Accura Healthcare Of Kenesaw
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenesaw, Nebraska.
- Location
- 100 West Elm Avenue, Kenesaw, Nebraska 68956
- CMS Provider Number
- 285166
- Inspections on file
- 26
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Accura Healthcare Of Kenesaw during CMS and state inspections, most recent first.
Surveyors found that the facility failed to protect several residents from falls and injuries by not implementing and not developing effective fall-prevention interventions. One resident with dementia and a history of falls had a care plan requiring close supervision and a reclined Broda chair, yet staff left the resident unattended and previously failed to keep the chair tilted, resulting in a serious head injury and subdural hematoma. Another resident with hemiplegia and a below-knee amputation, care planned and posted as requiring a full Hoyer lift with two staff, was instead pivot-transferred by two aides without the lift and fell, sustaining chest pain that required ER evaluation; required post-fall assessments were not completed. A third resident with stroke-related weakness and a seizure disorder experienced multiple falls linked in documentation to call-light use limitations, lack of non-skid footwear, lighting, and toileting needs, but the care plan did not consistently incorporate interventions addressing these specific root causes. The MDSC and DON acknowledged there was no fall policy and that interventions were not reliably based on identified root causes of falls.
Staff failed to maintain resident dignity and privacy when one cognitively intact resident who required assistance with upper body dressing was left in the dining area and then wheeled down the hall with their abdomen exposed, despite staff presence and the resident's inability to adjust clothing independently. In a separate incident, a medication aide and a laundry staff member entered a cognitively intact resident's room without knocking or announcing while the roommate was receiving personal care and had their lower body exposed. Both direct-care staff and the DON acknowledged that residents' body parts should not be exposed in public view and that staff are expected to knock and announce before entering rooms.
A resident with a history of wandering and intrusive behaviors repeatedly entered other residents’ rooms, leading to multiple resident‑to‑resident altercations, including being pushed to the floor with a resulting hematoma, and later incidents where the resident hit and choked another resident in a wheelchair and struck two additional residents in an activity area. Facility policy required identification of residents at risk of abusing others and implementation of protective measures, but only short‑term checks and temporary interventions such as redirection, music, snacks, toileting, 1:1 time, and PRN psychotropic medication were used. Interviews indicated that 1:1 supervision was inconsistent and that no long‑term interventions, such as continuous 1:1 supervision, were implemented despite ongoing aggressive behaviors, resulting in a failure to protect residents from physical abuse.
A medication aide administered a resident’s entire set of morning medications after the ordered time window, with all doses showing as late on the eMAR, and documented them as given before the resident actually consumed them. During the same pass, the aide gave an incorrect dose of Azelastine nasal spray by administering two sprays per nostril instead of the ordered one spray per nostril, and improperly discarded a prepared dose of Polyethylene Glycol powder into the trash rather than using the facility’s medication destruction method. The resident, an LPN, and the DON all confirmed the late administration and dosing/documentation errors, which resulted in a medication error rate far exceeding the required threshold.
The facility did not complete required nurse aide registry checks before three staff members began working with residents, and failed to report an adverse event involving a resident who fell during a transfer due to malfunctioning equipment. The incident resulted in soreness and bruising for the resident, and the event was not reported to the appropriate agencies as required by facility policy.
The facility did not ensure that employee health screens were reviewed by appropriate staff before employment began for several employees, and staff did not consistently follow proper hand hygiene procedures, including washing hands for the required duration and using clean paper towels to turn off faucets, as confirmed by both observation and staff interviews.
A resident with dementia and risk for skin integrity issues was prescribed an oral antibiotic for cellulitis without completion of required infection criteria assessments or a timely review of antibiotic appropriateness. The antibiotic was also prescribed outside recommended dosing guidelines, and the provider was not notified of this deviation, resulting in a failure to follow established antibiotic stewardship protocols.
A resident with schizophrenia and bipolar disorder, identified as high risk for elopement, repeatedly exited the facility without staff knowledge. Despite a physician order for a wander guard and documented incidents of the resident leaving the building, there were no incident reports or changes to interventions to prevent further unauthorized exits. The DON confirmed that no new measures were implemented during this period.
A resident with moderate cognitive impairment was moved to a new room without receiving written notification or explanation, and the resident's POA was not notified due to being unreachable. The move was made to prevent falls, but the required notification form, which allows for appeal, was not provided to the resident or their representative.
Two residents were incorrectly coded on the MDS as having received insulin during the assessment period, when in fact their MARs showed they received non-insulin injectable diabetes medications. The MDS Coordinator confirmed the error after review and interview.
Two residents did not receive required 30-day physician visits after admission, as confirmed by review of medical records and staff interviews. One resident with multiple diagnoses, including Alzheimer's and dyskinesia of the esophagus, missed the initial 30-day visit and was not seen by a physician until 60 days post-admission, despite significant weight loss. Another resident did not receive a follow-up physician visit 30 days after the initial assessment, with the next visit occurring 60 days later. These deficiencies were acknowledged by the DON and RNC.
A medication aide failed to follow proper procedures by not instructing a resident to rinse their mouth after inhaler use, not using a dosing card for topical medication, and administering a PRN pain medication without prior nurse approval, resulting in a medication error rate of 12%.
The facility did not consistently identify causes of falls or implement timely interventions after each fall incident for several residents with high fall risk, including those with cognitive impairment, mobility issues, and recent infections. Care plans were not promptly updated with new interventions, and staff often relied on verbal communication rather than documented updates, leading to repeated falls and delayed responses.
The facility did not ensure that residents with complex medical conditions were seen by a physician or physician delegate at the required intervals, as documented records showed gaps in mandated face-to-face visits. The DON and ADM confirmed that the available visit records did not meet regulatory requirements for several residents.
The facility failed to properly label and date food items, risking food-borne illnesses for 62 residents. Surveyors found unlabeled cereal, sandwiches, and nutritional shakes, as well as expired and dented items in storage. The Dietary Supervisor confirmed these deficiencies.
The facility failed to ensure accurate MDS assessments for two residents, resulting in deficiencies. One resident's MDS did not reflect a Stage 2 pressure injury, despite evidence and confirmation from staff. Another resident's hospice care status was inaccurately documented as 'No' in the MDS, despite being on hospice services. These errors were attributed to staffing changes and oversight.
A resident with muscle wasting, generalized muscle weakness, hemiplegia, and hemiparesis did not receive necessary restorative therapy or an assistance device for contractures. Despite the care plan indicating the need for a right hand splint, the resident reported never receiving a brace. Facility staff were unaware of the resident's contractures, and no restorative program was in place, leading to the deficiency.
A resident with moderate cognitive impairment and a history of falls was placed in a Broda chair without a safety evaluation. Observations showed the resident frequently attempted to climb out of the reclined chair and called for help without staff intervention. Interviews revealed the facility used the chair to prevent falls but failed to assess its appropriateness, as confirmed by the DON and a hospice RN.
A facility failed to provide non-pharmacological interventions before administering PRN Xanax to a resident with a high cognitive function and diagnoses of Sepsis and Pulmonary Embolism. The resident received Xanax 54 times in a month without documented non-pharmacological interventions, contrary to the facility's policy. The Administrator confirmed the expectation to attempt such interventions first, which was not met.
A malfunctioning emergency entrance/exit door at the south end of the 100-hallway hindered access during an emergency. The Kenesaw Fire Department was unable to enter through this door due to a keypad issue, confirmed by a resident and facility staff. Observations showed the door required pressure to release, and it was the closest entry to the 100-hallway, crucial for emergency access.
Failure to Implement and Develop Effective Fall-Prevention Interventions for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents, including falls, for multiple residents. For one resident with dementia, confusion, lack of safety awareness, and a history of falls with injury, the care plan identified the resident as high risk for falls and included specific interventions such as keeping the resident in visual range, not leaving the resident unattended in a wheelchair, and keeping the specialized Broda chair reclined unless staff were sitting with the resident. Despite these interventions, the resident was observed seated in a tilted Broda wheelchair in the dining room without staff nearby. Earlier in the month, this resident had a witnessed fall from the wheelchair in the dining room when the chair was not tilted back as required, resulting in the resident leaning forward, tumbling out of the chair, and sustaining a head laceration and subdural hematoma that required hospital admission. For a second resident with hemiplegia, a below-knee amputation, and dependence on staff for transfers, the MDS and care plan specified that the resident required a full mechanical Hoyer lift with two staff for all transfers. A sign above the bed also indicated the resident was a full Hoyer lift with two-person assist. Despite these documented requirements, two nurse aides performed a pivot transfer without using the Hoyer lift, during which the resident reported feeling weak and fell, becoming stuck between a shower chair and the wall and sustaining right chest pain that required emergency room evaluation. The facility’s own records showed that this fall was not followed by completion of a fall risk assessment or post-fall data collection, even though the facility’s risk management policy required all accidents and incidents, including falls, to be reported, investigated, and accompanied by triggered assessments. For a third resident admitted with a stroke affecting the left side and a seizure disorder, the MDS showed the resident used a wheelchair or walker, had unilateral range-of-motion limitations, required assistance with mobility and toileting, and had experienced falls without injury since admission. The care plan identified the resident as high risk for falls and included a general intervention to review information on past falls and determine root causes. Facility incident and post-fall documentation showed this resident had multiple falls over several days, with identified potential root causes including inability to use the standard call light due to hand function, lack of non-skid footwear, lighting issues, and attempts to self-transfer to the bathroom related to toileting needs. Although some interventions were added, such as a pressure call light, side rails, a bed alarm, nonskid strips, and anti-rollbacks on the wheelchair, the care plan did not consistently incorporate interventions directly tied to the documented root causes, such as addressing toileting needs, adjusting toileting schedules, or ensuring non-skid socks and improved lighting. The MDS Coordinator and DON confirmed that the facility did not have a fall policy and that interventions for this resident were not consistently based on the identified root causes of the falls. Additionally, interviews with facility staff confirmed systemic gaps in fall prevention processes. The MDS Coordinator stated that the facility did not have policies and procedures for falls or for resident lifts and transfers, and acknowledged that while incident reports and certain assessments were expected after falls, they were not always completed or used to drive care plan changes based on root cause analysis. For the resident with multiple falls, the MDS Coordinator confirmed that the resident’s toileting schedule and habits had not been evaluated despite toileting being identified as a root cause in several post-fall assessments. The DON confirmed that root causes should guide interventions and acknowledged that the interventions placed for this resident were not based on the documented root causes. These findings collectively demonstrate failures to implement existing care plan interventions, to use required equipment and assistance levels during transfers, and to develop and revise fall-prevention interventions in response to identified causal factors.
Failure to Maintain Resident Dignity and Privacy During Care and Room Entry
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and privacy by allowing exposure of body parts in public areas and by entering a resident room without knocking or announcing. One cognitively intact resident with Type 2 diabetes and spinal stenosis, who required substantial to maximal assistance with upper body dressing and used a wheelchair for mobility, was observed in the main dining area with their gray sweatshirt pulled up, exposing their abdomen to public view during a meal. Other residents were seated nearby and staff were present serving meals and drinks. When the resident requested to return to their room, a staff member pushed the wheelchair down the hallway without attempting to pull down the resident's shirt or otherwise cover the exposed abdomen. The resident later confirmed that their abdomen had been exposed both in the dining room and while being assisted down the hall, and stated they were unable to pull their shirt down independently and needed staff assistance to ensure their abdomen was covered. A nurse aide interviewed acknowledged that residents' body parts should not be exposed to public view and agreed this was a dignity issue. The DON also confirmed that residents' body parts should not be exposed for public view and that this constituted a dignity concern. A separate dignity and privacy concern was identified involving another cognitively intact resident with schizoaffective disorder and morbid obesity, who required assistance with bed mobility, transfers, and toileting. A medication aide entered this resident's room to administer medications by pushing open a partially open door without knocking or announcing, while other staff were providing personal care to the roommate, whose legs and lower body were exposed when the door was opened. During the medication pass, a laundry staff member also opened the door and entered the room without knocking while the roommate's lower body remained exposed. The resident later reported not being sure that staff always knock before entering and described waking up at times to find staff already in the room. The medication aide and the DON both confirmed that staff are expected to knock and announce themselves before entering a resident's room.
Failure to Prevent Resident-to-Resident Physical Abuse by a Behaviorally Challenging Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable adult from physical abuse by other residents despite ongoing behavioral concerns. Facility policy defined all adults in the facility as vulnerable adults and required systems to identify residents at risk of abusing others, continual assessment and care planning, and implementation of measures to protect residents from abuse. Resident 3 had a documented history of wandering into other residents’ rooms and intrusive behaviors. On one occasion, Resident 3 entered another resident’s room and would not leave, resulting in the other resident pushing Resident 3 out of the room, causing Resident 3 to fall face down and sustain a hematoma above the left eye. The care plan included short-term 15‑minute checks and later temporary interventions such as redirection, music, snacks, toileting, 1:1 time, and PRN psychotropic medication, but no long‑term interventions were initiated to address the ongoing risk of resident‑to‑resident altercations. Progress notes over the following weeks documented repeated episodes of Resident 3 wandering into other residents’ rooms, being invasive, touching other residents on the chest and head, and becoming physically aggressive toward staff. On a later date, staff responded to residents screaming for help and found Resident 3 in another resident’s room; the resident in the room reported that Resident 3 had hit and choked them while they were sitting in their wheelchair. On another occasion, Resident 3, while in an activity room, walked over and hit one resident on the top of the head and then pursued and hit another resident in the face. Interviews with the Facility Administrator and the MDS Coordinator revealed that 1:1 supervision for Resident 3 occurred only at times and that long‑term interventions such as continuous 1:1 supervision were not implemented, despite recognition that Resident 3’s behaviors placed other vulnerable adults at risk of abuse. These actions and inactions resulted in the facility’s failure to ensure that Resident 3 and other residents were free from physical abuse as required by policy and regulation.
Multiple Medication Administration Errors During Morning Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less when a medication aide (MA) was observed administering multiple morning medications to one resident outside the ordered administration time window of 0630 to 1100. During the observation period, all of the resident’s scheduled morning medications appeared in red on the electronic medication administration record (eMAR), indicating they were late. The MA acknowledged that administering medications late constituted a medication error, and the resident and an LPN both confirmed that all of the resident’s morning medications were given late. During the same medication pass, the MA did not follow facility policy or professional standards regarding the rights of medication administration and documentation. The MA removed medications from bubble packs, placed them into a medication cup, and documented them as given in the eMAR by clicking the “Y” button before the resident actually consumed them. The MA and the DON both confirmed that medications should not be signed out as administered until after the resident has taken them, and that this practice did not comply with the five rights of medication administration. The MA also administered an incorrect dose of a nasal spray and improperly handled a powdered laxative medication. For the nasal spray Azelastine 0.1%, which was ordered as one spray in each nostril, the MA administered two sprays in each nostril; both the MA and the resident confirmed the ordered dose and the error, and the DON confirmed this was a medication error. In addition, when preparing Polyethylene Glycol 3350, the MA poured the white granular powder into a 30 ml cup, realized grams could not be measured with that cup, and then discarded the medication-filled cup into a trash can instead of using the facility’s medication destroyer as required. The DON confirmed that this disposal method was not in accordance with facility policy.
Failure to Complete Registry Checks and Report Adverse Event
Penalty
Summary
The facility failed to complete nurse aide registry checks prior to staff having possible or probable contact with residents for three of six sampled staff members. Specifically, a nurse aide and a business office manager both began working before their registry checks were completed, with the checks occurring 10 and 12 days after their respective start dates. Additionally, a housekeeper worked multiple days without any evidence of a completed registry check. The facility administrator confirmed that these staff members worked prior to the completion of the required registry checks. The facility also failed to report an adverse event involving a resident who was admitted with spinal stenosis. The resident experienced a fall during a transfer from a wheelchair to a bed using a full body lift, when the sling strap broke, causing the resident to fall partially onto the bed and partially onto the floor. The incident resulted in soreness and bruising, and was attributed to malfunctioning equipment. The director of nursing confirmed that this event was an unusual, unanticipated event with the potential to cause serious injury, and acknowledged that it was not reported to the appropriate agencies as required by facility policy.
Failure to Review Employee Health Screens and Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that employee health screens were reviewed by appropriate staff prior to the start of employment for four out of five sampled employees. Specifically, the Employee Health History Screens for the Business Office Manager, two Nurses Aides, and a Housekeeper were completed and signed by the employees themselves, but there was no evidence that a facility staff member or nurse had reviewed these documents before the employees began working. Interviews with the MDS Coordinator, who serves as the infection preventionist, and the Director of Nursing confirmed that the required review process was not followed for these individuals. Additionally, the facility did not ensure that staff consistently performed hand hygiene according to professional standards. Observations of a Medication Aide and two LPNs revealed that hand washing was performed for less than the required 20 seconds, and in some cases, used paper towels were employed to turn off the water instead of a clean paper towel, contrary to facility policy. Staff interviews confirmed awareness of the correct procedures, but acknowledged that proper hand hygiene was not consistently practiced during the observed instances.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program standards for monitoring and surveillance of antibiotic use for one resident. According to the facility's policy, nurses are required to utilize infection criteria protocols to determine the necessity of antibiotics, document the rationale for antibiotic prescriptions, and monitor for effectiveness, side effects, and adverse consequences. In the case reviewed, a resident with dementia and at risk for skin integrity issues was prescribed an oral antibiotic for cellulitis of the left second toe. The antibiotic prescribed was noted to be outside the recommended dose and frequency, yet there was no assessment indicating that infection criteria protocols were completed or reviewed by the provider before or after the prescription. Additionally, the required 'antibiotic time out'—a review of the appropriateness of the antibiotic 24-48 hours after initiation—was not performed. The provider was not notified that the prescribed antibiotic was outside the recommended dosing guidelines, nor was there documentation that the provider was made aware of whether infection criteria were met. The facility's Infection Preventionist confirmed that these antibiotic stewardship processes were not followed for this resident.
Failure to Prevent Elopement and Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to prevent accidents and incidents for a resident with a high risk of elopement. The resident, who had diagnoses of schizophrenia and bipolar disorder with psychotic features, was assessed as cognitively intact but had a history of wandering, episodes of disorientation, and confusion. Despite being identified as high risk for elopement on a risk assessment, documentation inconsistently described the resident as only a moderate risk, and a wander guard was removed. The resident had a physician order for a wander guard to be in place and functioning, with staff directed to check its placement and function every shift. Multiple incidents occurred where the resident exited the building without staff knowledge, including being found outside by therapy staff and being brought back inside on two separate occasions after exhibiting aggressive behaviors. On another occasion, the resident exited the building by following another resident who had entered the security code to the front door, and was only noticed and assisted back inside by an LPN after about a minute. There was no documentation of incident reports or changes to interventions following these events, and the DON confirmed that no new interventions were implemented to prevent further unauthorized exits during this period.
Failure to Provide Written Notification Before Resident Room Change
Penalty
Summary
The facility failed to provide written notification to a resident or their Power of Attorney (POA) prior to a room change. Record review showed that the resident was moved to a new room to prevent falls, as decided by the Interdisciplinary Team (IDT) and the Director of Nursing (DON). The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, reported having no knowledge of the move or the reason for it. The resident's belongings were packed and moved without their prior awareness. Interviews with facility staff revealed that the Social Services Director (SSD) was typically involved in room changes but was not familiar with this particular move. The DON stated that the resident was spoken to about the move and had agreed, but also described the resident as not alert and oriented, with hallucinations and delusions, and unable to make such decisions. The DON confirmed that the POA could not be reached and that no written notification was provided to either the resident or the POA. The SSD confirmed that a notification form, which includes information about the right to appeal, should have been provided but was not.
Incorrect MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two of seventeen sampled residents, as required by federal and state regulations. Specifically, the MDS for both residents was coded to indicate that they had received insulin injections during the 7-day look back period. However, a review of the Medication Administration Records (MAR) for both residents showed no documented administrations of insulin during that time frame. Instead, the records indicated that the residents had received other injectable medications for Type 2 Diabetes—Trulicity and Ozempic—which are not classified as insulin. The Minimum Data Set Coordinator (MDSC) confirmed during an interview that the residents did not receive insulin during the assessment period and acknowledged that the MDS coding was incorrect. The coding error was attributed to the misclassification of non-insulin injectable diabetes medications as insulin in the MDS documentation. This discrepancy was identified through record review and staff interview, confirming that the facility did not follow the correct coding instructions as outlined in the Resident Assessment Instrument (RAI) Manual.
Failure to Provide Required 30-Day Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents received their required 30-day physician visits, as mandated by facility policy and federal regulations. For one resident with Alzheimer's dementia, anxiety, dyskinesia of the esophagus, and high blood pressure, there was no documentation of a physician visit within 30 days of admission. The first documented physician visit occurred 60 days after admission, during which the resident had already experienced a 7.14% weight loss and required new nutritional orders. Both the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) confirmed the absence of the required 30-day physician visit for this resident. Another resident, admitted with a documented initial physician visit, did not receive the subsequent required 30-day follow-up visit. The medical record showed a gap between the initial visit and the next documented physician encounter, which did not occur until 60 days after the previous visit. Interviews with the DON and RNC confirmed that the required 30-day physician visit was not completed for this resident as well. These lapses prevented timely physician assessments necessary for developing and updating comprehensive care plans, verifying orders, and prescribing appropriate treatments.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication aide (MA) failed to follow proper medication administration procedures for a resident, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. During observed medication administration, the MA did not instruct the resident to rinse their mouth after using the Trelegy Ellipta inhaler, as required by both manufacturer instructions and facility competency guidelines. Additionally, the MA did not use the provided dosing card to measure the correct amount of Diclofenac Sodium gel before applying it to the resident's ankles, instead using a finger to scoop the medication from a cup. These actions were confirmed by the MA during an interview. Further, the MA administered an as-needed (PRN) dose of acetaminophen to the resident for a reported headache without first obtaining permission from the nurse, as required by facility protocol. The MA only informed the nurse of the administration after the fact. The nurse confirmed that the MA should have sought approval prior to giving the PRN medication. These failures in medication administration practices were observed and documented during the survey, affecting one of five sampled residents.
Failure to Identify Fall Causes and Update Care Plans After Incidents
Penalty
Summary
The facility failed to identify causal factors for falls and did not implement timely or appropriate interventions to prevent new falls after each incident, as required by their own policies and regulatory standards. This deficiency was observed in three residents, all of whom were at high risk for falls due to various medical conditions such as cognitive impairment, use of anticoagulants, gait and balance problems, incontinence, and recent infections. Despite multiple falls, the care plans for these residents were not consistently updated with new interventions after each incident, and some interventions identified in fall reports were not incorporated into the care plans at all. For one resident, multiple unwitnessed and witnessed falls occurred over a short period, with post-fall reports indicating issues such as improper footwear, incontinence, and changes in mental and physical status. However, interventions such as ensuring the call light was within reach or obtaining therapy referrals were not always added to the care plan, and updates were sometimes delayed until after additional falls had occurred. Another resident experienced falls associated with urinary symptoms and was later diagnosed with a urinary tract infection and sepsis, yet care plan updates did not occur with each incident, and communication of changes to staff was inconsistent. Staff interviews revealed that updates to care plans were often communicated verbally or through informal means such as whiteboards or binders, rather than being systematically documented and accessible to all staff. Charge nurses and nurse aides reported relying on word of mouth for care updates, and not all staff reviewed care plans directly. The Director of Nursing and MDS Coordinator confirmed that not all interventions from fall reports were added to care plans, and that root causes for falls were not always identified. This lack of timely and comprehensive care plan updates and failure to address causal factors for falls placed residents at risk and resulted in an Immediate Jeopardy situation.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that all residents were seen by a physician or physician delegate at the required intervals, as outlined in their own policy and federal regulations. Specifically, the policy requires that residents be seen by a physician within 30 days of admission, at least every 30 days for the first 90 days, and at least every 60 days thereafter. Record reviews and interviews revealed that five sampled residents did not have documentation of face-to-face physician visits that met these mandated timeframes. The Director of Nursing (DON) and Administrator (ADM) confirmed that the available records did not cover all required physician visits for these residents. The sampled residents had various medical conditions, including osteoporosis, atrial fibrillation, dementia, diabetes, chronic kidney disease, hypertension, depression, stroke, COPD, history of falls, use of anticoagulants, anxiety, bipolar disorder, schizophrenia, hemiplegia, and end stage renal disease. Despite the complexity of their medical needs, the documentation provided for each resident showed significant gaps in the frequency of physician visits, as required by policy. The deficiency was identified through review of medical records and staff interviews, which confirmed the lack of compliance with mandated physician visit schedules.
Deficiencies in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, which could potentially lead to food-borne illnesses for all 62 residents served from the kitchen. During an initial kitchen tour, surveyors observed several deficiencies in food storage and labeling practices. Five bags of opened cereal were found on a metal cart without any labels or dates. In the upright refrigerator, 12 half chicken salad sandwiches and an open Med Pass nutritional shake were found without dates, despite the manufacturer's label instructing use within four days of opening. Further inspection revealed a can of dented mandarin oranges in the dry storage room, a large bag of taco seasoning open without a date, a container of chicken bouillon cubes past their best-by date, and a bag of semi-sweet chocolate chips open without a date. In the walk-in refrigerator, a plastic container of pears was found with a use-by date that had passed, and a container of sliced jalapenos was labeled with an open date but no use-by date. The Dietary Supervisor confirmed these findings, acknowledging the lack of proper labeling and the presence of expired items.
Inaccurate MDS Assessments for Pressure Injury and Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care needs. For one resident, identified as Resident 33, the MDS did not accurately reflect the presence of a Stage 2 pressure injury. Despite the resident reporting a sore on their bottom and observations confirming a red, open area on the left buttock, the MDS inaccurately indicated that the resident did not have any unhealed pressure ulcers. This discrepancy was confirmed by the facility's administrator, who acknowledged that the pressure ulcer should have been coded on the MDS. Another resident, identified as Resident 16, was inaccurately documented in the MDS regarding their hospice care status. Although the resident had been admitted to hospice services, as confirmed by both the hospice RN and the Director of Nursing, the MDS incorrectly marked the hospice section as 'No'. This error was attributed to changes in MDS staffing at the time, leading to a failure in accurately updating the resident's care status in the MDS.
Failure to Provide Restorative Therapy and Assistance Device for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary restorative therapy and an assistance device for a resident with contractures. Resident 58, who was admitted with diagnoses including muscle wasting, generalized muscle weakness, hemiplegia, and hemiparesis, was not receiving restorative therapy for their condition. The resident's care plan indicated the need for a right hand splint to be applied daily by staff, but the resident reported never having received a brace for their contracted hand. Observations confirmed the resident's inability to open contracted fingers on the right hand, move the right wrist, and limited elbow extension. Interviews with facility staff, including a Certified Occupational Therapy Assistant (COTA) and the Director of Nursing (DON), revealed that the therapy department was unaware of the resident's contractures and that no restorative program was in place for the resident. The facility's policy on contracture prevention and management outlined procedures for providing range of motion exercises and splint/brace application, but these were not implemented for Resident 58. The lack of a restorative program and failure to provide an orthotic device contributed to the deficiency identified by the surveyors.
Failure to Evaluate Broda Chair Safety for Resident
Penalty
Summary
The facility failed to evaluate the safety of a Broda chair before its use for a resident, identified as Resident 16, who was admitted to the facility with a diagnosis of senile degeneration and was placed on hospice care. The resident's cognitive skills for daily decision-making were moderately impaired, and they required substantial assistance for transfers. The care plan noted the resident's potential for falls due to confusion, gait/balance problems, and unawareness of safety needs. Despite these risks, the facility did not assess the Broda chair's suitability for the resident, who had a history of falls when using a regular wheelchair. Observations revealed that Resident 16 was frequently left unsupervised in the Broda chair, which was often reclined, making it difficult for the resident to sit up or move independently. On multiple occasions, the resident was observed attempting to climb out of the chair, calling for help, and trying to get the attention of staff, who did not respond. The resident's family member also reported seeing the resident in a precarious position in the chair, indicating a lack of proper supervision and intervention by the facility staff. Interviews with facility staff, including a hospice RN and the DON, confirmed that the Broda chair was used to prevent falls and support the resident's weak core. However, the facility had not conducted an evaluation to determine the appropriateness of the Broda chair for Resident 16. The DON acknowledged the lack of assessment, and a corporate RN suggested that an occupational therapy assessment might be necessary, highlighting the oversight in ensuring the resident's safety and proper use of the Broda chair.
Failure to Implement Non-Pharmacological Interventions Before PRN Xanax Administration
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided prior to administering PRN Xanax for a resident, leading to a deficiency. The resident, who had a BIMS score of 15 indicating high cognitive function, was admitted with a primary diagnosis of Sepsis and Pulmonary Embolism with Acute Cor Pulmonale. The resident had orders for Alprazolam 0.5mg to be administered as needed for anxiety or sleep, with a maximum of three tablets in a 24-hour period. However, the facility did not document any non-pharmacological interventions before administering the medication. The facility's Comprehensive Care Plan for the resident included goals and interventions related to anxiety, such as administering medications as ordered and monitoring for side effects and effectiveness. Despite this, the Medication Administration Record showed that the resident was given PRN Xanax 54 times in July without any documented non-pharmacological interventions. The facility's policy on Behavior Management emphasized that non-pharmacological interventions should be the first choice in managing behavioral symptoms. An interview with the facility Administrator confirmed the expectation to attempt non-pharmacological interventions prior to administering PRN Xanax, which was not met in this case.
Emergency Door Malfunction
Penalty
Summary
The facility failed to ensure the proper functioning of the emergency entrance/exit door at the south end of the 100-hallway, which compromised the safety and accessibility of the building during an emergency. On June 21, 2024, the Kenesaw Fire Department (KFD) was called to the facility to investigate a shorted electrical receptacle in a resident's room. However, they were unable to access the building through the emergency door at the south end of the 100-hallway and had to use the main entrance instead. This issue was confirmed by a resident during an interview on June 25, 2024. Further observations on June 25, 2024, revealed that the keypad code on the emergency door allowed exit but did not permit re-entry from the street, despite sounding as if it had released the door. The egress mechanism required pressure for five seconds to release the door, which was not functioning as intended. The door was the closest entry point to the 100-hallway from the street, making it critical for emergency access. Interviews with the Senior Administrator and Maintenance Supervisor confirmed that the door was not functioning properly before repairs were made on June 25, 2024.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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