Resident 1, who required a strict 1,440ml daily fluid limit due to heart failure, was given a large blue cup containing 360ml of water each night shift. His doctor's order specified he should receive only 80ml during those hours.
The medication aide told inspectors on November 6 that Resident 1 "gets one of the blue cups with a white lid of water for the whole night shift every night." When inspectors observed the resident at 3:50 AM, they found the half-full cup on his bedside table within reach.
The registered nurse assigned to his hall that night had not received report about Resident 1 and was "unaware of the fluid restriction" or how much fluid he had consumed during the shift. The nurse also revealed she was unaware of being assigned to Resident 1's hall "until a couple hours prior to being interviewed."
During meals, dietary staff provided Resident 1 with 12-ounce Styrofoam cups of liquid. A dietary aide confirmed the cups held 360ml each, though his meal ticket specified "1 beverage only per meal for fluid restriction and heart failure." The ticket failed to indicate the proper amount of fluids for each meal.
The facility's medication administration record showed the doctor had ordered the fluid restriction on October 3, with specific allocations: 320ml each for breakfast, lunch and dinner from dietary staff, plus 200ml each from nursing during day and evening shifts, and 80ml during nights.
Nobody tracked what dietary provided.
Dietary aide E told inspectors that dietary staff "do not record what fluids are provided by the dietary department." Another dietary worker confirmed staff "do not record or write down what fluids are provided from the dietary department."
The breakdown extended beyond water. The Director of Nursing confirmed that a cup of coffee provided to Resident 1 on November 5 at 11:25 AM "was not recorded and should have been." The DON said the maroon coffee cups held 240ml each.
Activity staff also provided fluids to Resident 1 during programs. The DON said she "would have to inform the activity staff not to provide fluids to Resident 1 during activities."
Even intravenous fluids weren't properly tracked. The DON told inspectors she "was not aware of how the IV fluids were included in the daily total fluid intake for Resident 1."
The facility's process required staff to "record on the MAR what the resident received from dietary and nursing for the shift and then the total fluids are calculated for the entire 24-hour period, to ensure the fluid restriction was followed," according to RN G. But that system had collapsed.
Licensed Practical Nurse A explained that "the amount of fluids documented on the MAR for November 2025 is the amount nursing provided to Resident 1 and dietary staff write down what their department provides." Yet dietary staff weren't writing anything down.
The DON acknowledged on November 6 that "Resident 1's fluid restriction was not consistently monitored and should have been."
When inspectors asked about policies governing fluid restrictions, they discovered the facility had none. The DON revealed "the facility did not have a policy for the implementation of a fluid restriction."
The facility couldn't provide additional information about how they managed Resident 1's fluid restriction before inspectors completed their investigation.
For heart failure patients, fluid restrictions prevent dangerous fluid buildup that can worsen their condition and lead to hospitalization. The systematic failure to monitor Resident 1's intake meant his medical team had no accurate data about his fluid consumption while his heart condition required precise management.
The inspection found actual harm to few residents, with the facility's complete breakdown in communication between departments, lack of policies, and absent supervision creating conditions where a vulnerable cardiac patient's care plan was ignored across multiple shifts and departments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Elkhorn from 2025-11-06 including all violations, facility responses, and corrective action plans.