Adept Nursing & Rehab Of Ashland
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Nebraska.
- Location
- 1700 Furnas Street, Ashland, Nebraska 68003
- CMS Provider Number
- 285140
- Inspections on file
- 29
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Ashland during CMS and state inspections, most recent first.
Two residents received omeprazole after eating breakfast instead of 60 minutes prior as ordered, and one resident did not have their mouth rinsed after using Trelegy Ellipta, resulting in a medication error rate of 12% during observed medication passes. The errors were confirmed by the MA and DON, and were not in accordance with facility policy or medication instructions.
A resident receiving multiple psychotropic medications for anxiety and depression did not have documented education or informed consent for their use, despite facility policy requiring this prior to medication initiation or increase. The DON confirmed the absence of a psychotropic consent form in the resident's record.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents requiring noninvasive ventilator support did not have care plans reflecting the use of a Trilogy machine, and staff had not received training or competency testing for its use. Despite physician orders and the presence of the machines at bedside, only some nurses were able to assist residents appropriately, as confirmed by both resident interviews and the DON.
A resident with PTSD and a history of trauma, substance use, and homelessness was admitted without a trauma-based assessment or trauma-informed care plan. The care plan did not address the resident's known triggers or mental health needs, despite facility policy requiring culturally competent and trauma-informed care.
Two residents with cognitive impairment were involved in an altercation, but their Comprehensive Care Plans were not updated to reflect new behavioral interventions or documentation of the incident. The DON confirmed that required documentation and notifications were not completed, despite facility policies mandating timely care plan revisions and individualized behavioral health interventions.
Three residents with known fall risks experienced falls and injuries due to the facility's failure to implement and maintain care plan interventions, including leaving a resident unattended in a dining room, allowing another to attempt a self-transfer without proper equipment, and not ensuring that call lights and personal items were within reach for a resident with repeated falls.
During a COVID outbreak, staff failed to consistently wear masks or wore them incorrectly, and soiled linens were carried against uniforms instead of being bagged. Additionally, reusable dishes from a COVID-positive resident's room were placed in a common dining area, contrary to infection control policy. Staff interviews confirmed these lapses in protocol.
The facility failed to ensure two nurse aides completed the required 12 hours of continuing education to maintain their certification. A review showed that one aide completed 5.5 hours and another 2.5 hours in the past year. This was confirmed by the facility educator, despite the policy requiring 12 hours annually.
The facility failed to maintain safe water temperatures in the Memory Care Unit, with temperatures ranging from 122 to 136 degrees Fahrenheit, exceeding the safe limit of 120 degrees. This issue arose after a new water heater was installed, and the DOM confirmed that water temperatures had not been checked in the MCU since then. The DOM also admitted to not knowing how to calibrate the thermometer used for temperature checks.
The facility failed to ensure proper mechanical ventilation in the Memory Care Unit bathrooms, affecting all 9 resident rooms. Observations noted a strong urine odor, and vents were unable to pull up toilet paper, indicating malfunction. Staff interviews confirmed the vents were not checked or cleaned regularly, and maintenance procedures were inadequate, with no regular checks or Guardian Angel rounds addressing the issue.
The facility failed to provide weekly baths to three residents, despite their cognitive awareness and medical needs. One resident with muscle wasting experienced a nine-day gap between baths, while another with cerebral palsy had inconsistent bathing intervals. A third resident with hemiplegia reported infrequent baths, confirmed by a 15-day gap in records. Interviews with the Administrator and DON acknowledged the failure to meet the facility's bathing expectations.
The facility failed to accurately code the MDS for two residents, resulting in incorrect assessments of severe cognitive impairment with hallucinations and delusions. Despite the MDS entries, there was no supporting documentation in the residents' Behavior and Progress Notes. The Regional Nurse Consultant and DON confirmed the inaccuracies.
The facility failed to ensure routine bowel movements for two residents with severe cognitive impairment and occasional bowel incontinence. One resident had no documented bowel movements for two periods totaling seven days, and another for two periods totaling eleven days. No bowel medications were given, and no assessments were documented. Interviews with the DON and an LPN confirmed the absence of bowel medication orders, lack of bowel movement records, and no system to track residents' bowel movements.
A resident with congestive heart failure, under hospice care, passed away in the facility. Despite the facility's Comprehensive Care Plan requiring notification of hospice and family, the facility did not notify the hospice nurse; the resident's representative made the call instead. Interviews confirmed the facility's failure to follow its post-mortem care policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to practitioner’s orders and manufacturer’s recommendations, resulting in a medication error rate of 12% based on 25 observed medication administration opportunities. Specifically, two residents received omeprazole after consuming breakfast, despite clear instructions on the medication card to administer the drug 60 minutes prior to meals. Both the medication aide and the Director of Nursing confirmed that the medication was not given at the correct time, as required. Additionally, one resident did not have their mouth rinsed after receiving Trelegy Ellipta, an inhaled medication, contrary to the instructions to rinse the mouth after use. The medication aide acknowledged this omission during the interview, and the Director of Nursing confirmed that the mouth should have been rinsed. The facility’s own Medication Administration policy also requires mouth rinsing after inhaler use and administration of medications within the specified time frame.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of psychotropic medications for one resident. Review of the facility's policy indicated that residents, families, or resident representatives must be informed of the benefits, risks, and alternatives to psychotropic medications, including any black box warnings, prior to starting or increasing such medications. For the resident in question, medical records showed active orders and administration of multiple psychotropic medications, including alprazolam, buspirone, sertraline, and trazodone, for conditions such as anxiety and depression. Despite the resident being cognitively intact, as evidenced by a BIMS score of 14, there was no documentation of informed consent for the use of these medications in the resident's medical record. The care plan and medication administration records confirmed ongoing use of these medications, and the DON verified that no psychotropic consent form was present for the resident as required by facility policy and regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Lack of Staff Training and Competency for Trilogy Ventilator Use
Penalty
Summary
The facility failed to provide staff training and competency testing for the use of a Trilogy machine, a noninvasive ventilator, for two residents who required this specialized respiratory support. Record reviews showed that the facility's assessment did not identify the capability or capacity to provide specialized respiratory care or services, despite having a policy in place for noninvasive ventilation. The policy outlined the use of devices such as CPAP, BiPAP, AVAPS, and Trilogy, but there was no evidence that staff were trained or tested for competency in using these machines. For one resident, the medical record indicated a history of chronic hypercapnic respiratory failure, COPD, obstructive sleep apnea, aspergillosis, histoplasmosis, and other lung conditions, with physician orders for specific Trilogy machine settings. The resident's care plan did not mention the use of the Trilogy machine, although the medication administration record showed that noninvasive ventilation was provided as ordered. Observations confirmed the presence of the Trilogy machine in the resident's room, and the DON acknowledged that staff had not received training on its use. Another resident with COPD, idiopathic sleep-related nonobstructive alveolar hypoventilation, and sleep apnea also had physician orders for Trilogy machine use. The care plan referenced CPAP/BiPAP but did not include interventions for the Trilogy machine. The resident reported needing assistance with the Trilogy mask and noted that only some nurses were knowledgeable about its use, while others were not. The DON confirmed the lack of staff training on the Trilogy machine for this resident as well.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to evaluate and implement interventions to manage trauma triggers for a resident with a self-reported diagnosis of Post Traumatic Stress Disorder (PTSD). Record review showed that the resident had a history of PTSD related to previous domestic abuse, as well as other diagnoses including stroke, hypertension, diabetes mellitus, anxiety disorder, and bipolar disorder. The resident reported specific triggers, such as not liking water poured over the face due to past abuse, and had a history of substance use, homelessness, and legal issues. Despite this, the resident's care plan did not include any focus area related to anxiety, depression, mood, or past traumatic event triggers. Interviews and record reviews confirmed that the facility had not completed a trauma-based assessment or initiated a trauma-informed care plan upon the resident's admission, as required by facility policy. The facility's policy mandates culturally competent and trauma-informed care, including minimizing triggers and re-traumatization for trauma survivors. However, the lack of assessment and care planning for the resident's trauma history and triggers constituted a failure to provide care and services in accordance with these standards.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCPs) for two residents following an altercation between them. An incident report documented that one resident, with severe cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, stuck their tongue out at another resident, who then physically grabbed the first resident. Staff immediately separated the residents. However, a review of both residents' progress notes and CCPs revealed no documentation of behaviors or new interventions related to the incident. The CCPs for both residents had not been updated around the time of the altercation, despite one resident having a history of verbal aggression and both having cognitive impairments. During an interview, the DON confirmed that there was no behavior documentation, care plan update, physician notification, or family notification regarding the incident, although these actions should have occurred. Facility policies require that care plans be reviewed and revised as necessary, with updates for new or modified interventions, and that behavioral health services be individualized and person-centered. The lack of documentation and care plan revision following the incident constituted a failure to meet these standards.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective interventions to prevent falls and accidents for three residents, despite their known risks and care plan directives. One resident with significant cognitive impairment, muscle weakness, and a history of falls was left unattended in a dining room, contrary to care plan instructions. The resident fell from a wheelchair with unlocked brakes, resulting in a hip fracture. Staff interviews confirmed that the resident was left alone, and the only intervention known to the nurse on duty was to offer restroom breaks and snacks, with no active supervision provided at the time of the fall. Another resident, also with a history of falls and impaired mobility, was dependent on staff for transfers and toileting. Despite this, the resident attempted a self-transfer to the toilet when staff were busy, resulting in a fall and subsequent ankle fracture. The care plan required the use of a sit-to-stand lift or Hoyer lift for transfers, but during the incident, a nursing assistant allowed the resident to attempt a pivot transfer without the appropriate equipment or intervention to prevent the fall. The resident and staff confirmed that the transfer was not performed according to the care plan, and the necessary assistive devices were not used. A third resident with muscle weakness, a history of falls, and cognitive awareness experienced multiple falls over several months. Observations revealed that care plan interventions, such as keeping the call light and personal items within reach, were not consistently implemented. The call light was found on the floor and out of reach, the urinal and TV remote were not accessible, and the overbed table was positioned so that the resident could not reach necessary items. These lapses in following the care plan contributed to repeated falls and injuries for the resident.
Failure to Adhere to Infection Control Protocols During COVID Outbreak
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control practices during a COVID outbreak. Staff were observed not wearing masks, wearing masks incorrectly, or removing masks while providing care or serving food. Specifically, a nursing assistant was seen serving breakfast without a mask, a medication aide removed their mask while speaking during resident care, and another staff member wore a mask under their chin. Interviews with staff, including the LPN, DON, and Infection Preventionist, confirmed that masks were required to be worn properly during the outbreak, but these protocols were not followed. Additional deficiencies were observed in the handling of soiled linens and reusable items. A medication aide was seen carrying dirty linens against their uniform through the hallway instead of placing them in a plastic bag as required by facility policy. Furthermore, reusable breakfast dishes from a COVID-positive resident's room were placed on a table in the dining room, potentially exposing others to contamination. Staff interviews confirmed that these actions were not in compliance with established infection control policies.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that two nurse aides, who had been employed for more than one year, completed the required 12 hours of continuing education necessary to maintain their certification. A review of the education records for five staff members revealed that Nurse Aide O, hired on February 2, 2020, had only completed 5.5 hours of continuing education, while Nurse Aide P, hired on April 23, 1995, had completed just 2.5 hours within the past year. This deficiency was confirmed during an interview with the facility educator, who also serves as the Assistant Director of Nursing. The facility's policy, titled 'Nurse Aide Training Program' and dated August 1, 2023, mandates that each nurse aide receive at least 12 hours of in-service training annually, based on their employment date. The responsibility for coordinating and providing this education falls under the Staff Development Coordinator, with oversight from the Director of Nursing. Despite these guidelines, the facility did not meet the continuing education requirements for the two nurse aides, leading to a deficiency in compliance with the licensure reference number 175 NAC 12-006.04B(ii)(1).
Unsafe Water Temperatures in Memory Care Unit
Penalty
Summary
The facility failed to ensure safe water temperatures in the Memory Care Unit (MCU), which had the potential to affect all nine sampled resident rooms. During observations, water temperatures in the resident rooms were found to be significantly above the safe limit of 120 degrees Fahrenheit, with readings ranging from 122 to 136 degrees Fahrenheit. The issue was identified following the installation of a new 100-gallon water heater, which was set at 130 degrees Fahrenheit. The Director of Maintenance (DOM) confirmed that the water temperatures had not been checked in the MCU since the installation of the new water heater. Interviews revealed that the DOM was unaware of how to calibrate the thermometer used for measuring water temperatures and that maintenance staff only checked random bathroom water temperatures monthly. The DOM acknowledged that temperatures over 120 degrees Fahrenheit were too high and should be lower. Additionally, it was confirmed that no specific actions were taken to address water temperature checks in the MCU after the new water heater was installed. The Administrator confirmed that all water from bathroom faucets should be under 120 degrees Fahrenheit and noted that no residents had suffered burns from the water.
Inadequate Ventilation in Memory Care Unit Bathrooms
Penalty
Summary
The facility failed to ensure that the mechanical ventilation in the bathrooms of the Memory Care Unit (MCU) was functioning properly, affecting all 9 resident rooms on the unit. During an observation, a strong and stale urine odor was noted upon entering the MCU, and further inspection revealed that the bathroom vents were unable to pull up a single ply of toilet paper, indicating inadequate ventilation. Interviews with staff, including the Licensed Practical Nurse (LPN), Director of Maintenance (DOM), and Director of Housekeeping (DOH), confirmed that the vents were not functioning and were not regularly checked or cleaned. The facility's maintenance procedures were found to be lacking, as there were no regular maintenance rounds performed, and the Guardian Angel rounds conducted by facility managers did not include checks of the bathroom vents. The DOM confirmed that the ventilation system had not been checked, despite facility instructions to inspect exhaust fans monthly. Additionally, it was revealed that no Guardian Angel Rounds were performed on the MCU in May, and the rounds conducted in April and June did not identify any maintenance concerns. The Administrator confirmed the oversight in checking the ventilation system.
Failure to Provide Weekly Baths to Residents
Penalty
Summary
The facility failed to ensure that residents received baths at least once weekly, as evidenced by the cases of three residents. Resident 87, who was admitted with muscle wasting and atrophy, was documented to have received a bath on 5/29/24 and 6/7/24, resulting in a nine-day gap without a bath. Despite being cognitively intact with a BIMS score of 14, Resident 87 reported not receiving a bath since shortly after admission. Similarly, Resident 7, diagnosed with cerebral palsy and also cognitively intact with a BIMS score of 15, experienced inconsistent bathing, with records showing a bath on 5/9/24 and then not again until 5/26/24, followed by another gap until 6/6/24. Resident 36, who has hemiplegia and hemiparesis following a cerebral infarction, also with a BIMS score of 15, reported that baths were hardly once a week. Documentation confirmed a 15-day gap between baths from 5/22/24 to 6/6/24. Interviews with the facility Administrator and the DON confirmed that the facility's expectation was for residents to receive a bath at least once weekly, which was not met for these residents.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded correctly for two residents, leading to inaccuracies in their assessments. For Resident 53, the Quarterly MDS indicated severe cognitive impairment with hallucinations and delusions, despite the absence of documentation supporting these symptoms in the Behavior and Progress Notes from May 1, 2024, through June 13, 2024. The Regional Nurse Consultant confirmed the lack of documentation for hallucinations or delusions during an interview, acknowledging the incorrect marking on the MDS. Similarly, Resident 75's Quarterly MDS also indicated severe cognitive impairment with hallucinations and delusions, yet there was no documentation of these symptoms in the Care Plan or Behavior and Progress Notes from April 1, 2024, through May 1, 2024. The Regional Nurse Consultant confirmed the absence of documentation for hallucinations or delusions during the specified period, indicating an error in the MDS coding. The Director of Nursing confirmed that the facility used the Resident Assessment Instrument manual for guidance to ensure MDS accuracy.
Failure to Ensure Routine Bowel Movements for Residents
Penalty
Summary
The facility failed to ensure routine bowel movements for two residents, both of whom had severe cognitive impairment and were occasionally incontinent of bowels. Resident 53, with a primary diagnosis of Alzheimer's Disease, had no documented bowel movements for two separate periods totaling seven days. Despite a previous hospital admission for a small bowel obstruction, no bowel medications were given, and no bowel assessments were documented during this time. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the absence of bowel medication orders, lack of bowel movement records, and the absence of bowel assessments. Similarly, Resident 75, also diagnosed with Alzheimer's, had no documented bowel movements for two separate periods totaling eleven days. No PRN bowel medications were administered, and there were no bowel assessments documented. Interviews with the DON and LPN confirmed the lack of bowel movement records and the absence of a system to track residents' bowel movements. The DON acknowledged that without a bowel list, there was no way to know which residents had not had a bowel movement in two or more days, and no bowel movement audits were being conducted in the facility.
Failure to Notify Hospice Provider of Resident's Death
Penalty
Summary
The facility failed to notify a hospice provider regarding the death of a resident who was under hospice care. The resident, who had congestive heart failure, was admitted to hospice on 2/22/24 and passed away in the facility on 3/4/24. The facility's Comprehensive Care Plan for the resident included instructions to notify hospice and family of any changes. However, when the resident passed away at 9:50 PM, the facility did not notify the hospice nurse; instead, the resident's representative made the call to the hospice company. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the hospice nurse had been informed earlier in the day that the resident was declining. Despite this, the facility did not follow its own policy for post-mortem care, which required documentation of the date and time of death and notification to the physician, family, funeral home, and hospice. The failure to notify the hospice nurse was acknowledged by both the Administrator and the DON during their interviews.
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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