Adept Nursing & Rehab Of Central City
Inspection history, citations, penalties and survey trends for this long-term care facility in Central City, Nebraska.
- Location
- 2720 South 17th Avenue, Central City, Nebraska 68826
- CMS Provider Number
- 285147
- Inspections on file
- 21
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Central City during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses experienced several episodes of severe behavioral disturbance, including screaming and combative actions. An LPN administered Zyprexa IM twice during one shift in response but did not notify the physician, guardian, or emergency contact about the incident or the resident's later transfer to a hospital, contrary to facility policy. Interviews and record reviews confirmed that required notifications were not made.
Staff failed to consistently use gloves or perform proper hand hygiene when handling ready-to-eat foods, and food items in storage were found unsealed, undated, or without required temperature monitoring. Additionally, hot and cold foods were served outside of safe temperature ranges, with staff demonstrating inconsistent knowledge of required standards. These actions did not comply with facility policies and created the potential for foodborne illness among all residents receiving food from the kitchen.
Surveyors found that four Medication Assistants did not have documented competencies completed as required by facility policy and regulation. Record reviews and interviews with the DON and RDO confirmed the absence of competency documentation for these staff, despite the facility's policy mandating such training and assessment.
A resident with moderate cognitive impairment was admitted without a signed advance directive on file, despite facility policy and regulatory requirements. Record reviews showed no documentation of an advance directive or code status at the time of review, and staff confirmed the document was only received and filed after the deficiency was identified.
The facility did not provide timely Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) to two residents when their Medicare coverage ended, as required by policy. In one case, the notices were signed after the last covered date, and in another, the notices were not completed at all. Staff interviews and record reviews confirmed these deficiencies.
A resident was discharged from the facility, but staff did not notify the state ombudsman as required. Review of records and staff interviews confirmed that notifications of emergency transfers and discharges were not consistently sent each month, resulting in the omission of the required discharge notification for this resident.
Staff failed to keep a urinary catheter drainage bag below the bladder during a Hoyer lift transfer for a resident with neurogenic bladder, contrary to the care plan and facility policy. Both the MA and NA involved were unsure of proper catheter bag placement, and the DON confirmed the correct procedure was not followed.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Surveyors found that meals were not consistently served at safe and appetizing temperatures, with hot foods below the required 135°F and some dishes appearing unappetizing or in the wrong texture. Several residents, including those with diabetes and swallowing issues, reported dissatisfaction with meal temperature and appearance, and some left food uneaten. The Food Service Manager and Administrator confirmed the deficiencies in food temperature and texture.
The facility did not provide alternative vegetables or fruits to residents who declined or did not select the items initially served, despite residents' dietary needs and preferences. Two residents reported not receiving substitutes for disliked or difficult-to-eat foods, and staff confirmed that only main dish alternatives were available, not sides. This practice was observed during meal service and confirmed by both the Food Service Manager and Administrator.
Surveyors observed strong urine odors and sticky floors in multiple hallways and rooms, with the issue persisting even after housekeeping cleaned affected areas. The DON and Administrator acknowledged the ongoing problem, attributing it to humidity, and facility policies for cleaning and inspection were not effective in resolving the unsanitary conditions.
Three cognitively intact residents who required assistance with mobility and transfers experienced repeated, prolonged delays in call light response, with documented wait times often exceeding 30 minutes and sometimes lasting over an hour. Residents reported frequent long waits for staff assistance, and leadership acknowledged that call light response times were sometimes longer than appropriate, with technical issues occasionally affecting the system.
A resident with obstructive sleep apnea did not receive appropriate follow-up for an Auto-PAP machine due to complaints about the mask being too tight. Despite frequent refusals to use the device and inquiries about a new CPAP, there were no orders addressing these concerns. Staff interviews revealed a lack of awareness and follow-up, contributing to the deficiency in care.
The facility failed to secure a catheter properly, leading to potential cross-contamination for a resident with dementia and other conditions. Additionally, staff did not adhere to hand hygiene protocols during peri care and wound care for three residents. The facility's hand hygiene policy was not followed, as confirmed by staff and the DON.
A facility failed to accurately complete a PASRR for a resident with schizoaffective disorder and PTSD. Despite these diagnoses being documented in medical records, they were omitted from PASRR screenings. Staff interviews confirmed the oversight, acknowledging that the PASRR should have included these diagnoses.
Failure to Notify Physician and Family of Significant Behavioral Changes and Transfer
Penalty
Summary
The facility failed to notify the physician, guardian, and emergency contact of a resident's significant behavioral episodes as required by policy. Record reviews showed that the resident, who had multiple psychiatric diagnoses including bipolar disorder with psychotic features, anorexia nervosa, and major depressive disorder, experienced several episodes of screaming, flailing, hitting, and combative behavior. On one occasion, an LPN was notified by a nurse aide about the resident's episode and administered Zyprexa IM twice during the shift but did not notify the physician, family, or guardian about the incident. Interviews confirmed that the guardian and emergency contact were not informed of these behavioral changes or the subsequent transfer to a hospital until after the events occurred. Facility policy requires prompt notification of the resident, physician, and representative in the event of significant changes in condition, including behavioral deterioration or transfer to another facility. Interviews with facility leadership confirmed that the nurse should have contacted the physician, guardian, and emergency contact regarding the behavioral episodes and transfer. Documentation and interviews with the resident's contacts further confirmed that required notifications were not made in accordance with policy.
Deficient Food Handling, Storage, and Temperature Control
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential for foodborne illness, as evidenced by multiple observations and staff interviews. Staff were seen handling ready-to-eat foods such as bread, sandwiches, and salad with bare hands, and in some cases, gloves were not used or hand hygiene was not performed before or after glove use. Additionally, staff were observed not washing their hands for the required 20 seconds, and hand hygiene was not performed after touching personal items like cell phones or after removing gloves. The facility's own policies require hand hygiene before donning gloves, after glove removal, and prohibit bare hand contact with food, but these were not consistently followed. Food storage practices were also deficient. Opened bags of macaroni noodles, raw hamburger, bread, spices, and vanilla were found unsealed, undated, or both in dry storage and refrigerators. A milk refrigerator was found without a thermometer, and staff confirmed that thermometers should be present in all refrigerators. These lapses in labeling, sealing, and temperature monitoring are contrary to the facility's food safety policies, which require all food to be stored, labeled, and maintained at safe temperatures. Temperature control of food and fluids was not maintained according to policy or professional standards. Observations showed that hot foods such as cauliflower/broccoli, tuna melt sandwiches, and hamburger patties were served below the required holding temperatures, and milk was found above the safe cold temperature threshold. Staff interviews revealed inconsistent knowledge of the correct temperature standards, with some staff citing different minimum temperatures for hot food. The facility's policy requires hot foods to be held at 135°F or greater and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Document Medication Assistant Competencies
Penalty
Summary
The facility failed to ensure that all Medication Assistants (MAs) had completed and documented competencies as required by policy and regulation. Record reviews for four sampled MAs revealed that none had documentation of completed competencies for 2024 and 2025. The MAs reviewed had hire dates ranging from 2016 to 2025, indicating that both new and existing staff were affected. Interviews with the Director of Nursing and the Regional Director of Operations confirmed that the facility was unable to provide documentation of the required competencies for these staff members. The facility's Training Requirements policy mandates that all staff, including those under contract and volunteers, must have competencies and skill sets consistent with their expected roles. The Medication Aide Procedure Checklist, which outlines the required skills for MAs, was available, but there was no evidence that the competencies had been completed or documented for the four MAs reviewed. The facility had a census of 58 at the time of the survey.
Failure to Timely Obtain and Document Advance Directive
Penalty
Summary
The facility failed to have a signed advance directive for one resident out of eight sampled, despite requirements to inform and provide written information to all adult residents regarding their right to formulate an advance directive. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had expressed that preferences for customary routine activities were important. Upon admission, the resident was experiencing adjustment issues, and interventions were in place to support their preferences and autonomy. However, a review of the resident's records, including the Minimum Data Set, care plan, clinical census, and electronic medical record, revealed no documentation of an advance directive or code status at the time of review. Further investigation showed that the facility's policy required communication of code status and adherence to residents' rights regarding advance directives. Despite this, the advanced directive for the resident was not present in the medical record and was only located later in the social service office, with documentation indicating it was received and dated after the initial record review. Interviews with facility staff confirmed the delay in obtaining and filing the advance directive, indicating a lapse in ensuring that the resident's rights regarding advance directives were honored in a timely manner.
Failure to Provide Timely Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide timely notice of the end of Medicare coverage to two residents, as required by policy and federal regulations. For one resident, the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) were not signed until after the last covered date, rather than at least two days prior to the end of Medicare-covered services. This was confirmed by the Regional Business Office Manager, who acknowledged that the required notices were not provided within the appropriate timeframe. For another resident, there was no evidence that the NOMNC or ABN were completed at all when Medicare Part A services ended. The facility's policy states that such notices must be provided at least two days before the end of Medicare coverage to allow residents or their representatives sufficient time to make informed decisions regarding their care and financial responsibility. Record reviews and staff interviews confirmed that these procedures were not followed for the two residents in question.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge as required by regulation. Record review showed that the facility's process for emergency transfers and discharges mandates monthly notification to the ombudsman. However, documentation revealed that notifications were not consistently sent each month, with records only available for two months within the review period. Specifically, the discharge of one resident was not reported to the ombudsman, as confirmed by both record review and staff interviews. The Regional Director of Operations acknowledged that the required notification for the resident's discharge was not completed.
Failure to Maintain Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
A deficiency was identified when staff failed to maintain a urinary catheter drainage bag below the level of the bladder for a resident with an indwelling catheter. During a Hoyer lift transfer, the catheter drainage bag was attached to the lift arm hook at the resident's eye level, rather than being kept below the bladder as required by facility policy and the resident's care plan. Both the medication assistant and nursing assistant involved in the transfer were unsure of the correct placement for the catheter bag during the procedure. The resident involved had a history of neuromuscular dysfunction of the bladder and was dependent on staff for most activities of daily living. The care plan specifically noted the need to position the catheter bag and tubing below the bladder to prevent urinary tract infections. At the time of the incident, the resident was being treated for a urinary tract infection with antibiotics. The Director of Nursing confirmed that the catheter drainage bag should be kept below the level of the bladder, in accordance with facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide residents with nourishing and palatable meals, as required by both facility policy and the Nebraska Food Code. Observations revealed that hot foods were not consistently served at the required temperature of 135°F or higher, with a sample meal showing a sloppy joe at 124.3°F and broccoli and cheese at 132.4°F. The broccoli and cheese dish, intended to be regular texture, appeared ground or pureed and was described as unappetizing in both appearance and texture. Several residents were observed not eating this dish, and interviews confirmed dissatisfaction with the temperature and palatability of the meals. The pears served with the meal were cold, and the appearance of the food was also questioned, with one resident stating the broccoli and cheese looked like someone had thrown up on the plate. Resident interviews further confirmed that hot foods were not always served hot, especially for those who typically ate in their rooms. Residents with various medical conditions, including diabetes, vitamin deficiencies, and swallowing issues, were affected by these inconsistencies. The Food Service Manager acknowledged that the broccoli and cheese dish was not served in the correct texture, and the Administrator confirmed that meal temperatures did not meet required standards. These findings indicate a failure to adhere to established food preparation and service guidelines, impacting the quality and palatability of meals provided to residents.
Failure to Offer Alternate Meal Items for Unselected or Refused Foods
Penalty
Summary
The facility failed to ensure that residents were offered alternative meal items when they chose not to eat the food initially served, as required by their own policy and regulatory standards. Observations during lunch revealed that several residents did not eat the broccoli and cheese dish provided, and review of a sample meal tray showed limited options, with the vegetable appearing unappetizing. Residents received menus in advance to select their meal preferences, but if they did not mark a particular item, such as a vegetable or fruit, no alternative was provided. This practice was confirmed by both residents and the Food Service Manager, who stated that only main dish alternatives were available, and that no substitute vegetables or fruits were offered if the original item was declined or unselected. Interviews with two cognitively intact residents highlighted that they did not receive alternatives for items they disliked or could not eat, such as pears or broccoli, due to personal preference or difficulty eating certain foods. The Food Service Manager and Administrator both acknowledged that the facility did not routinely offer alternative vegetables or fruits, and that residents who did not select these items simply went without them. This failure to provide appropriate alternatives had the potential to affect all residents receiving meals from the kitchen, as it did not accommodate individual dietary needs and preferences as outlined in the facility's policy.
Failure to Maintain Clean and Homelike Environment Due to Persistent Urine Odors
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and homelike environment, as required by policy and regulation. Upon entering the facility, a faint odor of urine was detected at the front door, which became stronger further inside, particularly in the carpeted hallway leading from the east entrance to the main nurses' station, as well as in the south hall and some resident rooms. Specific observations included a private, unoccupied room in the east hallway that smelled strongly of urine and had a sticky floor. Later, after housekeeping mopped the floor in another room on the East Hall, the stickiness increased and the odor of urine became even more pronounced. Interviews with the DON and the Administrator confirmed awareness of the persistent urine odors throughout the hallways and some rooms, attributing the issue to humidity and seasonal changes. Both acknowledged the difficulty in addressing the odors, with the Administrator stating that staff had become accustomed to the smells. Review of facility policies indicated that regular environmental inspections and routine cleaning and disinfection were required, but these measures were not effective in preventing or eliminating the odors and unsanitary conditions observed.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for three cognitively intact residents who required varying levels of assistance with mobility and activities of daily living. Documentation from the Minimum Data Set (MDS) and call light logs revealed that these residents experienced significant delays, with call lights remaining unanswered for periods ranging from over 20 minutes to more than two hours on multiple occasions throughout the month. These delays were corroborated by resident interviews, where each resident described frequent and prolonged waits for staff assistance, sometimes exceeding an hour. One resident, who had a history of stroke and required moderate assistance to walk, reported that call light response times had temporarily improved after filing a grievance but subsequently worsened again. Call light logs for this resident showed repeated instances of delays, including several occasions where the call light was not answered for over 30 minutes and, in one case, for more than an hour. Another resident, who used a wheelchair due to fall precautions, also reported waiting an hour or more for assistance, particularly when needing to use the restroom. The call light logs for this resident similarly documented multiple extended response times, some exceeding an hour. A third resident, who was unable to walk and required a mechanical lift with two staff members for transfers, described staff sometimes turning off the call light and promising to return, only for the resident to continue waiting. This resident's call light logs included several instances of delays over an hour, with the longest being more than two hours. Interviews with facility leadership confirmed awareness of the issue, with the Director of Nursing and Facility Administrator acknowledging that call light response times were sometimes longer than appropriate and that there had been technical issues with the call light system on certain days.
Failure to Follow Physician's Orders for Auto-PAP
Penalty
Summary
The facility failed to follow up and complete a physician's order for an Auto-PAP machine for a resident diagnosed with obstructive sleep apnea. The resident, who was admitted with a history of using CPAP since 2018, reported that the mask was too tight, which led to frequent refusals to use the device. Despite the resident's complaints and inquiries about a new CPAP, there were no orders addressing these concerns. The resident's use of the Auto-PAP decreased significantly over time, with the resident refusing to use it more often than not. Interviews with staff revealed a lack of awareness and follow-up regarding the resident's refusal to use the Auto-PAP. The RN was unaware if the doctor had been notified about the refusals, and the DON confirmed that the orders for the Auto-PAP should have been placed upon admission. Additionally, there was a lack of follow-up after contacting Midwest Respiratory for recommendations, and the facility's administrator speculated that the resident's beard might be causing the mask to feel tight. This lack of action and communication contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to secure a catheter properly, leading to potential cross-contamination during catheter care for Resident 53. During an observation, a registered nurse (RN) was seen changing the catheter bag for Resident 53, who has dementia, neurogenic bladder, intellectual disabilities, and hypothyroidism. The RN dropped the new catheter drainage bag and tubing on the floor twice but continued to use them after wiping with alcohol wipes, which was confirmed by the Infection Control Preventionist as having the potential to cause cross-contamination. Additionally, the facility failed to adhere to proper hand hygiene protocols during peri care and wound care for Residents 53, 26, and 8. A medication aide (MA) did not change gloves or perform hand hygiene after providing pericare to Resident 53, which was confirmed by the MA and the Infection Control Preventionist. Similarly, an RN did not perform hand hygiene between glove changes during wound care for Resident 26, and a licensed practical nurse (LPN) failed to perform hand hygiene before donning gloves and between tasks during wound care for Resident 8. The facility's hand hygiene policy, which requires hand hygiene when moving from a contaminated body site to a clean body site and before donning gloves, was not followed. Interviews with the staff involved and the Director of Nursing (DON) confirmed the lapses in hand hygiene practices, which are crucial to preventing the spread of infection within the facility.
PASRR Screening Deficiency for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a PASRR (Pre-admission Screening and Resident Review) for individuals with a mental disorder or intellectual disability was accurately completed for one resident. This deficiency was identified during a review of records and interviews with staff. The resident in question, who was part of a sample of 20 residents, had a history of schizoaffective disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Despite these diagnoses being documented in various medical records, they were not accurately reflected in the PASRR screenings conducted on two separate occasions. The PASRR dated 3/30/21 noted major depressive disorder and substance abuse but omitted schizoaffective disorder and PTSD. A subsequent PASRR dated 6/8/22 failed to list any diagnoses. Interviews with the Director of Nursing, Administrator, and Social Service Director confirmed the oversight, acknowledging that the PASRR should have included the resident's diagnoses of schizoaffective disorder and PTSD. The Administrator noted that the PASRR was initially completed at the hospital and was done incorrectly, and the facility's Social Worker did not identify the error.
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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