Accura Healthcare Of O'neill
Inspection history, citations, penalties and survey trends for this long-term care facility in O' Neill, Nebraska.
- Location
- 1102 North Harrison Street, O' Neill, Nebraska 68763
- CMS Provider Number
- 285108
- Inspections on file
- 24
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Accura Healthcare Of O'neill during CMS and state inspections, most recent first.
Facility staff failed to timely report an elopement to the State Agency as required by policy and state regulations. A resident with severe cognitive impairment, who required total assistance with toileting and extensive assistance with dressing and hygiene but could ambulate independently, opened a back door, exited into the parking lot, and triggered a door alarm. A NA first checked the front door, then the back door, and upon opening it observed the resident walking in the back parking lot and redirected the resident inside. Review of facility reporting records showed the incident was not reported within required timeframes, and the DON confirmed the elopement had not been reported as it should have been.
The facility did not follow its own Antibiotic Stewardship Program protocols, failing to track, document, or review antibiotic use and related laboratory data. The Infection Preventionist confirmed that there was no identification or analysis of organisms to determine if antibiotic prescribing met established criteria, potentially affecting all residents.
Several residents did not receive timely lab work, prescribed medications, or required treatments due to delays, lack of documentation, and failure to follow physician orders. There were also failures to monitor fluid restrictions, administer eye drops and compression garments, and complete weekly wound assessments, with staff and the DON confirming these deficiencies.
Staff did not consistently follow individualized care plans and facility policies for safe transfers and fall prevention. For example, a resident with hemiplegia was not always assisted by two staff during mechanical lift transfers, and several residents at high risk for falls did not have required interventions such as alarms, stop signs, or body pillows in place. Additionally, new interventions were not developed after repeated falls, and some residents were not laid down after meals as care planned. These actions and inactions resulted in an unsafe environment and failure to prevent accidents.
The facility did not ensure that GDRs for psychotropic medications were addressed in a timely manner or that clinical rationales for not attempting GDRs were documented. For three residents with histories of mental illness or depression, the consultant pharmacist made repeated recommendations for GDRs, but prescribers either declined without providing clinical justification or did not address the recommendations, and the required documentation was missing.
Multi-dose insulin pens for several residents with diabetes were not dated when first opened, as required by facility policy and professional standards. During a medication cart observation, it was found that insulin pens lacked opening dates, and both an LPN and the DON confirmed that insulin should be dated to prevent use beyond 28 days. This deficiency affected multiple residents receiving scheduled and sliding scale insulin.
Surveyors observed staff failing to perform proper hand hygiene, use required PPE during high-contact care for residents on Enhanced Barrier Precautions, and clean shared equipment such as mechanical lifts between uses. These deficiencies were noted during care for residents with incontinence, MDRO history, wounds, and indwelling devices, with staff often not following facility policies for infection prevention.
A resident with an indwelling catheter and multiple medical conditions was repeatedly observed with their catheter drainage bag uncovered and visible from the hallway, contrary to facility policy requiring privacy bags. The DON confirmed that dignity bags should have been used for all residents with catheters, but this was not done in this case.
The facility did not notify practitioners when two residents experienced missed medications, non-compliance with fluid restrictions, and absence of prescribed compression garments. One resident did not receive an anticoagulant for several days without physician notification, while another exceeded fluid limits, missed steroid eye drops, and went without compression garments for an extended period, with delayed and incomplete communication to the physician.
The facility did not document clinical rationales for not attempting gradual dose reductions of psychotropic medications for a resident with serious mental illness, and also failed to limit and properly renew PRN antipsychotic medication orders for another resident with severe cognitive impairment, as required by policy and regulation.
A resident admitted with a stage II sacral pressure ulcer did not receive any wound care or treatment orders during their stay, despite clear documentation of the ulcer and its required care. The resident, who had multiple health issues, left the facility after reporting the lack of wound care. The DON confirmed that no treatment orders were obtained and no policy for pressure ulcer management was in place.
The facility failed to develop and implement a water management program, including a risk assessment and control measures/testing protocols, to address potential hazards. The administrator confirmed the absence of these measures, affecting all 34 residents.
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions. Recurring concerns such as cold food, untimely call light responses, and missing laundry were documented, but no evidence of corrective actions or sustained resolutions was found. Interviews confirmed that the facility had not come up with solutions or followed up with residents to ensure acceptable resolutions.
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation revealed a locked cabinet with a large quantity of medications without any record keeping. The DON confirmed the absence of required documentation, putting the medications at risk of potential loss or theft.
The facility failed to maintain food service equipment cleanliness, allowed outdated food to be available for consumption, and did not ensure staff adhered to safe handling of ready-to-eat food. Observations included a nurse aide handling food with bare hands and significant cleanliness issues in the kitchen, including a grease-coated stove and overdue fire suppression system inspection.
A resident was transferred to the hospital after a fall, but the facility failed to provide the required written bed hold notification to the resident or their representative. The DON confirmed the notification was not given as per policy.
The facility failed to complete a PASARR for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. This was confirmed through medical records and staff interviews.
Failure to Timely Report Resident Elopement to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an elopement to the State Agency as required by its reporting policy and state licensure regulations. The facility’s undated policy titled “Reporting requirements” states that whoever first identifies or is notified of a potential self-report event must immediately notify the DON and Administrator after ensuring safety, and that the Administrator or DON will then proceed with required notifications and investigations. Record review of the facility’s reports to the State Agency showed that the elopement incident involving one resident was not reported within the required timeframes. The resident involved had a BIMS score of 5 on the MDS, indicating severe cognitive impairment, required total assistance with toileting, and extensive assistance with dressing and hygiene, but could walk 150 feet independently. Progress notes documented that the resident opened the back door of the facility and went out into the parking lot; the door alarm sounded and the resident was redirected back into the facility. A nursing assistant reported hearing a door alarm, checking the front door and finding no one exiting, then checking the back door, which was closed, and upon opening it observed the resident walking in the back parking lot. In an interview, the DON confirmed that the facility had not reported this elopement to the State Agency and acknowledged that it should have been reported.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policies and regulatory standards. Although the facility had established protocols and policies for antibiotic stewardship, including the use of infection screening evaluations, laboratory testing, and monitoring of antibiotic use, these were not followed in practice. A review of infection surveillance records for a one-year period revealed that there were no documented culture results, no data on pathogens, and no evidence of review to determine if antibiotic prescribing met established criteria. During an interview, the Infection Preventionist confirmed that the facility had not identified, tracked, or analyzed organisms found through laboratory testing to assess whether antibiotic use was appropriate or met treatment criteria. This lack of monitoring and documentation meant that the facility could not ensure antibiotics were being used according to best practices, as outlined in their own policies and procedures. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Provide Timely Care, Medication, and Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident, laboratory work was not obtained in a timely manner, with significant delays between the ordering and collection of blood and stool tests. Documentation was lacking regarding when orders were received, when labs were obtained, and when results were communicated to the provider. The DON confirmed that staff did not document refusals, collection, or notification of lab results as required by facility policy. In multiple cases, residents did not receive prescribed medications due to unavailability, and there was no evidence that the facility took appropriate steps to address the situation. One resident missed seven days of an anticoagulant medication, while another missed several days of blood pressure medication, aspirin, and electrolyte replacement. The facility did not document efforts to determine the cause of the unavailability, did not notify the physician, and did not monitor the residents for adverse effects during the period the medications were not administered. The DON confirmed these lapses and the absence of required documentation and follow-up. Additional deficiencies included failure to monitor and document a resident's fluid restriction, with intake exceeding the prescribed limit on multiple occasions and no evidence of physician notification or documentation of the reason for the restriction. Another resident did not receive prescribed eye drops or compression garments as ordered, with delays in obtaining the necessary supplies and lack of timely physician notification. Furthermore, a resident with a pressure injury did not have weekly wound assessments or documentation as required by facility policy. These failures were confirmed through interviews and record reviews.
Failure to Implement and Monitor Fall Prevention and Safe Transfer Interventions
Penalty
Summary
Staff failed to utilize safe transfer techniques and follow individualized care plans for multiple residents, resulting in an unsafe environment. For one resident with left-sided hemiplegia and a history of stroke, staff did not consistently use two staff members during mechanical lift transfers as required by the care plan and facility policy. Observations showed that the resident's left arm was not properly supported during transfers, and staff confirmed that two-person assistance was not always provided, despite education on this requirement. Several residents at risk for falls did not have their care plan interventions implemented or revised as needed. One resident with severe cognitive impairment and contractures had a mesh stop sign and body pillow ordered as fall interventions, but these were repeatedly not in place during observations. The DON confirmed that these interventions were not consistently implemented after falls. Another resident with dementia and a history of falls was left unattended in their wheelchair without required alarms in place, and staff confirmed that the resident was sometimes left alone despite care plan instructions. Additional deficiencies included a resident who was to be laid down after meals as a fall prevention measure, but this was not consistently done within the expected timeframe. Another resident with a history of falls and high fall risk did not have new interventions implemented after multiple falls, despite care plan reviews and incident reports. These failures to implement, monitor, and revise fall prevention interventions and safe transfer practices directly contributed to the facility's noncompliance with accident prevention requirements.
Failure to Document Clinical Rationale for Not Attempting Gradual Dose Reductions
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were addressed in a timely manner and that clinical rationales for not attempting GDRs were documented, as required by policy. For one resident with a history of serious mental illness, including anxiety, bipolar disorder, and schizophrenia, the record showed ongoing administration of anti-psychotic, anti-depressant, and anti-anxiety medications. Although a GDR for Venlafaxine was marked as contraindicated by the prescriber, there was no documented clinical rationale provided for this decision. Another resident, admitted with diagnoses including stroke, high blood pressure, seizure disorder, and depression, was receiving daily antidepressant medications. The consultant pharmacist made multiple recommendations over several months for GDRs of Prozac and Trazadone. While the physician declined the GDRs, there was no evidence that a clinical rationale was documented to explain why the reductions were not clinically appropriate. Eventually, only the Trazadone dose was reduced, with no documentation regarding the Prozac. A third resident, with diagnoses of debility, heart failure, previous stroke, depression, and anemia, was also receiving daily antianxiety and antidepressant medications. The consultant pharmacist repeatedly recommended GDRs for Buspar and Remeron, but the prescriber did not order dose reductions and failed to provide a clinical rationale for not doing so. Interviews with the DON confirmed the absence of required documentation for all three residents, despite multiple pharmacist recommendations and follow-up communications.
Failure to Date Opened Insulin Pens for Multiple Residents
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens for four residents were dated when first opened, as required by both facility policy and professional standards. During an observation of the medication carts, it was found that insulin pens for these residents did not have dates indicating when they had been accessed. The facility's policies specify that all multi-use vials must be dated upon first use and discarded within 28 days unless otherwise specified by the manufacturer. Record reviews confirmed that these residents had orders for various types of insulin, including Glargine, Novolog, and Insulin Aspart, administered on scheduled and sliding scale regimens for diabetes management. Interviews with an LPN and the Director of Nursing confirmed that insulin is required to be dated when opened to prevent use beyond the recommended period. The lack of dating on the insulin pens meant there was no way to ensure the insulin was not being used past the effective date, which is contrary to both facility policy and accepted professional practice. The facility census at the time was 45, and six residents were identified as receiving insulin injections.
Infection Control Deficiencies: Hand Hygiene, PPE, and Equipment Cleaning
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to hand hygiene, use of personal protective equipment (PPE), and cleaning/disinfection of shared equipment. Staff were observed failing to perform hand hygiene at critical points, such as before donning gloves, after removing soiled gloves, and between resident contacts. In several instances, staff did not provide complete perineal care to residents who were incontinent, and failed to change gloves or perform hand hygiene when required by facility policy. For example, during care for a resident with cancer, dementia, and incontinence, staff did not wash hands before or after glove use, did not provide full perineal hygiene, and did not disinfect the mechanical lift after use. The report also documents failures in the use of Enhanced Barrier Precautions (EBP) for residents with a history of multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for residents on EBP. In one case, a medication aide assisted a resident with a history of MRSA with toileting and perineal care without wearing a gown and failed to change gloves or perform hand hygiene at appropriate intervals. Another instance involved a nurse not removing PPE before exiting a resident's room and placing potentially contaminated items on the medication cart without a barrier or cleaning. Additionally, the facility failed to clean and disinfect mechanical lifts between resident uses, as required by policy. Multiple staff members confirmed during interviews that lifts were not cleaned after transferring residents, including those with cognitive impairments and those dependent on staff for mobility. These lapses in infection control practices were observed across several residents and staff, indicating a systemic failure to adhere to established protocols designed to prevent cross-contamination and the spread of infection within the facility.
Failure to Use Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
Staff failed to ensure the use of a privacy bag for a resident's catheter drainage bag, as required by facility policy. Multiple observations over several days showed the resident's catheter bag hanging on their walker without a privacy cover, making it visible from the hallway. This occurred both when the resident was in bed and when the catheter bag was attached to the walker, with no privacy bag in use during any of the observed times. The resident involved had an indwelling catheter due to neurogenic bladder and other medical conditions, including renal disease, anxiety, depression, and schizophrenia. The resident's care plan specified that the catheter bag and tubing should be kept below the bladder and away from the entrance room door, but did not address the use of a privacy bag. Interviews with the DON confirmed that dignity bags were expected to be used for all residents with catheters, but this was not done for this resident.
Failure to Notify Practitioners of Missed Medications and Non-Compliance with Care Orders
Penalty
Summary
The facility failed to notify practitioners regarding significant changes and issues affecting two residents. For one resident with severe cognitive impairment and multiple diagnoses including cancer, atrial fibrillation, and malnutrition, the facility did not administer a prescribed anticoagulant (Xarelto) for seven consecutive days. Despite the facility's policy requiring physician notification when medications are unavailable or missed, the resident's practitioner was not informed of the missed doses. Another resident, who had orders for fluid restriction, steroid eye drops post-cataract surgery, and thigh-high compression garments, experienced multiple lapses in care. The facility did not notify the physician when the resident repeatedly exceeded fluid intake limits, missed multiple doses of prescribed eye drops, and went without compression garments for over a month while waiting for a larger size. Although the physician was eventually notified of increased edema and the absence of compression garments, this notification was delayed, and there was no documented follow-up with the physician after the initial contact.
Failure to Document GDR Rationale and Limit PRN Antipsychotic Orders
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were properly documented with a clinical rationale when not attempted for a resident with serious mental illness. Specifically, a resident with diagnoses of anxiety, bipolar disorder, and schizophrenia was receiving multiple psychotropic medications, including Haloperidol, Quetiapine, Clonazepam, and Lorazepam. Although GDRs for these medications were marked as contraindicated in communications with the prescribing provider, there was no documented clinical rationale in the resident's medical record explaining why dose reductions were not attempted. Additionally, the facility did not comply with requirements for limiting as-needed (PRN) antipsychotic medication orders to 14 days for another resident with severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, anxiety, and depression. The resident was receiving a PRN antipsychotic combination (ABH gel) for agitation and restlessness, with the order in place and administered intermittently over several months. Despite repeated recommendations from the consultant pharmacist to add a stop date and renew the order every 14 days, the facility continued to administer the medication without proper renewal or documentation of appropriateness by the prescribing practitioner. Interviews with the Director of Nursing confirmed the lack of required documentation for both the clinical rationale for not attempting GDRs and the failure to renew PRN antipsychotic orders as mandated. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and management of psychotropic medications.
Failure to Provide Pressure Ulcer Treatment Upon Admission
Penalty
Summary
Facility staff failed to obtain and provide pressure ulcer treatment for a resident who was admitted from the hospital with a stage II pressure ulcer to the sacral region. Upon admission, the resident's medical record and skin assessment documented the presence of a 3.5 cm by 2.8 cm pressure ulcer with a depth of 1.5 cm, and the hospital discharge summary indicated the need for dressing changes 1-2 times daily. Despite these findings, there was no evidence in the electronic medical record from admission through discharge that any treatment was ordered or completed for the pressure ulcer. The resident, who had diagnoses including chronic pain, adult failure to thrive, malnutrition, and alcohol use, reported to staff that the wound was not being treated or assessed. The resident subsequently decided to leave the facility, citing the lack of wound care as the reason. An interview with the DON confirmed that no admission orders for wound care were obtained, staff did not contact the resident's physician for a treatment order, and the facility did not have a current policy for pressure ulcer care and management.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to develop and implement a water management program that included a risk assessment and control measures/testing protocols to address potential hazards. The facility's policy, dated 9/2022, indicated the need for a water management plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. However, a review of the facility's water management program revealed no documentation of a risk assessment or implementation of control measures and testing protocols. During an interview, the administrator confirmed that no risk assessment had been completed and no control measures or testing protocols were in place to address potential hazards. This deficiency had the potential to affect all 34 residents in the facility.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions of resident concerns. The facility's grievance policy stated that residents had the right to voice grievances without fear of reprisal and that the facility would ensure prompt resolution and keep residents informed throughout the process. However, a review of the Resident Council Meeting Minutes from March 2023 through April 2024 revealed recurring concerns such as cold food, untimely call light responses, missing laundry, and inadequate snack options. There was no evidence that the facility discussed old business or included what actions were taken to resolve previous concerns in subsequent meetings. The facility's grievance log from June 2023 through April 2024 showed multiple grievances related to call light response times, food options, snack cart availability, treatment and medication concerns, missing laundry items, and the availability of fresh water/ice. Despite these documented grievances, there was no evidence that the facility had implemented corrective actions or sustained resolutions to prevent repeat concerns. Interviews with Resident Council Representatives confirmed that the facility had not come up with solutions to grievances or followed up with residents to ensure the resolutions were acceptable. The facility Administrator confirmed that the facility had not implemented a grievance process that consistently identified repeat grievances or ensured sustainable resolutions. The facility also lacked evidence of presenting sustainable resolutions to the Resident Council to ensure the resolutions were acceptable to those involved in the grievance process. This failure to address and resolve resident grievances led to ongoing dissatisfaction and repeated concerns among the residents.
Failure to Document Medications Awaiting Destruction
Penalty
Summary
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation of the medication storage room revealed a locked cabinet labeled 'destroyed medications' containing a large quantity of medications without any record keeping or accounting. The facility policy requires a Non-Controlled Medication Destruction Record to be maintained for all non-controlled drugs destroyed, verified by the consultant pharmacist, and include specific information such as the name and address of the facility, date medication destroyed, prescription number, name, strength, and quantity of the medication being destroyed, and signatures of persons witnessing the destruction. However, this documentation was missing for the medications of Residents 12, 138, 139, 140, 141, 142, 143, and 144. During an interview, the Director of Nurses (DON) confirmed the absence of documentation for the medications awaiting destruction, which included various medications such as Bisacodyl, Insulin Aspart, Insulin Lantus, Milk of Magnesia, Aloe Vesta, Maalox, Antacid-antigas, Lasix, Melatonin, Tylenol, Aspercreme, zinc oxide cream, Baza cream, Biofreeze gel, Desitin cream, Vaseline jelly, triamcinolone cream, Nystatin cream, Betamethasone cream, Nystatin powder, Gabapentin, and Omeprazole. The lack of required documentation put the residents' medications at risk of potential loss or theft, as there was no record of the residents' names, dates, medication names, dosages, and quantities of each medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food service equipment was cleaned and maintained, outdated food was not available for consumption, and staff adhered to safe handling of ready-to-eat food. During an observation, a nurse aide was seen handling a resident's toast and bacon with bare hands, which is against the facility's policy. Additionally, a large container of egg salad dated beyond the allowable three days was found in the walk-in refrigerator. The dietary aide confirmed that leftovers should be disposed of after three days, indicating a lapse in following the facility's food safety protocols. Further inspection revealed significant cleanliness issues in the kitchen. The stove/oven had a buildup of grease and grime, and the fire suppression system was overdue for inspection and cleaning. The piping above the stove was also coated with grease and debris. The facility lacked evidence of a cleaning schedule for food service equipment, and the cook confirmed that cleaning was done only when staff had time. The Corporate Certified Dietary Manager acknowledged these deficiencies, confirming that staff should not handle ready-to-eat food with bare hands and that the leftover egg salad should not have been available for consumption.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide Resident 35 or the resident's representative with the required bed hold notification when the resident was transferred to the hospital. The facility's policy mandates that written notice be given at the time of transfer, specifying the duration of the bed-hold policy and information about the resident's return. Resident 35 was transferred to the hospital after a fall, but there was no documented evidence that the resident or the resident's representative received the required written notification. The Director of Nurses confirmed that the notification was not provided as required by the facility's policy.
Failure to Complete PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. Resident 22 was diagnosed with Post Traumatic Stress Disorder (PTSD) on 3/14/23 and had been taking an antipsychotic medication (Seroquel) since 2/13/24. Despite these significant changes, no new PASARR was completed for Resident 22. This was confirmed by both the Social Services Director and a Registered Nurse during interviews on 4/17/24. Similarly, Resident 24, who had diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder, and Alzheimer's disease, was receiving antipsychotic and antidepressant medications. The resident's medical records indicated that they had been taking Quetiapine for bipolar disorder since 3/14/23. However, there was no documentation that a new PASARR had been completed following the new diagnosis of bipolar disorder. This oversight was confirmed by a Registered Nurse during interviews on 4/17/24.
Latest citations in Nebraska
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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