsible staff for screening residents' immunization status upon admission. This oversight resulted in Residents 31, 197, and 244 not receiving the necessary education or being offered the influenza and pneumococcal vaccines. The facility's failure to implement its immunization policy and procedures led to this deficiency, impacting the residents' access to essential vaccinations.
Failure to Offer COVID-19 Vaccine and Education
Penalty
Summary
The facility failed to provide evidence that three residents were offered the COVID-19 vaccine or educated about its risks and benefits. The facility's policy required residents to be screened at admission to determine their vaccination status and eligibility, and to receive education about the vaccine before it was offered. However, the records for Residents 31, 197, and 244 showed no evidence of such screening, education, or vaccine offering. This deficiency was identified through a review of the residents' electronic medical records. During an interview, the Director of Nursing confirmed that the facility did not have a process in place for screening residents' immunization status at admission, and no staff were responsible for this task. Additionally, there was no evidence that the residents or their responsible parties received education about the COVID-19 vaccine or were offered the vaccine. This lack of process and documentation led to the deficiency noted in the report.
Failure to Notify PCP of Medication and Treatment Lapses
Penalty
Summary
The facility failed to notify the Primary Care Physician (PCP) regarding significant lapses in medication and treatment administration for two residents. Resident 17 did not receive the prescribed medication Memantine for 13 days and was not provided with a CPAP machine for 15 days, as ordered. Additionally, Resident 17 was not assisted with walking as prescribed on multiple occasions. There was no evidence that the PCP was informed about these failures, which were confirmed by the Director of Nursing (DON). Resident 22 did not receive the prescribed Prednisone for several days due to unavailability, which was not communicated to the PCP. This resident experienced shortness of breath and was eventually hospitalized with a diagnosis of pneumonia. The DON confirmed that the PCP was not notified about the unavailability of the medication and the resident's subsequent condition.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to adhere to practitioner's orders for two residents, leading to significant deficiencies in care. Resident 17, who was admitted with multiple diagnoses including Alzheimer's disease and obstructive sleep apnea, did not receive prescribed Memantine medication for 13 out of 28 days due to unavailability. Additionally, the resident's CPAP machine, ordered for nightly use, was not provided for 15 out of 28 days. Furthermore, the resident was not assisted with walking as ordered, missing numerous scheduled ambulation times. The Director of Nursing confirmed these lapses, noting the absence of a policy related to following physician orders. Resident 22, with diagnoses including heart failure and respiratory failure, was prescribed Prednisone for respiratory issues but did not receive the medication for 8 out of 14 days due to pharmacy unavailability. This resident experienced worsening respiratory symptoms, including shortness of breath and diminished lung sounds, and was eventually hospitalized with pneumonia. The Director of Nursing acknowledged the medication was not available and confirmed the resident's subsequent hospitalization.
Failure to Document Antibiotic Duration for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 16 and 19, had a documented duration of use for their long-term antibiotic therapy. The facility's Antibiotic Stewardship Program (ASP) policy requires that antibiotic orders include the indication, dose, and duration, and that the pharmacy consultant reviews and reports antibiotic usage monthly. However, the records for both residents showed continuous antibiotic administration without specified stop dates. Resident 16, who has moderate cognitive impairment and diagnoses including Parkinson's Disease and dementia, was receiving Bactrim DS for a urinary tract infection from April through December 2024. Similarly, Resident 19, with moderate cognitive impairment and a history of bladder infections, was receiving Keflex from June through December 2024. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility staff had reached out to the providers for education regarding the need for stop dates, but the antibiotics were continued without them. This oversight indicates a failure to adhere to the facility's ASP policy, which aims to optimize antibiotic use and reduce adverse events. The lack of documented stop dates for the antibiotics prescribed to Residents 16 and 19 represents a deficiency in the facility's medication management practices.
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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