Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Elkhorn during CMS and state inspections, most recent first.
The facility failed to notify the practitioner when ordered meds were unavailable for two residents. One resident with osteomyelitis had missed or undocumented doses of ciprofloxacin when the supply ran out, and another resident with frequent pain had no available Butrans patch and later no oxycodone. Progress notes and staff interviews confirmed the meds were not available, the pharmacy was contacted to reorder, and the practitioner was not notified when the supplies ran out.
A resident with intact cognition and limited assistance needs had a PRN diazepam order for anxiety with no stop date. The pharmacist flagged the order because it lacked a stop date and recommended discontinuation or documentation of the indication, intended duration, and rationale for continued use, but the provider response did not clarify this and follow-up for clarification did not occur.
A resident with frequent, severe chronic pain had orders for a weekly Butrans patch and PRN oxycodone, but the facility ran out of both medications. Staff reported the meds could not be obtained from the EMS because the pharmacy was closed for weekend authorization, and the resident later reported a pain level of 9/10 and said only Tylenol was given.
A resident with osteomyelitis and a chronic left heel/midfoot ulcer with necrosis did not receive ordered Ciprofloxacin 250 mg at bedtime for several days. The MAR showed missed administrations, and PN documented the medication was on order, unavailable, and later awaiting pharmacy arrival. The RNC and DON confirmed the drug should have been obtained through the pharmacy or EMS and agreed the omission was a medication error.
Three nurse aides did not complete the required 12 hours of annual in-service education, with training hours ranging from 3 to 5 hours. The DON confirmed the deficiency and acknowledged the absence of an effective tracking system for staff education compliance.
Dishwasher Competency and Temperature Failure: A Dietary Aid was observed operating the dishwasher while it reached only 100 degrees F in the wash cycle and 110 degrees F in the rinse cycle, below the 120 degrees F minimum listed by Ecolab. The aide confirmed not knowing what to do if the dishwasher did not reach 120 degrees F, and the ADM confirmed the aide had not received training or competency validation for dishwasher use.
Dishwashing temperatures and kitchen sanitation deficiencies: The facility failed to ensure the dishwasher reached the required 120°F wash and rinse temperatures, with logs missing for multiple meal periods and direct observation showing the machine running below standard. The facility also had food debris and dark waxy buildup on the dish room floor and buildup on the double convection ovens, which staff and the ADM confirmed were present.
Staff failed to follow infection control protocols by carrying soiled linens against their bodies, neglecting to clean nebulizer kits and PAP equipment after use, and not using enhanced barrier precautions during catheter care for a resident with an indwelling device. These actions were observed and confirmed by staff and facility leadership as not meeting established policies.
Surveyors found that ventilation systems in the bathrooms of four resident rooms were not functioning, as evidenced by a lack of airflow during testing with toilet paper. The Maintenance Supervisor confirmed the issue and stated that no routine checks of the ventilation systems had been performed.
A resident with multiple serious medical conditions and moderate cognitive impairment was admitted without receiving or acknowledging the required notice of rights, as documented in facility policy. The admission paperwork was incomplete, and the electronic health record did not contain evidence that the resident or their representative had been informed of their rights at admission.
A resident with multiple complex medical conditions and moderate cognitive impairment was admitted without completion of required admission paperwork, including documentation of privacy practices, resident rights, and other key policies. The Admissions Director confirmed the omission, resulting in an incomplete medical record.
Failure to Protect Resident from Verbal Abuse Allegation: A cognitively intact resident with multiple medical and psychiatric diagnoses reported that the DON told them they did not belong in the facility and had upset staff, and also yelled at them in the hallway several times. The resident felt verbally abused, unwanted, and afraid of retaliation. The facility’s abuse policy required the accused employee to be removed from resident care areas and placed on suspension pending investigation, but the DON later confirmed they had never been formally suspended.
Unnecessary Antipsychotic Medication Use: A resident with dementia, depression, and Parkinson's disease received daily Quetiapine for a documented order tied to Parkinson's disease, but the DON confirmed Parkinson's was not a medically accepted diagnosis for continued use of the antipsychotic and that no other documented medically accepted diagnosis supported it. The record also noted the resident was on Seroquel for dementia with behavioral disturbance, yet the DON documented there was no behavior at the time and the physician denied discontinuation.
Failure to Timely Report Abuse Allegation: A cognitively intact resident with multiple chronic conditions reported that the DON publicly humiliated and bullied them by yelling in the hallway, and said they feared the DON and retaliation from staff. The SSD documented the concern and informed the ED, but the ED did not investigate or report the abuse/bullying allegation when it was received, despite facility policy requiring immediate reporting of suspected abuse.
Failure to Investigate Allegation of Abuse: A resident with multiple medical and behavioral diagnoses, including anxiety, depression, and suicidal ideation, reported that the DON and ADON were bullying them and that they felt their life was in danger. The SSD reported the concern to the ED, but the ED did not investigate or report the allegation. The resident later stated the DON publicly humiliated them by yelling in the hallway and that they feared retaliation from staff.
Missing Care Plans for Prophylactic Antibiotic and Anticoagulant Use: The facility failed to develop CCPs for a resident receiving prophylactic antibiotics and another resident receiving an anticoagulant. One resident had UTI-related diagnoses, a foley catheter, hospice antibiotic orders, and Macrobid for UTI prevention, but the CCP did not address antibiotic prophylaxis. Another resident had atrial fibrillation and stroke history, was ordered Apixaban, and had orders to monitor for bleeding, but the CCP did not address anticoagulant use or bleeding risk; the DON confirmed both omissions.
Tube feeding not administered as ordered. A resident with a G-tube, dysphagia, encephalopathy, and severe protein-calorie malnutrition had an order for Osmolite 1.5 via pump, but observations showed the feed hanging without running, the pump in alarm, and the container not labeled with the date and time it was hung. An LPN later confirmed the feed was not dated or timed and that the resident did not receive the full ordered amount.
Two residents had invalid PAP orders because the orders did not include required details such as mode and pressure settings, and one of those residents also lacked a valid oxygen order. One resident with COPD, chronic respiratory failure, and OSA used a PAP device daily, but the order was incomplete. Another resident with morbid obesity, HF, hypoxemia, Guillain-Barre syndrome, and OSA had a PAP device and oxygen in use, but the record did not include a complete PAP order or a separate oxygen order with a specific liter flow.
A resident with PTSD and other mental health diagnoses was not evaluated for trauma triggers, and the trauma-informed care assessment was marked not applicable. The resident’s care plan contained no interventions related to past traumatic experiences, and the SSA confirmed there was no trauma history entered and no interventions listed.
Unsecured medications were found in the rooms of two residents. One resident had nasal spray, nystatin powder, and a Dulera inhaler stored in an open basket on a dresser, while another resident had multiple eye-drop bottles on a bedside table. In both cases, the care plans did not address self-administration, physician orders did not include several of the medications found, and an LPN confirmed the medications were not secured and should not have been in the rooms.
A resident with heart failure did not consistently receive daily weights or have significant weight gains reported to the practitioner as ordered. Fluid restrictions were not properly implemented or monitored, with frequent overages and incomplete documentation. Staff interviews and observations revealed a lack of awareness and communication regarding the resident's fluid management, and the facility did not have a policy in place for fluid restriction implementation.
Facility staff did not notify the practitioner of significant weight increases in a resident with heart failure, despite clear orders and policy requiring notification for weight gains of 1 to 5 lbs. Multiple weight increases exceeding this threshold were not reported, as confirmed by record review and DON interview.
A resident with heart failure did not consistently receive BiPAP therapy as ordered, with multiple missed applications documented over several weeks. Staff interviews revealed poor communication and lack of clarity regarding responsibility for applying the BiPAP mask, and there was no documentation of resident refusal when the therapy was not provided.
A resident experienced significant weight loss due to the facility's failure to implement recommended nutritional interventions. Despite a Registered Dietician's recommendation for a Magic Cup supplement, it was not provided with meals, and staff were unaware of the recommendation. The facility did not adhere to its policy on hydration and nutrition, failing to assess and address the resident's weight loss.
The facility failed to maintain proper food safety and sanitation practices, affecting all 86 residents. Observations revealed unsealed, unlabeled, and undated food items in refrigerators and freezers, improper food handling by Cook-M, and unsanitary kitchen conditions. The DFS and Registered Dietician confirmed these deficiencies, which were not in line with the facility's policies.
The facility failed to update care plans for four residents, leading to deficiencies in their care. A resident's care plan was not updated after a Foley catheter was discontinued. Another resident's care plan did not reflect multiple open wounds. A third resident's care plan was outdated regarding feeding tube orders, and a fourth resident's care plan did not accurately reflect their dental status. These oversights were confirmed by facility staff.
The facility failed to maintain safe water temperatures in resident bathrooms, with readings between 123.4 and 132.4 degrees Fahrenheit, affecting 14 residents. Interviews with the Maintenance Supervisor and DON confirmed awareness of the issue, leading to the water being shut off in the affected area.
The facility failed to maintain flooring in good repair for 12 resident rooms, affecting 13 residents. Observations revealed missing transition strips between hall carpets and room flooring, and cracked or bubbled linoleum in several bathrooms. The Maintenance Supervisor confirmed these issues, indicating a potential safety concern.
The facility staff failed to clean and sanitize respiratory equipment for several residents, leading to potential cross-contamination. Observations showed that equipment was not maintained according to policy, with visible contamination. Additionally, staff did not implement enhanced barrier precautions during care activities for residents with wounds or indwelling devices, and failed to provide necessary signage for a resident with venous stasis ulcers. Interviews confirmed these deficiencies, highlighting lapses in hygiene and precautionary measures.
A resident experienced a significant weight loss of 6.6 pounds, or 5.47%, over a short period, but the facility failed to notify the physician. Despite the resident's awareness of the weight loss and the RD's recommendation for nutritional supplements, the facility did not follow its policy to inform the physician of such concerns.
A resident with dementia and other conditions fell in the bathroom, resulting in a laceration requiring stitches. Despite the facility's policy to report serious injuries within two hours, the incident was not reported to the state agency, leading to a deficiency finding.
A facility failed to accurately document a resident's care needs in the MDS, omitting tube feeding and incorrectly including insulin administration. The resident, with multiple medical conditions, was on enteral feeding via a G-tube, not insulin. Observations and interviews confirmed the MDS inaccuracies, leading to a deficiency finding.
The facility failed to adhere to oxygen orders for two residents, leading to deficiencies in respiratory care. One resident with COPD and Chronic Respiratory Failure was observed without prescribed oxygen therapy multiple times, despite having orders for continuous oxygen. Another resident was using oxygen continuously without a physician's order for such use outside of AVAPS. Interviews confirmed these discrepancies, highlighting the facility's failure to ensure valid and followed oxygen orders.
The facility failed to ensure proper assessment of dialysis shunt sites for two residents before and after their dialysis treatments. The Pre/Post Dialysis Communication forms were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Observations showed that one resident was left unattended in the hallway after dialysis, and the LPN responsible did not know the location of the shunt site or perform the necessary assessments. The DON confirmed that the staff was not completing the communication sheets accurately, and the shunt site assessments were not always conducted.
Failure to Notify Practitioner When Ordered Medications Were Unavailable
Penalty
Summary
The facility failed to notify the residents’ practitioner when ordered medications were unavailable for two residents. One resident had osteomyelitis of the left foot and ankle and was ordered ciprofloxacin 250 mg at bedtime for prophylaxis related to a chronic ulcer of the left heel and midfoot with necrosis. The medication administration record showed missed or undocumented administrations on multiple days, and progress notes documented that the ciprofloxacin was not available and later was awaiting arrival from the pharmacy. An interview with the ADON and RNC confirmed the practitioner was not notified when the ciprofloxacin supply ran out and should have been. A second resident had frequent pain that interfered with sleep, therapy, and day-to-day activities and had a care plan addressing pain relief and pain medication administration. The resident was ordered a Butrans transdermal patch 7.5 mg weekly and oxycodone 2.5 mg every 4 hours as needed for pain. The MAR and progress notes showed the patch was not available and the pharmacy was contacted to reorder it, and the resident reported that the facility had run out of the patch and later ran out of oxycodone. An LPN confirmed the medications ran out and could not be obtained from the EMS because the pharmacy was closed on the weekend to obtain an authorization code, and the ADON and RNC confirmed the practitioner was not notified when the pain medications ran out and should have been.
PRN Diazepam Lacked Required Re-evaluation and Documentation
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication was re-evaluated by the medical practitioner for the rationale and duration of continued use beyond 14 days for one resident. Resident 1 had a BIMS score of 15, indicating cognitive intactness, and required limited assistance with bathing, lower body dressing, and transfers. The resident had an order for diazepam 10 mg every 8 hours as needed for anxiety with no stop date, and the MAR reflected the same order without a stop date. The pharmacist identified the PRN anxiolytic order as lacking a stop date and recommended discontinuing diazepam or, if it could not be discontinued, documenting the indication for use, intended duration of therapy, and rationale for the extended period. The PCR showed a note of declined by provider without date, signature, or notation, and the signed faxed copy from the provider stated to implement as written but did not specify whether to discontinue diazepam or provide the rationale and intended duration for continued use. The ADON and RNC confirmed the pharmacy recommendation did not include the rationale and duration for the PRN diazepam and that follow-up with the provider in 3 to 5 days for clarification did not occur.
Pain Medication Unavailable for Resident With Chronic Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who had orders for a Butrans transdermal patch 7.5 mg weekly and oxycodone 2.5 mg every 4 hours as needed for pain. The resident’s MDS showed frequent pain that occasionally affected sleep and frequently interfered with therapy and almost constantly interfered with day-to-day activities, and the care plan directed staff to evaluate pain interventions and give pain medication as ordered. The MAR documented the Butrans patch was administered on 05-09-2026, but the progress notes stated the patch was not available and the pharmacy was contacted to reorder. The resident reported that the facility ran out of the Butrans patch on 05-09-2026 and ran out of oxycodone on 05-10-2026. An LPN confirmed the resident ran out of the patch on Saturday and oxycodone on Sunday, and stated the medications could not be obtained from the EMS because the pharmacy was closed on the weekend to obtain an authorization code to unlock the EMS. The resident later reported a pain level of 9 out of 10 on Sunday and stated only Tylenol was given. The ADON and RNC confirmed the resident did not receive the Butrans patch on 05-09-2026 and ran out of oxycodone on 05-10-2026, and confirmed the pharmacy was available on weekends and the nurse should have called the pharmacy and received authorization to obtain the medication from the EMS.
Medication Omission for Ordered Ciprofloxacin
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when Ciprofloxacin 250 mg ordered at bedtime for prophylaxis related to a chronic ulcer of the left heel and midfoot with necrosis was not administered as ordered. Resident 2 had a diagnosis of osteomyelitis of the left foot and ankle, was cognitively intact with a BIMS score of 13, and required varying levels of assistance with mobility, bathing, dressing, toileting, and transfers. Record review showed the medication was documented as not given on multiple days in May 2026, with no documentation of administration on 05-05-2026 and 05-06-2026, and progress notes indicated the medication was on order, not available, and later awaiting arrival from the pharmacy. The facility’s EMS formulary showed Ciprofloxacin 500 mg and 250 mg tablets were available in the emergency medication supply, and the facility policy required staff to contact the pharmacy, obtain authorization to use EMS, and escalate to the provider or Medical Director if the medication was unavailable. Interviews with the Regional Nurse Consultant and the Assistant Director of Nursing confirmed that when the medication was not available, the pharmacy should have been notified and the medication obtained from the EMS or delivered by the pharmacy. They also confirmed Resident 2’s Ciprofloxacin 250 mg was not administered from 05-02-2026 through 05-07-2026 and that the omission of the medication was a medication error.
Failure to Ensure Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides completed the required 12 hours of annual in-service education, as mandated by licensure regulations. Record reviews showed that one nurse aide had completed only 3.5 hours, another 5 hours, and a third 3 hours of training, despite being employed for sufficient time to meet the requirement. The Director of Nursing confirmed during an interview that the 12-hour education training requirement had not been met for these nurse aides and acknowledged that the facility lacked an effective system to track and ensure compliance with the required training hours. This deficiency had the potential to affect all 86 residents in the facility.
Dishwasher Competency and Temperature Failure
Penalty
Summary
The facility failed to ensure staff were competent to operate the dishwasher. Record review of the dishwasher information from Ecolab showed the minimum operating temperature during the wash cycle and rinse cycle was 120 degrees F. During an observation on 12-03-2025 from 9:17 AM to 10:00 AM, Dietary Aid K was observed washing dishes in the dishwasher, including plates, plate covers, cups, bowls, and a tray of cups. The dishwasher reached only 100 degrees F during the wash cycle and 110 degrees F during the rinse cycle each time it was used. During the observation, Dietary Aid K removed dishes from the dishwasher and allowed them to dry, then placed additional cups and later bowls and cups into the dishwasher. An interview with Dietary Aid K at 10:00 AM confirmed the dishwasher reached 100 degrees F for the wash cycle and 110 degrees F for the rinse cycle, and the aide stated not knowing what to do if the dishwasher did not reach 120 degrees F. An interview with the Administrator on 12-04-2025 at 1:50 PM confirmed Dietary Aid K had not received training or competency completion for use of the dishwasher and should have.
Dishwashing temperatures and kitchen sanitation deficiencies
Penalty
Summary
The facility failed to ensure the dishwasher reached the minimum required temperature of 120 degrees Fahrenheit during the wash and rinse cycles. Record review showed gaps in the dishwasher temperature logs for October and November 2025, with multiple meal periods missing documented temperatures. During an observation, DA K washed dishes in the dishwasher and the machine reached only 100 degrees Fahrenheit during the wash cycle and 110 degrees Fahrenheit during the rinse cycle. DA K confirmed the temperatures and stated not knowing what to do if the dishwasher did not reach 120 degrees Fahrenheit. The Kitchen Manager also observed the dishwasher reaching 110 degrees during the wash cycle and 118 degrees during the rinse cycle and confirmed it should be 120 degrees Fahrenheit. The facility also failed to keep the dish room floor and kitchen equipment clean. Observations showed the floor under the dish shelves in the dish room had food debris and a dark waxy buildup, and the double convection ovens had waxy buildup on the outside near the control knobs, along with dark waxy buildup and hard water buildup around both the upper and lower doors. A later observation again found food debris and dark waxy buildup on the dish room floor. DA K confirmed the buildup was present and that the floor needed mopped. The Administrator later confirmed the dish room floor had a dark waxy buildup and the double ovens had waxy buildup and hard water buildup, and stated cleaning logs were not retained to ensure consistent cleaning.
Infection Control Failures in Linen Handling, Equipment Cleaning, and Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in several instances involving the handling of soiled linens, cleaning of respiratory equipment, and use of enhanced barrier precautions. Observations revealed that nursing assistants carried soiled linens and bedding against their bodies and clothing, contrary to facility policy, which requires soiled linen to be bagged and handled with minimal agitation to prevent contamination. Staff were seen carrying soiled items uncovered through hallways and placing soiled gowns under their arms while assisting residents, actions confirmed by both the staff involved and facility leadership as improper. Additionally, staff did not consistently clean and disinfect non-critical patient care equipment such as nebulizer kits and PAP (Positive Airway Pressure) machines. Multiple observations showed nebulizer kits with residual medication and facial oils left uncleaned on bedside tables after use for two residents. Similarly, a resident's BiPAP machine and mask were found with facial oils, water left in the humidifier, and missing filters over several days, despite orders and manufacturer guidelines requiring daily and weekly cleaning. Interviews with staff and a family member confirmed that cleaning was not performed as required. The facility also failed to implement enhanced barrier precautions during high-contact care activities for a resident with a urinary catheter. During catheter and incontinence care, staff did not wear gowns as mandated by facility policy for residents with indwelling medical devices. Staff interviews confirmed awareness of the requirement but acknowledged that enhanced barrier precautions were not used during the observed care.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure operational ventilation systems in resident bathrooms for four rooms (106, 108, 114, and 115) out of fifteen occupied rooms on the 100 hall. During an inspection with the Maintenance Supervisor, it was noted that the ventilation system did not draw a single ply of toilet paper to the surface of the ventilation cover in these bathrooms, indicating the systems were not functioning properly. The Maintenance Supervisor confirmed these findings and also acknowledged that no routine checks had been conducted to verify the operational status of the ventilation systems.
Failure to Provide Notice of Resident Rights on Admission
Penalty
Summary
The facility failed to provide a notice of resident rights upon admission for one resident. According to the facility's own admission policy, residents or their representatives must be informed of their rights and facility policies both orally and in writing, with accommodations for impairments and language needs. The policy also requires written acknowledgment of this explanation to be documented in the admission agreement. Record review showed that for the resident in question, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no documentation in the electronic health record indicating that the resident or their representative received or acknowledged the notice of rights at admission. Further review revealed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork, including the required notice of rights, had not been completed at the time of admission, and the medical record lacked the necessary documentation to show that the resident or their representative had received this information.
Failure to Complete Admission Paperwork for Resident
Penalty
Summary
The facility failed to complete required admission paperwork for one resident upon admission. According to the facility's own admission policy, residents or their legal representatives must be oriented to various policies and receive a copy of the admissions agreement, which is to be signed and filed in the resident's chart. Record review revealed that for this particular resident, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no completed admission paperwork in the electronic health record. This included missing documentation on privacy practices, antidiscrimination policy, grievance policy, resident rights, trust fund, financial agreement, smoking policies, resident care policies, and other required documents. Further review showed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork had not been completed at the time of admission and that the resident's medical record was incomplete due to the absence of these documents.
Failure to Protect Resident from Verbal Abuse Allegation
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse during the investigation of an abuse allegation. Resident 14 had diagnoses including Type 1 diabetes mellitus with hyperglycemia, anxiety disorder, diabetes insipidus, chronic pain, adrenocortical insufficiency, spinal stenosis with claudication, depression, suicidal ideation, and other speech and language deficits following cerebral infarction. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. A facility investigation note dated 11/7/2025 stated that on 11/3/2025 the facility was made aware of a verbal abuse allegation from Resident 14 regarding a comment made by the DON. The resident reported that the DON said, “you do not belong here, and you have upset all of my staff,” and the resident felt verbally abused and unwanted in the facility. The investigation note stated that, as an immediate intervention, the DON was suspended pending investigation. However, the facility’s Abuse - Reporting and Response Policy and Procedure required that an accused employee be removed from resident care areas immediately and placed on suspension pending the investigation, and an interview with the DON later confirmed they had never been formally suspended during an investigation. Resident 14 also reported that the DON publicly humiliated them by yelling in the hallway several times and that they feared retaliation from staff members.
Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure an antipsychotic medication was used to treat a medically accepted, diagnosed, specific condition for 1 resident reviewed for unnecessary medications. The facility policy stated that psychotropic drugs, including antipsychotics, are to be given only when necessary to treat a specific diagnosed and documented condition, and the medical record must show adequate indications for use and the diagnosed condition for which the medication is prescribed. Resident 10 was admitted with diagnoses including major depressive disorder and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The quarterly MDS showed severe cognitive impairment, diagnoses of Alzheimer's dementia, Parkinson's, and depression, and daily use of antipsychotic medications. The physician ordered Quetiapine Fumarate at bedtime related to Parkinson's disease without dyskinesia, and the resident received it daily as ordered in November and December 2025. A progress note stated the resident was on Seroquel for dementia with behavioral disturbance, but the DON documented that there was no behavior at that time and requested discontinuation. During interview, the DON confirmed the physician denied the request to discontinue the medication, confirmed Parkinson's was not a medically accepted diagnosis for continued use of Quetiapine Fumarate, and confirmed there were no other documented medically accepted diagnoses for its use.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure that an abuse allegation involving one cognitively intact resident was reported to officials within the required time limits. Resident 14 had diagnoses including Type 1 diabetes mellitus with hyperglycemia, anxiety disorder, diabetes insipidus, chronic pain, adrenocortical insufficiency, spinal stenosis with claudication, depression, suicidal ideation, and speech and language deficits following a cerebral infarction. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Facility policies stated that alleged or suspected mistreatment, abuse, neglect, injuries of unknown origin, and misappropriation of resident property were to be immediately reported to the administrator and/or DON, and that verbal abuse included conduct such as yelling at a resident with the intent to intimidate. A social services event note documented that the resident came to the social services office regarding an encounter with the DON and ADON and stated their life was in danger and that the DON was bullying them; the SSD then reported the incident to the ED. The resident later stated that the DON publicly humiliated them by yelling at them in the hallway several times, that they were afraid of the DON and retaliation from staff, and that the incident occurred on 11/13/25. The ED confirmed that the first step when receiving an allegation was to speak with the resident to clarify the situation, but in this case the ED did not investigate the allegation of abuse/bullying and did not report it on 11/13/25.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse for one resident. Resident 14 had diagnoses including Type 1 diabetes mellitus with hyperglycemia, anxiety disorder, diabetes insipidus, chronic pain, adrenocortical insufficiency, spinal stenosis with claudication, depression, suicidal ideation, and speech and language deficits following a cerebral infarction. The resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment. The facility’s abuse reporting and response policy stated that alleged violations related to mistreatment, exploitation, neglect, or abuse must be reported and investigated within prescribed timeframes, and the abuse and neglect policy required documentation of what was reported and the date and time the report was made to the SA. An event note documented that the resident came to social services about an encounter with the DON and ADON and stated their life was in danger and that the DON was bullying them. The SSD reported the incident to the ED after the resident left the office. The ED confirmed that the first step taken when receiving an allegation was to talk to the resident to clarify the situation, but in this case the ED did not investigate the allegation of abuse/bullying and did not report it on the day it was made. The resident later reported that the DON publicly humiliated them by yelling at them in the hallway several times and that they were afraid of the DON and retaliation from staff members. The resident stated the incident occurred on 11/13/25 and that they had filed a complaint of neglect and abuse against the DON.
Missing Care Plans for Prophylactic Antibiotic and Anticoagulant Use
Penalty
Summary
The facility failed to develop a Comprehensive Care Plan related to prophylactic antibiotic use for Resident 8. Resident 8 was admitted with diagnoses including UTI, chronic kidney disease, and bladder neck obstruction, and the significant change MDS dated 10/21/25 identified a BIMS score of 11, indicating the resident was cognitively intact, and noted a foley catheter with obstructive uropathy. The EMR showed the resident was hospitalized with UTI and bladder stones, received Rocephin in the emergency room, and was changed to Ertapenem while in the hospital. The resident was admitted to hospice care on 10/15/25 on Bactrim DS twice daily for 7 days, and physician orders dated 10/28/25 included Macrobid daily for UTI prevention. The CCP dated 11/4/25 contained no information related to prophylactic antibiotic use, and the DON confirmed that no CCP had been developed for this medication use. The facility also failed to develop a Comprehensive Care Plan related to anticoagulant use and bleeding risk for Resident 14. Resident 14 was admitted with diagnoses including unspecified atrial fibrillation and cerebral infarction, and the admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, with daily anticoagulant medication use identified. Physician orders dated 10/21/25 included Apixaban 5 mg by mouth twice a day for unspecified atrial fibrillation and monitoring for signs and symptoms of bleeding every shift, including black tarry stools, bleeding gums, bruising, and nosebleeds. The CCP dated 11/3/25 contained no information related to anticoagulant medications or the risk for bleeding, and the DON confirmed that no CCP had been developed for anticoagulant use or bleeding risk.
Tube feeding not administered as ordered
Penalty
Summary
The facility failed to administer tube feeding as ordered for one resident with a G-tube. The resident was admitted with diagnoses including encephalopathy and severe protein-calorie malnutrition. The resident’s MDS indicated food was held in the cheek or left in the mouth after meals, complaints of difficulty swallowing, a feeding tube present on admission, a mechanically altered diet, and receipt of 51% or more of total calories and 501 mL or more of fluid through tube feeding. The care plan included G-tube water flushes, weight monitoring, meal intake monitoring, a regular easy-to-chew diet, and tube feed per MD with Osmolite 1.5. The MAR showed an order for Osmolite 1.5 via G-tube at 55 mL per hour for 18 hours via pump, totaling 990 mL, with tube feed scheduled from 4:00 PM to 10:00 AM. During observations, the tube feeding was hanging but not running, the pump was in alarm and displayed infusion complete, and the tube feeding container was not labeled with the date and time it was first hung. Later, the pump displayed that 645 mL had been administered, and an LPN confirmed the tube feeding was not dated or timed when hung and that the resident did not receive the total amount of tube feeding nutrition as ordered by the provider.
Invalid PAP and Oxygen Orders
Penalty
Summary
The facility failed to obtain valid PAP device orders for two residents and failed to obtain a valid oxygen order for one of those residents. The facility’s PAP administration policy stated that when a PAP was ordered, the mode, pressure setting, size and type of mask, liters of oxygen if ordered, and frequency of use had to be included in the written order. The oxygen administration policy stated oxygen orders should include the specific liter flow. One resident had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, and was assessed as cognitively aware. The resident’s care plan included CPAP per order, and the clinical physician orders showed CPAP/BIPAP while sleeping/napping and oxygen with CPAP/BIPAP, but the order did not contain the mode or pressure settings. The resident’s MAR and TAR showed the PAP was worn every day, and observations showed the ResMed Airsense 10 BiLevel ST device present in the room on multiple occasions. The DON and an LPN confirmed the PAP order did not contain the required elements to make it a valid order. Another resident had diagnoses including morbid obesity, heart failure, hypoxemia, Guillain-Barre syndrome, obstructive sleep apnea, and need for assistance with personal care, and was also cognitively aware. The resident’s care plan indicated CPAP and oxygen use, but the clinical physician orders only showed oxygen with CPAP/BIPAP and CPAP/BIPAP while sleeping/napping, without an order for oxygen apart from the PAP or a specific oxygen setting. During observation, the resident was in bed with oxygen via nasal cannula at 1 liter per minute and had a ResMed Airsense 11 AVAPS PAP device on the overbed table, but there was no oxygen tubing or bleed-in adapter connected to the PAP. The resident stated oxygen was used all the time and did not think oxygen was used at night with the PAP, and the LPN and ADON confirmed the PAP order lacked the mode and pressure settings and that there was no written oxygen order for use when the resident was not on the PAP.
Failure to Assess PTSD Triggers and Document Trauma-Informed Interventions
Penalty
Summary
The facility failed to evaluate for and identify situational triggers for PTSD for 1 sampled resident, Resident 9. The resident was admitted on 4/26/2024 and had diagnoses including schizoaffective disorder, major depressive disorder, generalized anxiety disorder, obsessive-compulsive disorder, and PTSD. The resident’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and also identified PTSD. Record review showed the facility’s Trauma Informed Care evaluation dated 5/6/2024 was marked not applicable. The resident’s comprehensive care plan contained no interventions related to past traumatic experiences. During interview, the Social Services Assistant confirmed the resident had a PTSD diagnosis, that there was no history of trauma entered on the form, and that no interventions were listed on the resident’s care plan.
Unsecured Medications Kept in Residents’ Rooms
Penalty
Summary
The facility failed to provide secured storage for medications kept in residents’ rooms for 2 residents. The facility’s Self-Administration of Medications policy, last revised 06/01/2024, stated that the care plan would reflect whether a resident could self-administer medications and whether the resident or facility staff were responsible for storage, and that the facility should provide a secured compartment for medication storage in the resident’s room that would be locked when not in use. For one resident, records showed a BIMS score of 15 and diagnoses including COPD, but no diagnosis of allergic rhinitis. The care plan did not include a self-administration focus area or interventions. Physician orders included fluticasone propionate nasal spray and nystatin powder, but not Dulera inhaler. Observations in the resident’s room showed a plastic basket on the dresser containing 3 bottles of fluticasone propionate nasal spray, 1 bottle of nystatin powder, and 1 Dulera inhaler with spacer, visible from the hall and not in a locked storage compartment. The charge nurse confirmed the medications were unsecured and that the resident did not have an assessment or physician order to self-administer medications. For the second resident, records showed a BIMS score of 15 and diagnoses including attention and concentration deficit following cerebrovascular disease, need for assistance with personal care, muscle weakness, other lack of coordination, and dry eye syndrome. The care plan did not include self-administration interventions. Physician orders included Systane Balance, Xalatan, and Artificial Tears, but not Ketorolac Moxifloxacin, Ketorolac Tromethamine, or Prednisolone. Observations showed multiple pill bottles on the bedside table, including 2 bottles of Prednisolone, 2 bottles of Refresh Liquagel, 1 bottle of Ketorolac Moxifloxacin, and 1 bottle of Ketorolac Tromethamine, all labeled with the resident’s name and directions. The charge nurse confirmed the medications were in the room and should not have been there.
Failure to Follow Physician Orders for Daily Weights and Fluid Restrictions
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with a diagnosis of heart failure, specifically regarding daily weights and fluid restrictions. The resident had multiple orders for daily weights, with instructions to notify the practitioner of weight increases between 1-5 lbs. However, there were several documented instances where daily weights were not obtained, and significant weight gains were not reported to the practitioner as required. For example, an 8.6 lb. weight gain in one day and other increases of 6.7 lbs., 3.9 lbs., and 3.8 lbs. were not communicated to the practitioner. These omissions were confirmed by the DON during interviews. Additionally, the facility did not consistently implement or monitor the resident's fluid restriction orders. The resident was placed on various fluid restrictions, including 1000 ml and later 1440 ml per day, with specific allocations for dietary and nursing staff. Despite these orders, the resident's fluid intake regularly exceeded the prescribed limits, and there were days when fluid intake was not recorded at all. Observations and interviews revealed that staff were not always aware of the fluid restriction, did not consistently document fluids provided, and dietary staff did not record the amount of fluids given. The DON confirmed that the facility lacked a policy for implementing fluid restrictions and was unaware of how IV fluids were included in the daily total. The resident experienced multiple hospitalizations for conditions related to heart failure, fluid overload, and other complications during the period in question. Observations showed the resident receiving unmeasured fluids during meals and activities, and staff interviews indicated a lack of communication and understanding regarding the resident's fluid management needs. The facility was unable to provide additional information or documentation regarding the implementation of fluid restrictions prior to the survey exit.
Failure to Notify Practitioner of Significant Weight Changes
Penalty
Summary
Facility staff failed to notify the medical practitioner of significant changes in a resident's daily weights, as required by both facility policy and physician orders. The resident, who was cognitively intact and had a diagnosis of heart failure, had orders in place for daily weights with instructions to call the physician for any weight increase of 1 to 5 pounds. Despite this, the medical record review showed multiple instances where the resident experienced weight gains exceeding the notification threshold, including an 8.6-pound increase in one day and other increases of 6.7, 3.9, and 3.8 pounds on separate occasions. There was no documentation that the practitioner was informed of these changes. Interviews with the Director of Nursing confirmed that the practitioner was not notified of the significant weight increases, despite the clear orders and facility policy requiring such communication. The lack of notification was corroborated by the absence of related documentation in the resident's progress notes, faxes, and practitioner orders. The deficiency was identified through record review and staff interviews, which established that the required notifications did not occur as specified.
Failure to Provide Ordered BiPAP Respiratory Care
Penalty
Summary
Facility staff failed to ensure that a resident with a diagnosis of heart failure received appropriate respiratory care as ordered. The resident required BiPAP therapy while sleeping or napping, as documented in physician orders and the treatment administration record (TAR). Multiple instances were identified where the BiPAP was not applied during various shifts across September and October, despite clear orders. The resident was cognitively intact and required extensive to total assistance with activities of daily living. Documentation showed that the BiPAP was not used on several occasions, and there was no record of resident refusal or staff documentation of such refusals. Interviews with staff revealed confusion and lack of communication regarding responsibility for applying the BiPAP mask. Medication aides indicated that only nurses could apply the mask, but nurses interviewed were either unaware of the resident's needs or had not been informed of the mask not being in use. Observations confirmed the resident was not wearing the BiPAP mask when required, and the resident reported discomfort from air blowing in the eyes when the mask was applied. The Director of Nursing confirmed that the nurse assigned to the resident should have ensured the BiPAP was applied and documented any refusals, which did not occur.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to evaluate and implement interventions to prevent significant weight loss for a resident, identified as Resident 37. The resident was admitted following surgery for a diaphragmatic hernia with obstruction and had other diagnoses including GERD, Barrett's Esophagus with dysphagia. The resident's Minimum Data Set (MDS) indicated a weight of 120 pounds and required assistance with various activities of daily living. Despite the resident's awareness of weight loss, the facility did not take appropriate action to address the issue. The resident's weight was recorded multiple times, showing a decrease from 120.6 pounds to 114.0 pounds over a period of less than a month, indicating a significant weight loss of 5.47%. The facility's Registered Dietician (RD) had recommended nutritional supplements, specifically a Magic Cup, to be added to the resident's meals to address the low BMI and potential weight loss. However, this recommendation was not implemented, as evidenced by the absence of the Magic Cup on the resident's meal trays during observations. Interviews with facility staff, including the RD, Director of Food Service (DFS), and nursing staff, revealed a lack of communication and follow-through on the dietary recommendations. The RD was not informed of the resident's weight loss, and the DFS was unaware of the recommendation for the Magic Cup. Additionally, the facility's policy on hydration and nutrition, which requires ongoing assessment and physician notification of concerns, was not adhered to, as there was no documentation of further nutritional evaluation or physician notification regarding the resident's significant weight loss.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, which had the potential to affect all 86 residents consuming food from the kitchen. Observations revealed multiple food items in the kitchen's refrigerators and freezers were not sealed, labeled, or dated, contrary to the facility's Food Safety policy. Items such as an open bag of shredded purple substance, a zip lock bag of white chunks, and an open package of bologna were found without proper labeling or sealing. Additionally, the dry storage contained unsealed bags of macaroni and overripe bananas, while the walk-in refrigerator and freezer had unlabeled and undated food items. The Director of Food Services (DFS) confirmed these observations and acknowledged the failure to adhere to food safety protocols. Further deficiencies were noted in food preparation and kitchen cleanliness. Cook-M was observed handling beef packages in a manner that allowed the outside of the packaging to contact the food product, and did not follow the recipe or measure ingredients during food preparation. The DFS and Registered Dietician confirmed these practices were inappropriate. Additionally, the facility's cleaning logs did not show evidence of regular cleaning of floors, vents, and fans, leading to unsanitary conditions such as crumbs on the kitchen floor, brown drippings on the freezer vent, and a gray fuzzy substance on HVAC vents. The DFS and Maintenance Supervisor confirmed these areas were not cleaned as required, posing a risk of contamination to food and eating surfaces.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in their care. Resident 6, who was admitted with an indwelling Foley catheter, had the catheter discontinued, but the care plan was not updated to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer in use. This oversight was confirmed by the Minimum Data Set Nurse during an interview. Resident 68 had multiple open wounds on their legs, which were not documented in the care plan. Despite ongoing wound assessments indicating the presence of these wounds, the care plan remained focused on skin integrity related to urinary incontinence and xerosis cutis, without addressing the actual wounds. The Wound Nurse acknowledged that the care plan had not been updated to include the open wounds. Resident 34's care plan was outdated and did not reflect the current orders for bolus feedings via a feeding tube. The care plan incorrectly indicated continuous feeding, while the actual orders specified bolus feedings four times a day. This discrepancy was confirmed by the facility's Registered Dietician and the MDS Nurse. Additionally, Resident 14's care plan was not accurate, as it did not reflect the resident's current dental status, including the absence of teeth and the fact that dentures were at home. The Social Service Assistant confirmed the care plan was outdated.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident bathrooms, which posed a potential risk to 14 residents. During an observation on August 7, 2024, it was found that water temperatures in several resident rooms were above the recommended safe level of 120 degrees Fahrenheit, with temperatures ranging from 123.4 to 132.4 degrees Fahrenheit. This issue was identified in rooms 101, 102, 109, 113, 114, 117, 118, 120, 122, and 123. The facility census at the time was 86 residents. Interviews conducted with the Maintenance Supervisor and the Director of Nursing revealed awareness of the elevated water temperatures. The Maintenance Supervisor confirmed taking a water temperature reading above 124 degrees Fahrenheit in one of the rooms. The Director of Nursing acknowledged that the water temperatures in the bathrooms on the 100 Hall were too high, leading to the water being shut off. A review of the facility's Direct Supply TELS logbook indicated that water temperatures should be maintained below 120 degrees Fahrenheit for burn prevention, as per federal guidelines.
Deficiency in Flooring Maintenance
Penalty
Summary
The facility failed to maintain flooring in good repair for 12 resident rooms, which had the potential to affect 13 residents. During a tour with the Maintenance Supervisor, it was observed that rooms 104, 105, 106, 108, 109, 111, 113, 114, 121, and 122 did not have a transition strip between the hall carpet and the flooring in the resident's room. Additionally, rooms 104, 113, 114, 122, 123, and 207 had cracked or bubbled linoleum in the resident's bathroom. An interview with the Maintenance Supervisor confirmed that the resident room floors were not maintained and could potentially be a safety concern.
Infection Control and Precaution Failures in LTC Facility
Penalty
Summary
The facility staff failed to ensure proper cleaning and sanitization of respiratory equipment and supplies for several residents, leading to potential cross-contamination. Observations revealed that the BiPAP/CPAP masks, nebulizer kits, and oxygen concentrators for Residents 26, 38, and 42 were not cleaned according to the facility's policies. The equipment was found with facial oils, residual medication, and a gray fuzzy substance, indicating neglect in maintaining hygiene standards. Interviews with staff confirmed the equipment was not cleaned as required. Additionally, the facility staff did not implement enhanced barrier precautions during activities of daily living (ADL) care for Resident 14 and catheter care for Resident 37. Observations showed that staff did not wear gowns during high-contact care activities, despite the presence of enhanced barrier precaution signage. Interviews with staff confirmed the failure to adhere to the precautionary measures outlined in the facility's policy, which mandates gown and glove use during specific care activities for residents with wounds or indwelling medical devices. Furthermore, the facility failed to provide enhanced barrier signage for Resident 68, who had venous stasis ulcer wounds. Observations over several days revealed the absence of signage on the resident's door, which is necessary to alert staff of the need for precautions. The Infection Preventionist was unaware of the resident's condition, indicating a lapse in communication and policy implementation. The facility's policy requires signage to communicate the need for enhanced barrier precautions for residents with chronic wounds or indwelling medical devices.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician of a significant weight loss, which was identified during a survey. The resident, who had a history of diaphragmatic hernia surgery, GERD, BPH, and Barrett's Esophagus with dysphagia, experienced a weight loss of 6.6 pounds, or 5.47%, over a period of less than a month. Despite the resident's awareness of weight loss, the facility did not inform the physician of this clinically significant change. The resident's Minimum Data Set indicated a BIMS score of 15, suggesting cognitive intactness, and required varying levels of assistance for daily activities. The facility's Registered Dietician (RD) had noted the resident's low BMI and recommended nutritional supplements, but the weight loss was not communicated to the physician. The facility's policy on Hydration and Nutrition mandates physician notification of any concerns, including weight loss, but this protocol was not followed. The RD confirmed that the weight loss was significant and that the physician had not been updated, highlighting a lapse in the facility's communication and monitoring processes.
Failure to Report Resident Fall with Serious Injury
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury to the state agency for a resident. The resident, who had diagnoses of dementia, COPD, anxiety, and depression, was found on the bathroom floor by staff after their roommate called for help. The resident was crying and had bleeding from the right cheek, which required transfer to the hospital. At the hospital, the resident received three stitches for the laceration on the right cheek. Despite the facility's policy requiring immediate reporting of serious bodily injuries to the state agency, the incident was not reported. Interviews with the RN and the DON confirmed the fall and the subsequent hospital visit for sutures. The facility's policy mandates reporting such incidents within two hours, but this protocol was not followed, resulting in a deficiency finding during the survey.
Inaccurate MDS Documentation for Resident's Care Needs
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. The MDS dated 07/12/2024 did not include the resident's tube feeding requirement, and incorrectly documented the resident as receiving insulin and insulin injections, which were not part of the resident's care plan. The resident, who had multiple medical diagnoses including hemiplegia, chronic respiratory failure, and required G-tube feeding, was not accurately represented in the MDS, leading to a deficiency in the resident's comprehensive assessment. Observations and interviews confirmed the inaccuracies in the resident's MDS. The resident's Medication Administration Record and Treatment Administration Record from April to August 2024 showed the resident was on enteral feeding via a G-tube, with no record of insulin administration. Interviews with the resident's Power of Attorney and the facility's MDS Nurse corroborated that the resident was not on insulin or insulin injections, highlighting the error in the MDS documentation. This failure to accurately assess and document the resident's needs and treatments resulted in a deficiency finding during the survey.
Failure to Follow Oxygen Orders for Residents
Penalty
Summary
The facility failed to ensure proper adherence to oxygen orders for two residents, leading to deficiencies in respiratory care. Resident 26, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with Hypoxia, was observed multiple times without the prescribed oxygen therapy. Despite having a physician's order for continuous oxygen at 1 liter per minute via nasal cannula and oxygen with CPAP, the resident was found without oxygen on several occasions, both while sleeping and during activities. Interviews confirmed that the resident did not refuse oxygen, and the charge nurse acknowledged the resident's order for continuous oxygen was not being followed. Similarly, Resident 42, diagnosed with Chronic Respiratory Failure with Hypoxia and Obstructive Sleep Apnea, was observed using oxygen continuously, although there was no physician's order for oxygen use outside of the AVAPS setting. The resident confirmed continuous oxygen use, and the charge nurse verified the absence of an order for oxygen when not on AVAPS. These observations and interviews highlight the facility's failure to ensure valid and followed oxygen orders for the residents, resulting in a deficiency in providing safe and appropriate respiratory care.
Failure to Assess Dialysis Shunt Sites
Penalty
Summary
The facility failed to ensure proper assessment of dialysis shunt sites for two residents, Resident 26 and Resident 57, before and after their dialysis treatments. The facility's Hemodialysis Offsite Policy mandates ongoing assessment of residents' conditions and monitoring for complications related to dialysis. However, record reviews revealed that the Pre/Post Dialysis Communication forms for both residents were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Resident 57, who has multiple complex medical conditions including End Stage Renal Disease and dependence on renal dialysis, was not assessed for shunt site bruit, thrill, or bleeding as required. Observations showed that upon returning from dialysis, the resident was left unattended in the hallway, and the LPN responsible for the resident's care did not know the location of the shunt site or perform the necessary assessments. The Director of Nursing confirmed that the staff was not completing the Pre/Post Dialysis Communication sheets accurately, and the shunt site assessments were not always conducted. Similarly, Resident 26, who also has End Stage Renal Disease and is dependent on dialysis, did not receive the required shunt site assessments. The resident's Pre/Post Dialysis Communication forms were often incomplete, and the Medication Administration Record and Treatment Administration Record indicated that the shunt site was not assessed every shift as ordered. The Director of Nursing acknowledged the deficiencies in completing the communication sheets and the failure to perform the necessary shunt site assessments.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 385 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elkhorn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookestone Meadows Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| The Lighthouse At Lakeside Village | 4.3 mi | ★★★★★ | 2 | 0 |
| Rose Blumkin Jewish Home | 6.2 mi | ★★★★★ | 7 | 0 |
| Arbor Care Center-valhaven, Llc | 6.4 mi | ★★★★★ | 29 | 0 |
| The Banyan At Montclair | 6.6 mi | — | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.