Adept Nursing & Rehab Of Blue Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Blue Hill, Nebraska.
- Location
- 414 North Wilson Street, Blue Hill, Nebraska 68930
- CMS Provider Number
- 285144
- Inspections on file
- 21
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Blue Hill during CMS and state inspections, most recent first.
The facility did not consistently review resident grievances or develop process improvement plans as part of its QAPI program. Grievances related to personal care, bathing, and appearance were not systematically addressed in QAPI meetings, and no active improvement plans were in place, affecting all residents.
Staff used a malfunctioning dishwasher that did not reach the required sanitizing temperature and failed to follow hand hygiene and food handling protocols during meal service. An aide was observed handling food and utensils with bare hands, assisting multiple residents without hand sanitization, and not using gloves when touching ready-to-eat foods, affecting several residents.
The facility did not provide required CMS notifications, including the NOMNOC and SNF ABN, to three residents when their Medicare Part A skilled services ended due to reaching maximum potential or meeting therapy goals. As a result, the residents and their representatives were not informed about the end of coverage, potential financial liability, or their right to appeal.
Surveyors found that several residents' rooms and bathrooms were not properly maintained, including issues with inadequate lighting, missing flooring thresholds, non-draining sinks, soiled exhaust vents, and stained toilet bowls. The facility's own policies require a clean and comfortable environment, but these deficiencies were confirmed by the Facility Administrator during inspection.
Surveyors found that the facility exceeded the allowable medication error rate, with multiple errors involving late administration, giving medications at the wrong time relative to meals, and failure to provide required food with medications. These errors were confirmed by staff interviews and review of medication records.
Staff failed to perform hand hygiene between residents during medication administration and between glove changes during wound care. A medication aide did not use hand sanitizer or wash hands between giving medications to three residents, and an RN did not perform hand hygiene between glove changes while treating wounds on a resident. Both staff members confirmed the lapses in hand hygiene during interviews.
A resident with blindness and depression, who required staff assistance for mobility, was not provided with individualized one-on-one activities or invited to group activities, despite documented preferences and care plan interventions. Staff did not engage the resident or document any activity participation, leaving the resident isolated in a dark, silent room for extended periods.
A resident with dementia and diabetes, who was dependent on staff and receiving hospice care, did not have their pressure wound cleansed as ordered before the application of Dakins Solution. An RN applied the treatment without washing the wound, and both the RN and DON confirmed the physician's orders were not followed.
A resident with multiple psychiatric diagnoses and a history of self-harm experienced several incidents of self-inflicted injury, some requiring hospital transfer. Despite these events, the care plan was not consistently updated to include preventative interventions, and staff confirmed that required care plan revisions were not made after each incident.
Surveyors identified that bathroom exhaust vents were not functioning for two residents, as confirmed by direct observation and the Facility Administrator. The vents failed to operate as expected, and the facility did not have a maintenance director at the time, resulting in the vents remaining unrepaired.
The facility failed to maintain a sanitary environment for food storage and preparation, with missing cupboard doors, sticky substances on cupboard handles, and black and brown fuzz on various kitchen surfaces. The Dietary Manager confirmed the soiled conditions and lack of documentation for routine cleaning tasks.
The facility failed to evaluate, revise, and implement interventions for weight loss and nutritional needs for three residents. Despite policies requiring weekly weight monitoring, the residents were not weighed as required, and recommended nutritional interventions were not implemented. Staff interviews confirmed these oversights.
The facility failed to maintain a medication error rate below 5%, resulting in a 12.5% error rate. Errors involved improper insulin administration for three residents, where LPNs did not prime insulin pens as required.
The facility failed to ensure proper blood glucose monitoring and insulin pen priming procedures, leading to potential significant medication errors for three residents. LPNs did not use gauze or cotton balls to wipe away the first drop of blood and did not prime insulin pens before administration, resulting in potential inaccurate blood glucose readings and incorrect insulin doses.
The facility staff failed to ensure accurate documentation of advance directives and code status for two residents. One resident's records showed a Full Code status despite an advance directive requesting DNR, and another resident's records indicated Full Code despite an advance directive requesting no CPR. The DON confirmed these discrepancies.
The facility failed to provide two residents with necessary notifications regarding their Medicare coverage and potential liability for services not covered. One resident was not given an ABN and remained as a private pay resident, while another was discharged home without being informed of their appeal options.
The facility failed to notify a resident and their representative of the decision to discharge the resident, preventing the resident from returning to the facility. The discharge decision was made due to the resident's elopement risk, but no proper notification or documentation was provided, violating the facility's policy and regulatory requirements.
The facility failed to provide the required written notice of transfer and discharge to a resident and their representative. Despite the resident being admitted for long-term care and having no discharge planning, the facility decided to discharge the resident while they were hospitalized without proper notification. Interviews with staff confirmed the lack of documentation and notification, leading to the identified deficiency.
The facility failed to accurately complete MDS documentation for two residents. One resident was incorrectly documented as receiving parenteral or tube feeding, and another was inaccurately recorded as receiving an anticoagulant instead of an antiplatelet medication. These errors were confirmed through interviews and record reviews.
The facility failed to ensure a PASARR was accurately completed for a resident with mental health diagnoses. The resident was admitted with psychotic disorder and depression, and was receiving related medications. However, the PASARR Level 1 screening incorrectly indicated no known mental health diagnoses. The Social Services Director admitted that the facility did not follow the correct process for identifying and documenting the resident's conditions prior to admission.
A resident with multiple pressure ulcers did not receive wound care consistent with professional standards. The DON failed to clean the over bed table, did not follow proper wound cleansing techniques, and incorrectly placed dressings. The IP confirmed these lapses in protocol.
The facility failed to assess and manage pain during wound care for a resident with multiple diagnoses, including osteomyelitis and pressure ulcers. Despite the resident's clear signs of severe pain and a care plan that included pain management interventions, the DON did not stop the wound care to address the pain. The resident's pain should have been managed during the procedure, as confirmed by the Regional Nurse Consultant.
A facility failed to follow infection control practices during wound care for a resident with multiple pressure ulcers and osteomyelitis. The DON did not change gloves or sanitize hands between working on soiled and clean areas, potentially contaminating the wound site.
The facility failed to ensure staff were trained to check the function of elopement prevention equipment, leading to a resident with dementia eloping through the front door without triggering the alarm. Staff were only visually verifying placement of wander guard bracelets without using the required tester to confirm functionality.
The facility failed to develop and implement a Quality Assurance Process Improvement Plan related to elopements, affecting four residents identified as elopement risks. Documentation and review of elopement drills and staff education were missing from the QAPI reviews for the months when the drills were conducted.
Failure to Implement Ongoing QAPI Processes for Resident Grievances
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) process as required by policy. Although the facility's QAPI policy outlined the need to develop, implement, and monitor performance indicators using data from multiple sources, including grievance logs, the actual practice did not align with these requirements. Record reviews showed that grievances filed by residents regarding personal care, bathing, and appearance were not consistently reviewed during QAPI meetings, and no process improvement plans were developed in response to these grievances. Interviews with the Facility Administrator confirmed that while grievances were recognized as a source for process improvements, the facility did not have any active process improvement plans at the time of the survey. Additionally, there was a discrepancy between the number of grievances documented in the grievance logs and those discussed in QAPI meetings, indicating a lack of systematic review and follow-up. This failure to follow QAPI processes had the potential to affect all residents in the facility, with a census of 38 at the time of the survey.
Failure to Sanitize Dishware and Maintain Food Handling Hygiene
Penalty
Summary
The facility failed to ensure that the dishwashing machine was operating at the required minimum temperature for sanitization, as specified in the facility's own policy. Observations revealed that the dishwasher was used while only reaching wash cycle temperatures of 98 and 100 degrees, below the required 120 degrees. Despite being aware of the malfunction, staff continued to use the dishwasher for cleaning and sanitizing dishes and utensils, contrary to policy instructions to stop use if temperatures were not met. Additionally, staff did not adhere to proper hand hygiene and food handling protocols while assisting residents during meal service. One nurse aide was observed repeatedly handling food and utensils with bare hands, feeding residents, and assisting with personal items such as clothing and wheelchair wheels, all without performing hand sanitization between contacts. The aide also handled ready-to-eat foods, such as cookies, with bare hands and did not use gloves or utensils as required by facility policy. These actions were observed to affect at least three residents during meal service. The lack of proper dish sanitization and failure to follow hand hygiene and food handling procedures created conditions that could lead to cross-contamination and foodborne illness, as staff did not follow established professional standards for food safety and infection control.
Failure to Provide Required Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide required Centers for Medicare and Medicaid Services (CMS) notifications to residents or their representatives regarding the termination of Medicare Part A skilled services. Specifically, the facility did not issue the Notice of Medicare Non-Coverage (NOMNOC) or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents when their Medicare Part A coverage ended due to reaching their maximum potential or meeting therapy goals. This omission prevented the residents and their representatives from being informed about the end of coverage, their financial liability for continued services, and their right to appeal the decision. For one resident, Medicare Part A services ended after 77 days when therapy determined the resident had reached their highest practical level. The resident remained in the facility under a different payer source, but there was no documentation of the required NOMNOC or SNF ABN in the medical record. Interviews with the Business Office Manager and Facility Administrator confirmed that these notifications were not provided as required. Another resident's Medicare Part A services ended after 31 days when all therapy goals were achieved, and the resident was discharged home. Similarly, there was no NOMNOC in the medical record, and the Facility Administrator confirmed the notification was not given. A third resident's Medicare Part A services ended after 32 days due to reaching maximum potential, and the resident continued in the facility as a private pay patient. Again, there was no documentation of the required notifications, and the Facility Administrator confirmed they were not provided.
Failure to Maintain Clean, Safe, and Comfortable Resident Environments
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, comfortable, and homelike environment for several residents. Observations revealed that one resident's bathroom had inadequate lighting due to a non-functioning light and dull bulbs with yellowed covers, and the ceiling light was insufficient. Another resident's room had a missing threshold, resulting in a visible gap between the carpet and bathroom floor. A third resident's bathroom sink was not draining properly, with water remaining in the sink after use. Additionally, two residents' bathrooms had exhaust vent covers soiled with dark, fuzzy debris and rust-like material, and one of these bathrooms also had a toilet bowl that was scratched and stained with black marks. The facility's own Admission Agreement and Resident Rights documentation require the provision of a safe, clean, and comfortable environment, including adequate lighting and maintenance services. During interviews and observations, the Facility Administrator confirmed the presence of these issues, acknowledging the need for cleaning and repairs in the affected rooms and bathrooms. These findings demonstrate that the facility did not meet its obligations to maintain sanitary and orderly conditions for the residents involved.
Medication Error Rate Exceeds Regulatory Limit Due to Timing and Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During observation of 27 medication administrations, 13 errors were identified involving three residents. Errors included administering medications at incorrect times, such as giving Levothyroxine and Omeprazole to a resident while they were eating breakfast instead of the required time before meals, and failing to administer Cariprazine due to unavailability. Another resident received all scheduled morning medications late, and a third resident also received all morning medications late, with one medication (Carvedilol) administered without food as required, since the resident had not eaten nor been provided a snack. These deficiencies were confirmed through interviews with the medication aide, who acknowledged the timing errors, the lack of medication availability, and the failure to provide food with certain medications. The facility's own policies require adherence to the six rights of medication administration, including correct timing and administration with food when indicated, but these standards were not met during the observed medication passes.
Failure to Perform Hand Hygiene During Medication Administration and Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during medication administration and wound care, as observed and confirmed by staff interviews. During medication administration in the dining room, a medication aide did not perform hand hygiene between preparing and administering medications to three different residents. The aide acknowledged not following the required hand hygiene protocol during these interactions. Additionally, during wound care for a resident, a registered nurse did not perform hand hygiene between glove changes while treating multiple wounds. The nurse was observed changing gloves several times without using alcohol-based hand rub or washing hands between glove changes, despite handling different wound sites and supplies. Both the nurse and the Director of Nursing confirmed that hand hygiene should have been performed between glove changes, in accordance with facility policy and CDC guidelines.
Failure to Provide Individualized Activities for Resident with Blindness and Depression
Penalty
Summary
The facility failed to provide individualized one-on-one activities and engage a resident with blindness and depression in facility activities, as required by their own policy and care plan. The resident, who was dependent on staff for mobility and transfers, was observed multiple times lying in bed or sitting in a dark, silent room with no entertainment or engagement. Despite documented preferences for one-on-one activities and enjoyment of listening to conversations and sharing stories, there was no evidence that such activities were provided or documented. Staff interviews revealed a lack of awareness and implementation of individualized activities for the resident. The Activity Director admitted to not inviting the resident to group activities due to the resident's blindness and stated that in-room activities, such as reading, were supposed to be provided, but there was no documentation to support that these occurred. Nurse aides and other staff were also unaware of any one-on-one activities for the resident and did not routinely invite the resident to participate in facility activities. Observations confirmed that the resident was not invited to group activities, such as TV trivia or movie events, and was left alone in a dark room for extended periods. The resident expressed a desire to be invited to activities and confirmed that staff did not ask them to attend. The facility's failure to provide and document individualized activities for this resident, as outlined in their care plan and facility policy, led to the deficiency.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow physician orders for wound care treatment for a resident with dementia and Type 2 Diabetes Mellitus, who was also receiving hospice care. The resident was admitted with a pressure-related skin injury and had a care order to wash the right buttock wound with soap and water or wound wash, followed by the application of gauze soaked in Dakins (Sodium Hypochlorite) Solution for five minutes. During an observed wound care procedure, the RN applied the soaked gauze directly to the wound without first cleansing it as specified in the physician's order. The RN acknowledged during an interview that the wound should have been cleansed prior to applying the treatment. The Director of Nursing (DON) also confirmed that the physician's orders were not followed during the wound care procedure. The facility's policy requires treatments to be provided in accordance with physician orders and current standards of practice, which was not adhered to in this instance.
Failure to Update Care Plan and Implement Interventions After Repeated Self-Harm Incidents
Penalty
Summary
The facility failed to ensure that interventions were implemented to prevent further potential abuse or self-harm for a resident with a history of psychiatric and behavioral disorders. The resident, who was cognitively intact and had diagnoses including schizoaffective disorder, non-suicidal self-harm, generalized anxiety disorder, borderline personality disorder, and suicidal ideations, experienced multiple incidents of self-harm during their stay. These incidents included self-inflicted lacerations and abrasions to various parts of the body, often requiring medical attention and hospital transfers. Despite repeated episodes of self-harm, documentation revealed that the resident's care plan was not consistently updated after each incident or upon readmission from the hospital. Specifically, there were no care plan updates following several self-harm events, and when updates were made, they did not include preventative measures related to self-harm. The facility's own policy required that care plans be revised if a resident's needs changed as a result of an incident, but this was not followed in practice for this resident. Interviews with facility staff, including a registered nurse, the DON, and the facility administrator, confirmed that care plans were not updated as required. The administrator acknowledged that no interventions were put in place to prevent further harm, citing a reluctance to alter recommendations from the hospital. The facility assessment indicated that the facility was equipped to care for residents with psychiatric and behavioral needs, yet appropriate interventions were not implemented for this resident following multiple incidents of self-harm.
Non-Functioning Bathroom Exhaust Vents Identified for Two Residents
Penalty
Summary
The facility failed to ensure that bathroom exhaust vent fans were functioning for two residents. Observations conducted in the bathrooms of these residents revealed that the exhaust vents were not operational, as demonstrated by their inability to pull up a 1-ply square of toilet paper. These findings were confirmed during follow-up observations with the Facility Administrator, who acknowledged that the vents were not functioning and required repair. Record review indicated that the facility's resident rights policy requires a safe, clean, comfortable, and homelike environment, including necessary housekeeping and maintenance services. During an interview, the Facility Administrator confirmed that the facility did not currently have a maintenance director and acknowledged the requirement to maintain functional bathroom exhaust vents.
Sanitary Environment Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment for food storage and preparation, as observed during a survey. Specifically, three cupboards in the kitchen storage meal prep area were missing doors, exposing stored dishes. Additionally, a black and brown sticky substance was found on the handles of all cupboard doors along the back wall of the main kitchen area. The stainless steel hood above the stove had a cloudy yellow-white adhered substance, and black and brown fuzz coated an orange pipe suspended from the ceiling in the stove and meal prep area. The heat and air-conditioning unit installed in the back wall near the ceiling of the main kitchen area also had black and brown fuzz on its outside, top, and vent areas. In an interview, the Dietary Manager confirmed the missing cupboard doors and the soiled conditions of the cupboards, stainless steel hood, orange pipe, and air conditioning unit. The Dietary Manager also acknowledged that routine cleaning schedules for the kitchen and these areas were established and posted, but there was no documentation reflecting the completion of these tasks for the month of May 2024. The facility's failure to adhere to its own kitchen sanitization policy had the potential to affect all residents receiving food from the facility kitchen, with a stated census of 34 residents.
Failure to Monitor and Address Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate, revise, and implement interventions for weight loss and the nutritional needs of three residents. Resident 1, who was admitted with osteomyelitis, peripheral vascular disease, and pressure ulcers, experienced significant weight loss. Despite the facility's policy requiring weekly weight monitoring for residents with weight loss, Resident 1 was not weighed weekly after admission. Interviews with staff confirmed that the resident's weight was not monitored as required, and the dietary manager acknowledged the oversight. Resident 4, admitted with diagnoses including laminectomy, intervertebral disc degeneration, GERD, and osteoporosis, also experienced weight loss. The resident's care plan included interventions for poor intake and unintentional weight loss, but the resident was not weighed weekly or monthly as required. Interviews with staff and the dietary manager confirmed that the resident's weight was not monitored according to the facility's policy. Resident 28, admitted for a left hip prosthetic infection, experienced significant weight loss. The resident's care plan aimed to prevent weight loss, but the facility failed to monitor the resident's weight weekly and did not implement recommended nutritional interventions. The dietary manager confirmed that the resident's weight loss was not addressed according to the facility's policy, and the physician was not notified of the continued weight loss.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed medication error rate of 12.5%. This was based on observations of 32 medications administered, where 4 errors were identified, affecting 3 residents. The errors were primarily related to the improper administration of insulin using insulin pens, where the staff did not follow the facility's policy of priming the insulin pen before administering the dose. For Resident 19, the LPN did not prime the insulin pen before administering 3 units of insulin, despite the resident having a blood glucose level of 195. Similarly, for Resident 5, the LPN failed to prime the insulin pen before administering a combined dose of 13 units of insulin, which included 1 unit from the sliding scale and 12 units from the routine order. In both cases, the insulin pens were not primed, which is a necessary step to ensure the correct dose is administered. Resident 16 experienced two separate incidents where the insulin pen was not primed before administration. In the first instance, the LPN administered 4 units of insulin for a blood glucose level of 248 without priming the pen. In the second instance, another LPN administered 6 units of insulin for a blood glucose level of 282 without priming the pen. Interviews with the LPNs and the Director of Nursing confirmed that the staff were either unaware of or did not follow the requirement to prime the insulin pens, leading to these medication errors.
Failure to Follow Blood Glucose Monitoring and Insulin Pen Priming Procedures
Penalty
Summary
The facility failed to ensure that staff followed proper procedures for blood glucose monitoring and insulin pen priming, leading to potential significant medication errors. Specifically, Licensed Practical Nurse-A (LPN-A) did not use a gauze pad or cotton ball to wipe away the first drop of blood during blood glucose testing for Residents 19, 5, and 16. Instead, LPN-A used an alcohol prep pad, which could result in inaccurate blood glucose readings. Additionally, LPN-A did not prime the insulin pen before administering insulin to these residents, which is necessary to ensure the correct dose is delivered. Resident 19, who has a diagnosis of type 2 diabetes mellitus, was observed to have a blood glucose reading of 195. LPN-A did not prime the insulin pen before administering the routine order of 3 units of insulin. Similarly, Resident 5, diagnosed with diabetes mellitus, had a blood glucose reading of 161, and LPN-A again failed to prime the insulin pen before administering 13 units of insulin. Resident 16, also diagnosed with type 2 diabetes mellitus, had blood glucose readings of 248 and 282 on two separate occasions, and LPN-A did not prime the insulin pen before administering 4 units and 6 units of insulin, respectively. The Director of Nursing (DON) confirmed that the facility's policy requires the first drop of blood to be wiped away with a cotton ball or gauze to avoid inaccurate readings and that the insulin pen must be primed before setting the insulin dose. However, LPN-B, who was also involved in the care of Resident 16, was unaware of the requirement to prime the insulin pen and did not follow the procedure for wiping away the first drop of blood. This lack of adherence to established protocols resulted in potential significant medication errors for the residents involved.
Failure to Accurately Document Resident Advance Directives and Code Status
Penalty
Summary
The facility staff failed to ensure the accurate documentation of resident choices for advance directives and code status in the medical records of two residents. For Resident 27, the admission record and active physician orders indicated a Full Code status, while the advance directive signed by the physician requested a Do Not Resuscitate (DNR) status. The Director of Nursing (DON) confirmed that the advance directive was not updated timely to reflect the resident's wishes, leading to a discrepancy in the resident's code status documentation. Similarly, for Resident 23, the admission record and care plan indicated a Full Code status, while the advance directive signed by both the resident and the physician requested no Cardiopulmonary Resuscitation (CPR). The DON confirmed that the resident's care plan and physician orders did not accurately reflect the resident's wishes as indicated in the advance directive. These discrepancies highlight the facility's failure to ensure that resident choices for advance directives and code status were accurately documented and updated in their medical records.
Failure to Provide Medicare Coverage Notifications
Penalty
Summary
The facility failed to provide two residents with the necessary notifications regarding their Medicare coverage and potential liability for services not covered. Resident 88 was admitted under Medicare A services and the facility initiated the discharge from Medicare Part A services while benefit days were still remaining. However, the facility did not offer or present Resident 88 or their responsible party with an Advanced Beneficiary Notice (ABN) to inform them of the reason Medicare would not continue to pay, the cost of continuing to receive skilled services, and an option to appeal the facility's decision about coverage. As a result, Resident 88 remained in the facility as a private pay resident without being properly informed of their options and potential financial responsibilities. Similarly, Resident 91 was admitted under Medicare A services and the facility initiated the discharge from Medicare Part A services while benefit days were still remaining. The facility failed to provide Resident 91 or their responsible party with a Notice of Medicare Non-Coverage (NOMNC), which would have informed them of their appeal options. Consequently, Resident 91 was discharged home without being notified of their right to appeal the facility's decision. The Business Office Manager confirmed that the necessary notifications were not provided to either resident or their responsible parties.
Failure to Notify Resident of Discharge
Penalty
Summary
The facility failed to notify a resident and their representative of the decision to discharge the resident, which prevented the resident from returning to the facility. The facility's policy requires that a transfer or discharge notice be provided to the resident, their representative, and the Long-Term Care Ombudsman, especially in cases of emergency transfers to acute care settings. However, in this instance, the facility did not follow its own policy and did not provide the necessary notifications or documentation for the discharge of the resident, who was initially sent to the hospital for evaluation of a possible stroke. The resident, identified as Resident 89, was admitted to the facility for long-term care and had a bed hold agreement in place. Despite this, the facility decided to discharge the resident while they were still hospitalized, citing the resident's elopement risk as the reason. The Social Services Director and the Facility Administrator confirmed that no notification of discharge was given to the resident or their representative, and the medical record lacked any documentation of the discharge decision. Interviews with the facility staff revealed that the facility automatically discharges residents who do not sign a bed hold, which was the case for Resident 89. This practice led to the resident being discharged without proper notification, in violation of the facility's policy and regulatory requirements. The failure to notify the resident and their representative of the discharge decision was confirmed by both the Social Services Director and the Facility Administrator during the surveyor's investigation.
Failure to Provide Written Notice of Transfer and Discharge
Penalty
Summary
The facility failed to provide the required written notice of transfer and discharge to Resident 89 and their representative. According to the facility's policy, a notice must be provided at least 30 days prior to a facility-initiated transfer or discharge, with exceptions for urgent medical needs. However, in this case, there was no documentation of such notice being given. Resident 89 was admitted to the facility for long-term care and had a care plan indicating no need for discharge planning. Despite this, the resident was transferred to the emergency room due to concerns about a possible stroke, and the facility decided to discharge the resident while they were still hospitalized without providing the necessary notifications. Interviews with various staff members, including the Licensed Practical Nurse (LPN), Social Services Director (SSD), Medical Records staff (MR), and Facility Administrator (FA), confirmed the lack of documentation and notification. The LPN confirmed that the Transfer Form assessment, which should document notifications, was not completed. The SSD revealed that the decision to discharge Resident 89 was based on the resident being an elopement risk, but admitted that no notification of discharge was given to the resident or their representative. The MR staff confirmed the absence of a transfer form and written notice in the medical records. The FA also confirmed that there was no documented order for the transfer to the emergency room and no notification of discharge in the medical record. The facility's failure to provide the required written notice of transfer and discharge, as well as the lack of proper documentation, led to the deficiency identified in the report. This affected Resident 89, who was admitted for long-term care and had no discharge planning in place, highlighting a significant lapse in following regulatory requirements for resident transfers and discharges.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to accurately complete resident assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. For Resident 23, the Admission MDS indicated that the resident received parenteral or tube feeding, which was incorrect. The Minimum Data Set Coordinator (MDSC) confirmed that the resident did not receive such feeding, despite the MDS being signed off as accurate. Resident 23 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and an absence of the left leg above the knee, and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. For Resident 1, the 5-Day MDS inaccurately documented that the resident received parenteral or tube feeding and an anticoagulant medication. The MDSC confirmed that the resident did not receive parenteral or tube feeding and was actually on an antiplatelet medication, Clopidogrel, rather than an anticoagulant. Resident 1 was admitted with diagnoses including osteomyelitis, peripheral vascular disease, and pressure ulcers, and had a BIMS score of 8, indicating moderate cognitive impairment. These inaccuracies in the MDS documentation were confirmed through interviews with the MDSC and a review of the Medication Administration Record (MAR).
Failure to Accurately Complete PASARR Screening
Penalty
Summary
The facility failed to ensure a Preadmission Screening Resident Review (PASARR) was accurately completed or a new PASARR initiated for a resident with mental health diagnoses. Resident 3 was admitted with diagnoses of psychotic disorder and depression, and was receiving antipsychotic and antidepressant medications. However, the PASARR Level 1 screening form incorrectly indicated that the resident had no known or suspected mental health diagnoses. This discrepancy was found during a review of the resident's admission Minimum Data Set (MDS), care plan, and Medication Administration Record (MAR), which all documented the resident's mental health conditions and related medications. The Social Services Director (SSD) confirmed that the facility is responsible for PASARR screenings for residents admitted from locations other than hospitals. The SSD admitted that the facility's process for identifying residents with possible mental disorders or intellectual disabilities was not followed correctly in this case. The SSD did not review the resident's diagnoses or medications prior to admission and failed to list them on the preadmission screening tool. As a result, the PASARR Level 1 evaluation was not completed accurately, and the necessary information was not provided for the state to make an informed decision regarding the resident's care needs.
Failure to Perform Proper Wound Care
Penalty
Summary
The facility failed to perform wound care consistent with professional standards of practice for a resident with multiple pressure ulcers. The Director of Nursing (DON) did not clean the over bed table or place a clean field down before placing clean dressing supplies on it. Additionally, the DON did not follow proper wound cleansing techniques, as they wiped the wound in an up and down fashion instead of cleaning outward from the center of the wound. The DON also failed to ensure the correct placement of dressings as per physician orders, including Adaptic Touch and Duoderm dressings, and did not protect intact skin from the foam dressing as required by the 3M Vacuum Assisted Closure (VAC) Therapy Clinical Guidelines. The resident involved had a history of osteomyelitis, peripheral vascular disease, and multiple pressure ulcers, including a stage four pressure ulcer on the right heel and an unstageable pressure ulcer on the left heel. The resident was moderately cognitively impaired and required substantial assistance with daily activities. The facility's policies for Negative Pressure Wound Therapy and Clean Dressing Change were not adhered to during the observed wound care session. The Infection Preventionist (IP) confirmed that the over bed table should have been cleaned and a clean field placed on it before the dressing supplies were put down. The IP also confirmed that the dressings should have been placed according to the physician's orders and visually confirmed for correct placement. The gray foam dressing should not have been placed over intact skin without a vapor-permeable adhesive dressing. These failures in following proper wound care protocols contributed to the deficiency noted in the report.
Failure to Manage Pain During Wound Care
Penalty
Summary
The facility failed to assess and manage pain during wound care for a resident with multiple diagnoses, including osteomyelitis, peripheral vascular disease, and pressure ulcers. The resident, who was moderately cognitively impaired, reported frequent pain that interfered with daily activities and rated their pain at a level 10 on a scale of zero to ten. Despite having a care plan that included administering pain medications and evaluating the effectiveness of pain-relieving interventions, the facility did not adequately manage the resident's pain during wound care procedures. During an observation, the Director of Nursing (DON) and a Nursing Assistant (NA) provided wound care to the resident, who exhibited clear signs of pain, including verbalizing discomfort, using profanity, and attempting to withdraw their limbs. The DON did not stop the wound care to assess or treat the resident's pain, despite the resident's visible and vocal indications of severe discomfort. The DON informed the resident that pain medication would be administered after the completion of wound care, but did not address the immediate pain during the procedure. Interviews with the NA and the DON revealed that the resident always experienced pain during wound care, and the DON believed that administering an analgesic one and a half hours prior to the procedure was sufficient. However, the Regional Nurse Consultant (RNC) confirmed that the resident's pain should have been addressed during the wound care. The facility's pain management policy emphasized the importance of recognizing, evaluating, and managing pain consistent with professional standards and the resident's care plan, which was not followed in this instance.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to infection control practices during wound care for a resident with multiple pressure ulcers and osteomyelitis. The Director of Nursing (DON) did not change gloves or perform hand sanitization between working on soiled and clean areas of the resident's body. Specifically, the DON used the same gloves to wipe the resident's buttocks, cleanse the wound, and apply a new dressing, potentially contaminating the clean dressing and the wound site. The resident involved had a history of osteomyelitis, peripheral vascular disease, and multiple pressure ulcers, including a stage four ulcer and an unstageable ulcer. The resident was moderately cognitively impaired and required substantial assistance with daily activities. The facility's policy and CDC guidelines clearly stated the need for hand hygiene and glove changes between tasks to prevent cross-contamination, which were not followed during the observed wound care. The Infection Preventionist confirmed that the proper procedure was not followed, acknowledging that gloves should be changed and hand sanitization should be performed when moving from a soiled area to a clean area. This lapse in infection control practices was observed during a wound care session, where the DON failed to adhere to the established protocols, thereby increasing the risk of infection for the resident.
Failure to Ensure Proper Functioning of Elopement Prevention Equipment
Penalty
Summary
The facility failed to ensure that staff were adequately trained to check the function of individual resident elopement prevention equipment, specifically wander guard bracelets, to prevent elopement. This deficiency affected four residents identified as at risk for elopement. The facility's policy required that wander guard bracelets be checked for placement and function each shift, but staff were only visually verifying placement without using the required tester to confirm functionality. This led to an incident where Resident 1, who had a history of dementia and was identified as an elopement risk, managed to leave the facility unsupervised through the front door without triggering the alarm, as the wander guard system was not functioning properly. Resident 1's records indicated a diagnosis of dementia and a high risk for elopement, with a history of wandering. Despite the care plan specifying the use of a wander guard bracelet and the need for functional checks every shift, the staff failed to perform these checks correctly. On the day of the incident, a staff member on break noticed Resident 1 outside the facility and brought them back. The Assistant Director of Nursing (ADON) confirmed that the front door alarm did not sound, and no immediate investigation was conducted to determine why the alarm failed. Interviews with staff revealed a lack of training on the use of the wander guard tester, with the Licensed Practical Nurse (LPN) responsible for checking the wander guards unaware of the testing procedure. The Director of Nursing (DON) confirmed that the facility had not provided the necessary training to the LPN on using the tester. This lack of training and proper procedure adherence led to the failure in preventing Resident 1's elopement and highlighted a systemic issue in the facility's elopement prevention measures.
Removal Plan
- All wander guard amulets (bracelets) in use checked for placement, functioning, and expiration.
- Education provided to all licensed nurses in the facility on monitoring the wander guard amulet for placement, functioning, and expiration every shift.
- Education will be provided to all licensed nurses, including agency licensed nurses, prior to working their shift.
- All newly hired licensed nurses will be educated on monitoring of wander guard amulets during general orientation.
- All new agency licensed nurses will be educated on monitoring of wander guard amulets during orientation to the building.
Failure to Implement Quality Assurance Process for Elopements
Penalty
Summary
The facility failed to develop and implement a Quality Assurance Process Improvement Plan of action related to elopements, which has the potential to affect four residents identified as elopement risks. The facility's QAPI Plan, dated April 2014, mandates the development, implementation, and maintenance of an ongoing, facility-wide QAPI Plan to monitor and evaluate the quality and safety of resident care. However, the facility did not follow through with the required documentation and review processes for elopement drills conducted on 03/30/2023 and 11/21/2023. Specifically, the documentation of education provided to staff and the review of the drill outcomes were missing from the QAPI reviews for those months. During interviews conducted on 02/13/2024, the Facility Administrator confirmed the absence of documentation for staff education following the 03/30/2023 elopement drill and the lack of review for the 11/21/2023 drill in the QAPI review. The Regional Nurse Consultant also confirmed that the results from these drills should have been addressed in the respective month's QAPI review. This failure to document and review elopement drills and staff education indicates a significant lapse in the facility's quality assurance processes, potentially compromising resident safety.
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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