Adept Nursing & Rehab Of Grand Island
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Island, Nebraska.
- Location
- 800 Stoeger Drive, Grand Island, Nebraska 68803
- CMS Provider Number
- 285221
- Inspections on file
- 17
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Grand Island during CMS and state inspections, most recent first.
The facility did not complete required Nurse Aide Registry Checks prior to hiring four staff members, including a nurse aide, medication aide, LPN, and hospitality aide. These staff began working and providing care to residents before the checks were performed or documented, contrary to facility policy and state requirements.
The facility did not update its Facility Assessment to include ventilation services, despite a resident using a Trilogy Non-invasive ventilator continuously. The assessment was last revised without accounting for ventilator-dependent residents, and an LPN reported not receiving direct training on the device. The Regional Nurse Consultant confirmed the omission.
A staff member began work without a completed pre-employment health screening, and multiple staff failed to follow Enhanced Barrier Precautions by not wearing required PPE during high-contact care for two residents with wounds. Additionally, an ADT did not perform proper hand hygiene during wound care for a resident on EBP.
Staff were not trained on the Trilogy Non-invasive ventilator, despite a resident having physician orders for its use. The facility's assessment did not include ventilation services, and an LPN confirmed no training was provided on ventilator or dialysis care. The Regional Nurse Consultant also confirmed that required training had not been completed.
The facility did not post required daily nurse staffing information in any accessible location, as confirmed by multiple observations and interviews with facility leadership. Despite having designated frames for postings at nurse's stations, these remained empty throughout the survey, and the required information was not made available to residents, staff, or visitors.
Surveyors found that two residents received medications from stock bottles that were not labeled with the date opened, contrary to facility policy. Additionally, the medication storage room was observed to be unsanitary, with soiled floors, sink, and counters where medications were stored. Both the ADON and RNC confirmed these deficiencies.
Two nurse aides did not complete the required 12 hours of annual continuing education, with one aide completing no hours and another only 8 hours during their respective annual training periods. The facility's records and administrator confirmed the deficiency, as the required training was not provided within the specified timeframes.
Three residents, including individuals with schizophrenia, dementia, and other serious conditions, were administered psychotropic medications without documented informed consent. Facility records lacked evidence that residents or their representatives were informed of the benefits, risks, and alternatives to these medications, and staff confirmed that required consent documentation was missing or incomplete.
A resident with multiple diagnoses and intact cognition expressed a wish not to have CPR performed, which was also indicated by their responsible party. However, the electronic medical record, including order entry, profile header, and care plan, continued to list the resident as a full code. The DON confirmed that the resident's wishes were not accurately reflected in the documentation.
Two residents were administered psychotropic medications for unapproved indications: one received Quetiapine for anxiety and another received Mirtazapine for insomnia, despite neither condition being an FDA-approved use for these drugs or properly documented in the medical record. The DON confirmed the lack of appropriate indications for both cases.
A resident with a left leg amputation, chronic pain, and diabetes was inaccurately coded on the MDS regarding mobility device use and pain medication. The MDS documented walker use, but both the resident and staff confirmed wheelchair use. Additionally, the MDS failed to reflect that the resident received scheduled opioid pain medication, despite physician orders and medication records showing regular administration.
A resident with schizophrenia, anxiety, and major depression was admitted without a completed PASRR Level 1 screening, as required by facility policy and state Medicaid rules. The DON confirmed that the necessary pre-admission screening was not performed.
Three residents with significant medical conditions experienced prolonged periods without bowel movements, and facility staff failed to provide or document required bowel care interventions or assessments as ordered. Despite care plans and physician orders for as-needed laxatives and monitoring, there was no evidence of interventions or documentation in the medical records, as confirmed by nursing leadership.
A resident with multiple medical conditions experienced a progressive decline in hand function and upper extremity strength, impacting their ability to feed themselves and reposition in bed. Despite observable changes and increased dependence on staff, the care plan lacked interventions for impaired range of motion, and required therapy assessments were not completed. Staff and therapy leadership were unaware of the resident's decline, resulting in a failure to maintain the resident's ROM and functional abilities.
The facility did not ensure that two residents received their required initial post-admission visits from a physician within the mandated timeframe. In one case, a PA conducted the initial visit instead of a physician, and in another, the physician visit occurred after the required 30-day period.
A resident with chronic pain and diabetes, who required assistance with oral hygiene, reported having multiple broken teeth and had not seen a dentist since admission. The resident was not asked about dental needs, and observation confirmed dental issues. The care plan identified oral health risks, but no dental services were provided or arranged, as confirmed by the Regional Nurse Consultant.
A resident with a renal diet and strict religious restrictions against pork was repeatedly served meals containing pork products and other non-compliant items, despite clear documentation of their dietary needs. The dietary staff did not follow the specified restrictions, resulting in the resident being unable to eat the provided food.
A resident with severe cognitive impairment and multiple comorbidities was found to have a healing arm fracture of unknown origin. Facility staff did not report the injury or submit an investigation to the state agency or adult protective services within required time frames, despite policy requiring prompt notification for such incidents.
A resident at risk for pressure ulcers did not receive adequate care, as the facility failed to conduct weekly skin assessments, delayed dietary interventions, and did not ensure the use of heel boots. The resident's skin conditions worsened due to these deficiencies, as confirmed by staff observations and interviews.
The facility failed to ensure proper use of PPE, hand sanitization, and infection control practices, including incomplete pre-employment health screenings and improper urinary catheter care, increasing the risk of cross-contamination and infection among residents.
The facility failed to maintain three rooms and two halls in good repair, compromising residents' right to a safe, clean, and homelike environment. Observations included holes in ceilings, warped paint, yellow-brown stains, and gray-black fuzzy material. The Facility Administrator and Regional Director of Operations confirmed the damage was due to a water leak from holes in the roof, which had been repaired, but the interior damage remained unaddressed.
The facility failed to include necessary interventions for urinary elimination in a resident's care plan and did not document a discharge plan for another resident who expressed a desire to leave. These deficiencies were confirmed through observations, record reviews, and staff interviews.
The facility failed to conduct and document care plan meetings for several residents, including those with significant medical conditions, over extended periods. This deficiency was confirmed through record reviews and interviews with residents and their representatives, revealing a systemic failure to comply with care planning requirements.
The facility failed to ensure residents were free from significant medication errors, specifically in the administration and storage of insulin pens. An RN incorrectly primed an insulin pen, and several insulin pens were improperly labeled and stored, as confirmed by the DON.
The facility failed to ensure routine bowel movements for a resident with multiple diagnoses, including schizophrenia and chronic kidney disease. Despite the facility's constipation prevention protocol, the resident did not receive necessary interventions or assessments for extended periods. Staff interviews confirmed the lack of orders for an as-needed laxative and the absence of documented assessments or interventions.
The facility staff failed to manage complaints of pain for a resident admitted with multiple fractures and other medical conditions. Despite the resident's severe pain, no pain medication was administered until the following day. The facility did not follow protocols for timely medication delivery or utilize non-pharmacological pain interventions as documented in the care plan.
Failure to Complete Pre-Employment Nurse Aide Registry Checks
Penalty
Summary
The facility failed to ensure that Nurse Aide Registry Checks were completed prior to hire for four out of five sampled staff members, as required by facility policy and state regulations. Specifically, the employee files for a nurse aide, a medication aide, an LPN, and a hospitality aide either contained registry checks completed months after their hire dates or lacked documentation of the checks entirely. In each case, the staff members had already begun working and had completed initial orientation training before the registry checks were performed or documented. Interviews with the Facility Administrator confirmed that the expectation was for these checks to be completed before employment began, and acknowledged that this requirement was not met for the identified staff. Observations showed these staff members actively providing care or assistance to residents during the survey period. For example, the nurse aide was observed exiting a resident's room, the medication aide was assisting a resident at the medication cart, and the hospitality aide was helping residents access the courtyard. The lack of timely registry checks meant that the facility could not verify whether these staff had any findings of abuse, neglect, or misappropriation of property prior to their employment, contrary to the facility's written policies and procedures.
Facility Assessment Lacked Ventilator Services for Resident Needs
Penalty
Summary
The facility failed to review and revise its Facility Assessment to ensure it included all necessary resources to meet the needs of its residents, specifically omitting ventilation services. The Facility Assessment, last revised and reviewed in April 2025, did not account for residents requiring ventilator support. Record review showed that one resident had a physician's order for a Trilogy Non-invasive ventilator to be used at bedtime or while napping, but the resident reported using the ventilator continuously, only removing it for cleaning or hose changes. Additionally, an LPN stated they had not received direct training from the facility on the use of the Trilogy Non-invasive ventilator. The Regional Nurse Consultant confirmed that the Facility Assessment should have been updated to include ventilator services.
Deficiencies in Infection Control: Pre-Employment Screening, Enhanced Barrier Precautions, and Hand Hygiene
Penalty
Summary
The facility failed to ensure completion of pre-employment health history screening for one of five sampled staff members. Specifically, the employee file for a hospitality aide did not contain a fully completed Health Questionnaire, as required by facility policy. The section for test information, including vital signs and provider follow-up, was left blank, and the employee did not sign or date the form. Despite this, the Director of Nursing signed off on the document as complete, and the aide began working and providing direct assistance to residents. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy for residents with chronic wounds. During high-contact care activities, such as transferring a resident with a wound using a full body lift, two nurse aides failed to wear the required personal protective equipment (PPE), including gloves and gowns, despite signage and their own acknowledgment of the policy. Another instance involved the Assistant Director of Nursing in Training providing personal hygiene care to a resident on EBP without wearing a gown, contrary to facility policy and their own admission of the requirement. The facility also failed to ensure proper hand hygiene during wound care for a resident on EBP. The Assistant Director of Nursing in Training applied two different substances to the resident's wound area without changing gloves or performing hand hygiene between applications, as required by the facility's hand hygiene policy. This lapse was confirmed by both the staff member involved and the Assistant Director of Nursing.
Lack of Staff Training on Trilogy Non-Invasive Ventilator
Penalty
Summary
The facility failed to provide training to staff on the use of the Trilogy Non-invasive ventilator, as required by licensure regulations. Record review showed that the facility's assessment did not include ventilation services, despite having a resident with physician orders for the use of a Trilogy Non-invasive ventilator at bedtime or while napping. Interviews with a resident revealed that the ventilator was being used continuously, except during cleaning or hose changes. Additionally, an LPN reported not receiving any training on the Trilogy Non-invasive ventilator or on recognizing dialysis-related signs and symptoms. The Regional Nurse Consultant confirmed that training on ventilator and dialysis services had not been completed for staff review.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted as required by its own policy and federal regulations. The policy specified that nurse staffing information, including facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and nurse aides per shift, must be posted daily in a prominent and accessible location for residents, staff, and visitors. Multiple observations conducted over several days revealed that the daily nurse staffing posting was not present anywhere in the facility, including at entry doors, nurse's stations, administrative offices, dining room, and other common areas. Interviews with facility leadership, including the Facility Administrator and Regional Director of Operations, confirmed that the daily nurse staffing information was not posted as required. Although there were designated frames for the postings at nurse's stations, these remained empty throughout the survey period. The failure to post the required information had the potential to affect all 58 residents residing in the facility, as the information was not made available at any time during the recertification survey.
Failure to Properly Label and Sanitarily Store Medications
Penalty
Summary
Surveyors observed that stock medication bottles used for two residents were not labeled with the date they were opened, as required by facility policy and professional standards. During medication administration, a medication aide prepared and administered medications from bottles that lacked an opening date, and both the aide and the Assistant Director of Nursing confirmed that the bottles should have been dated but were not. The facility's policy specifies that stock medications must include the original manufacturer's or pharmacy-applied label and the expiration date, but this was not followed in these instances. Additionally, the medication storage room was found to be unsanitary during inspection. Observations included dried black splatters and debris on the floor, a sink with a thick layer of brown and black sticky substance with black fuzzy particles, and counters with dried liquid splatters in the area where medications were stored. Both the Assistant Director of Nursing and the Regional Nurse Consultant confirmed that the medication storage room was not clean or sanitary, despite facility policy requiring daily cleaning to ensure proper sanitation.
Failure to Ensure Nurse Aides Complete Required Annual Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required minimum of 12 hours of continuing education annually, as mandated by facility policy and state regulations. Specifically, one nurse aide (NA-G), who worked per diem throughout the year, did not complete any hours of continuing education during their annual training period based on their hire date. Facility records confirmed multiple work shifts for this aide during the relevant period, but no training hours were documented. The Facility Administrator acknowledged that the facility is responsible for ensuring all nurse aides, regardless of their work schedule, meet the annual training requirement and confirmed the deficiency for NA-G. Additionally, another nurse aide (NA-H) completed only 8 hours of continuing education during their annual training period, falling short of the 12-hour requirement. Although the Facility Administrator attempted to locate additional in-service documentation, the only additional trainings found were outside the required annual period. The deficiency was confirmed by the Facility Administrator, who acknowledged that the required training hours were not met for NA-H within the specified timeframe.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the use of psychotropic medications prior to administration for three residents. For one resident with schizophrenia, anxiety, and major depression, record reviews showed that antipsychotic medications were started upon admission, but there was no psychotropic medication informed consent form present in the medical record at the time of survey. When a consent form was later provided, it was incomplete, missing key information such as the resident's current medications and physician details. Further investigation revealed inconsistencies in the documentation, including a consent form with signatures that did not match the original, and no evidence that the resident's guardian had been properly informed or contacted regarding the consent. Another resident with hemiplegia, diabetes, dementia, and a history of stroke was found to be receiving antidepressant and antipsychotic medications on a routine basis. The medical record lacked documentation that the resident or their responsible party had been informed of the benefits, risks, and alternatives to these medications. Interviews with facility staff confirmed that such documentation was expected but not present in the resident's health record. A third resident with hydrocephalus, diabetes, and dementia, who was cognitively intact, was also receiving routine antidepressant medications. Similar to the other cases, there was no documentation in the medical record indicating that informed consent had been obtained or that the resident or their representative had been informed about the medications. Staff interviews confirmed the absence of required documentation for informed consent prior to the administration of psychotropic medications.
Failure to Accurately Document Resident Code Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding code status were accurately documented and reflected in the electronic medical health record. Specifically, a review of the resident's records showed that although the resident and their responsible party had indicated a desire not to have CPR performed, the electronic medical record, including the order entry, profile header, and care plan, continued to list the resident as a full code with instructions to begin CPR in the event of an arrest. The facility's policy required that code status be communicated and documented in designated sections of the medical record, but this was not followed in this case. The resident involved was admitted with diagnoses including metabolic encephalopathy, obesity, and schizoaffective disorder, and was assessed as cognitively intact with a BIMS score of 14. During an interview, the resident clearly stated they did not wish to have CPR performed. Despite this, the documentation in the electronic medical record did not reflect the resident's wishes, as confirmed by the DON, who acknowledged the discrepancy between the resident's expressed wishes and the information recorded in the system.
Psychotropic Medications Used Without Approved Indications
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed and administered only for approved indications in accordance with facility policy and regulatory requirements. For one resident with hemiplegia, type 2 diabetes, dementia, and a history of stroke, Quetiapine, an antipsychotic medication, was ordered and administered for anxiety, which is not an FDA-approved indication for this drug. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the medication was given routinely as per the physician's order. The Director of Nursing (DON) confirmed that anxiety was not an approved indication for Quetiapine. In another case, a resident with hydrocephalus, type 2 diabetes, and dementia was prescribed Mirtazapine, an antidepressant, for insomnia. The MDS showed the resident was cognitively intact and received the medication routinely. However, the resident did not have a diagnosis of insomnia documented in their medical record, and the DON confirmed that insomnia was not an approved indication for Mirtazapine. These findings demonstrate that the facility did not ensure psychotropic medications were used only for specific, diagnosed, and documented conditions as required.
Inaccurate MDS Coding for Mobility and Pain Management
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in multiple discrepancies between the resident's actual condition and the documented assessment. The resident, who was admitted with diagnoses including an absence of the left leg below the knee, chronic pain, and type 2 diabetes mellitus, was incorrectly coded in several MDS sections. Specifically, the MDS indicated that the resident used a walker for mobility, while interviews with the resident and staff confirmed that the resident used a wheelchair and rarely got out of bed. The Regional Nurse Consultant also confirmed that the MDS coding did not accurately reflect the resident's use of a wheelchair. Further review revealed that the MDS was incorrectly coded regarding the resident's pain management and medication use. Although the resident had a physician's order for scheduled Hydrocodone-Acetaminophen and received this opioid medication routinely during the look-back periods, the MDS was coded to indicate that the resident did not receive scheduled pain medication and was not taking an opioid. These inaccuracies were confirmed through interviews and review of the resident's medication administration records and physician orders.
Failure to Complete PASRR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) Level 1 screening prior to admitting a resident with diagnoses of schizophrenia, anxiety, and major depression. According to the facility's policy, all applicants must be screened for serious mental disorders or intellectual disabilities before admission, in accordance with state Medicaid rules. Record review showed that the resident was admitted without a completed PASRR Level 1 evaluation in the medical record. The Director of Nursing confirmed during an interview that the screening was not completed as required prior to the resident's admission.
Failure to Provide and Document Bowel Care Interventions
Penalty
Summary
The facility failed to provide appropriate bowel care services for three residents, as evidenced by a lack of interventions and documentation when residents did not have bowel movements for several days. For one resident with hemiplegia, diabetes, dementia, and a history of stroke, there was no documented bowel movement for seven consecutive days, and no interventions or assessments were recorded in the medical record during this period. The Medication Administration Record also showed no administration of as-needed cathartic medication, and the Assistant Director of Nursing (ADON) confirmed the absence of both interventions and documentation. Another resident, diagnosed with hydrocephalus, diabetes, and dementia, experienced multiple periods without documented bowel movements, including three days in April and four days in May. During these times, there was no evidence in the progress notes or MAR of any interventions or assessments to address the lack of bowel movements. The ADON confirmed that the medical record lacked documentation of both interventions to promote bowel movements and bowel assessments for this resident as well. A third resident, admitted with diabetes, a foot ulcer, and on palliative care, reported not having a bowel movement in two weeks and was aware of their own elimination patterns. The review of the resident's records showed the last documented bowel movement was over two weeks prior, and although there were physician orders for as-needed laxatives, there was no documentation of these being administered. The care plan included monitoring and recording bowel movements daily and following physician orders for laxatives if no bowel movement occurred for three or more days, but there was no evidence these interventions were implemented. Interviews with facility staff confirmed the absence of required documentation and interventions for all three residents.
Failure to Maintain Resident's Range of Motion and Functional Abilities
Penalty
Summary
The facility failed to ensure that a resident maintained their range of motion (ROM) to promote their highest practicable level of independence. The resident, admitted with diagnoses including absence of left leg below the knee, chronic pain, and type 2 diabetes mellitus, was cognitively intact and required staff assistance for bed mobility and transfers. The resident was noted to have impaired ROM in one upper extremity and both lower extremities, but their care plan did not include any focus area or interventions related to impaired ROM. The resident reported progressive loss of hand function, specifically curling of fingers and inability to straighten them, which affected their ability to feed themselves and reposition in bed—tasks they previously could perform. Observations confirmed the resident's difficulty in grasping utensils and repositioning independently, requiring increased staff assistance. Staff interviews corroborated the resident's decline in upper extremity function and increased dependence. The Director of Rehab acknowledged that a therapy screen or evaluation was not completed as required, and was unaware of the resident's decline in hand function and upper extremity strength. This lack of assessment and intervention contributed to the resident's continued decline in ROM and functional abilities.
Failure to Ensure Timely Initial Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that the required initial post-admission physician visit was completed for two residents. For one resident, the initial visit after admission was conducted by a Physician Assistant (PA) rather than a physician, as confirmed by both documentation and interviews with facility staff. Facility policy and regulatory requirements specify that the initial comprehensive visit in a skilled nursing facility must be performed by a physician, not by a non-physician practitioner. The progress note for this resident documented the visit by the PA as the initial skilled nursing facility care visit, which was not in compliance with the stated requirements. For another resident, there was no evidence that a physician completed the required initial visit within 30 days of admission. The first documented physician visit for this resident occurred beyond the 30-day window, and this was confirmed by the Regional Nurse Consultant. Both cases demonstrate a failure to meet the regulatory requirement for timely and appropriate physician visits following admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly provide or obtain dental services for a resident who had been admitted with multiple medical conditions, including chronic pain and type 2 diabetes mellitus. The resident reported having multiple broken teeth and stated they had not seen a dentist since admission. The resident also indicated they had not been asked about their dental needs or desires to see a dentist. During an observation, holes were noted in two of the resident's lower left back teeth. The resident expressed discomfort when chewing tough or hard foods and voiced a desire to see a dentist. A review of the resident's records showed that the care plan identified a risk for oral or dental health problems and included interventions for daily oral hygiene. The resident was assessed as cognitively intact and required assistance with eating and oral hygiene. Despite these documented risks and needs, there was no evidence that dental services had been provided or arranged since the resident's admission. The Regional Nurse Consultant confirmed that the resident had not been seen by a dentist during their stay.
Failure to Provide Diet Consistent with Resident's Medical and Religious Needs
Penalty
Summary
A deficiency occurred when a resident with a renal diet and strict religious dietary restrictions against pork or pork by-products was not provided meals in accordance with these requirements. Despite clear documentation on the resident's meal ticket and care plan specifying a renal diet, no added salt, no pork or pork by-products, and fluid restrictions, the resident was served a hot dog containing both beef and pork, as well as other menu items not aligned with their dietary needs. The Certified Dietary Manager (CDM) confirmed that dietary staff were not following the listed dietary restrictions, and the product label for the hot dogs revealed they contained a beef and pork blend, contrary to the resident's requirements. The resident expressed dissatisfaction and an inability to eat the provided food due to these issues. Further observations showed the resident was again served breakfast items that did not comply with their dietary restrictions, including a banana and orange juice, despite the meal ticket specifying no citrus or banana. The resident left some items uneaten, stating they could not consume them. Interviews with the resident's Power of Attorney confirmed the importance of adhering to the dietary restrictions for religious reasons, and the CDM acknowledged that appropriate meal options were not provided. The resident's medical history included nontraumatic intracerebral hemorrhage, dysphasia, malnutrition, and dependence on renal dialysis, making adherence to dietary requirements critical.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and submit an investigation for an injury of unknown origin to the State Agency and adult protective services within the required time frames for one resident. According to the facility's policy, all alleged violations, including injuries of unknown origin, must be reported to the administrator, state agency, and adult protective services immediately, but not later than two hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. A resident with severe cognitive impairment, hemiplegia, diabetes, dementia, and a history of stroke was found to have a healing humerus fracture of unknown origin after returning from a primary health care provider visit. The resident's care plan documented multiple prior falls without injury, and the medical record did not identify a probable or possible source for the fracture. Interviews with facility staff confirmed that the provider notified the facility of the fracture, and an internal investigation suggested the injury may have occurred prior to admission, based on information from the resident's responsible party. However, the Assistant Director of Nursing and the Regional Director of Operations both confirmed that the state agency and adult protective services were not notified, and no written report or investigation was submitted to the state agency as required by facility policy and regulatory requirements.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and treat pressure-related skin conditions for a resident. The resident, who was admitted with multiple diagnoses including spinal stenosis, spinal cord injury, diabetes, peripheral vascular disease, and dementia, was at risk for pressure ulcers. Despite being cognitively intact, the resident had functional limitations and was dependent on staff for mobility and toileting. The care plan identified the resident's risk for pressure ulcers and existing wounds, but lacked interventions for dietary changes and consistent use of heel boots. Observations and record reviews revealed that the facility did not adhere to its own policies for skin assessments and pressure injury prevention. The resident's skin assessments were not conducted weekly as required, and the resident was observed without the necessary heel boots, which were supposed to be worn at all times. Additionally, the resident's head of the bed was elevated beyond the recommended angle, contributing to pressure on the heels. The facility also failed to implement dietary recommendations from the registered dietitian in a timely manner, delaying the administration of ProStat, a dietary supplement for wound healing. Interviews with staff confirmed these deficiencies. The LPN acknowledged the absence of heel boots on the resident, and the DON confirmed the delay in starting the recommended dietary supplement. The DON also acknowledged the lack of documented weekly skin assessments, which coincided with the worsening of the resident's skin conditions. These failures in care and documentation contributed to the progression of the resident's pressure-related skin conditions.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that staff followed requirements for wearing and discarding of Personal Protective Equipment (PPE) in resident rooms for residents with Covid-19 infection and for residents requiring Enhanced Barrier Precautions. Observations revealed that staff did not consistently wear the required PPE, such as gowns, gloves, and face shields, when entering the rooms of residents with confirmed Covid-19. Additionally, staff did not perform proper hand sanitization between resident rooms during laundry delivery, increasing the potential for cross-contamination. Interviews with staff confirmed that they were aware of the PPE requirements but did not always adhere to them. The facility also failed to ensure that pre-employment health history screenings were completed and reviewed for five sampled staff members. The health questionnaires in the employee health files were either incomplete or lacked documentation of review by the Director of Nursing (DON). This oversight had the potential to expose residents to transmissible diseases from staff members. Furthermore, the facility did not maintain proper infection control practices during urinary catheter care for a resident. Observations showed that the urinary collection bag was allowed to rest on the floor, and the measuring container was not rinsed after use. Additionally, staff did not follow proper handwashing procedures before and after handling the urinary catheter equipment. These lapses in infection control practices increased the risk of cross-contamination and infection among residents.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility staff failed to ensure that three of twenty-seven rooms and two of three halls were maintained in good repair, compromising the residents' right to a safe, clean, comfortable, and homelike environment. During an environmental tour, it was observed that room [ROOM NUMBER] had a square hole in the ceiling exposing underlayment, warped and rippling paint, yellow-brown staining, gray-black fuzzy material along the wall to ceiling trim, and cracked ceiling material. Additionally, the curtain in the room had gray-black fuzzy material, and there was a large hole in the roof soffit outside the room. Room [ROOM NUMBER] had peeling and warped paint, yellow-brown staining on the ceiling, loose and missing trim, and was cluttered with wheelchairs in disrepair and opened and closed boxes. The hallway ceiling connecting B Wing to C Wing had yellow-brown stains, loose edging, and peeling wallpaper exposing dry wall beneath. Residents residing in these rooms and adjacent areas were directly affected by these conditions. In an interview, the Facility Administrator (FA) acknowledged the presence of water damage due to holes in the roof, which had been repaired, but was unsure when the damage had occurred. The Regional Director of Operations (RDO) confirmed the roof repair and stated that the water damage had occurred in November 2023. Despite the roof being fixed, the interior damage had not been adequately addressed, leading to the observed deficiencies in the rooms and hallway. The facility census at the time was 37 residents.
Deficiencies in Care Plan and Discharge Planning
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident 39 included necessary interventions for urinary elimination. Despite Resident 39 having a Foley catheter, the care plan did not document the indwelling urinary catheter or provide any interventions for staff to care for it. Observations revealed that the urinary collection bag was improperly placed, and the catheter tubing contained dark yellow urine. Interviews with staff confirmed that the care plan should have included the indwelling urinary catheter and related interventions, but it did not. This oversight was confirmed by the Regional Nurse Consultant (RNC) during an interview. Additionally, the facility did not include a discharge plan for Resident 1, who expressed a desire to leave the facility. Despite Resident 1 being cognitively intact and independent in various activities of daily living, the care plan did not reflect the resident's expressed discharge goal. The resident had contacted an Assisted Living facility, but the facility allegedly intervened, leading to the Assisted Living facility not accepting the resident. The Director of Nursing (DON) confirmed that there was no documentation in Resident 1's medical record or care plan reflecting the resident's discharge goal or any interventions to assist in meeting this goal. The facility's failure to include necessary interventions for urinary elimination in Resident 39's care plan and the lack of a discharge plan for Resident 1 were identified as deficiencies. These issues were confirmed through observations, record reviews, and interviews with staff, including the DON and RNC. The facility's policies on comprehensive care plans and discharge planning were not followed, leading to these deficiencies being noted by the surveyors.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted to allow residents and their representatives to participate in the development and revision of the residents' plans of care. This deficiency was identified for 5 out of 12 sampled residents, including those with significant medical conditions such as stroke, hemiplegia, dementia, major depression, and muscle weakness. The facility's policy mandates that care plan meetings should be held quarterly and that residents or their representatives should be involved in these meetings. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of care plan meetings for the affected residents over extended periods, ranging from 4.5 months to over 9 months. Interviews with residents and their representatives confirmed that they had not been invited to or informed about care plan meetings for significant durations, further corroborating the lack of compliance with the facility's policy and regulatory requirements. For Resident 11, who was admitted with diagnoses including stroke and dementia, there was no documentation of any care plan meetings from 8/1/23 to 5/14/24, despite a scheduled meeting on 8/17/23. Similarly, Resident 18, diagnosed with major depression and sleep apnea, had no documented care plan meetings from 8/1/23 to 5/14/24, and the resident confirmed not being invited to a meeting in over six months. Resident 14, admitted with muscle weakness and altered mental status, also had no documented care plan meetings from 12/31/23 to 5/14/24, and the resident's spouse confirmed the lack of meetings since admission. Resident 1, with diagnoses including personality disorder and bipolar disorder, had no documented care plan meetings from 8/11/23 to 5/14/24, and the resident could not recall the last meeting attended. Lastly, Resident 25, diagnosed with depressive and anxiety disorders, had no documented care plan meetings from 9/21/23 to 5/14/24, and the resident could not remember the last time they were invited to a meeting. The Facility Administrator confirmed the absence of documentation for care plan meetings for all these residents, indicating a systemic failure to comply with care planning requirements.
Significant Medication Errors in Insulin Administration and Storage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration and storage of insulin pens. During an observation of medication administration, a Registered Nurse (RN-C) was seen administering insulin to a resident without correctly priming the insulin pen as per the facility's policy and manufacturer instructions. The RN-C added 2 units of insulin to the prescribed dose for priming, which was incorrect. The Director of Nursing (DON) confirmed that RN-C did not prime the insulin pen correctly and had not received recent competency training on insulin administration. Additionally, several insulin pens for multiple residents were found to be improperly labeled and stored. Insulin pens for residents were missing critical information such as the open date, resident's name, prescribing physician's name, medication name, prescribed dose, strength, quantity, expiration date, and appropriate instructions and precautions. Some pens were stored in the medication cart instead of being refrigerated as required by both facility policy and manufacturer recommendations. The DON confirmed these deficiencies in labeling and storage. The residents involved in these deficiencies included those who required insulin for blood sugar regulation. The improper administration and storage of insulin could potentially lead to significant medication errors, impacting the residents' health. The facility's failure to adhere to its policies and manufacturer guidelines for insulin pen use and storage was evident in the observations and interviews conducted during the survey.
Failure to Ensure Routine Bowel Movements for Resident
Penalty
Summary
The facility failed to ensure routine bowel movements for a resident diagnosed with schizophrenia, a compression fracture of the vertebra, chronic kidney disease, and type two diabetes. The resident, who was cognitively severely impaired with a BIMS score of 3, did not have a documented bowel movement from 04/20/2024 to 04/24/2024 and 04/29/2024 to 05/05/2024. Despite the facility's constipation prevention protocol, which required offering an as-needed laxative on the third day without a bowel movement and a suppository on the fourth day, there were no orders for an as-needed laxative for the resident. Additionally, there was no documentation of any intervention or assessment of the resident's abdomen, bowel sounds, pain, or appetite during these periods of constipation. Interviews with the facility staff, including a registered nurse, a medication aide, the infection prevention nurse, and the director of nursing, confirmed that the resident did not receive the necessary interventions or assessments as per the facility's protocol. The staff reported that they relied on a list provided by the DON or IP nurse to identify residents needing bowel movement interventions, but the resident in question did not receive any such interventions. The DON confirmed the lack of orders for an as-needed laxative and the absence of any documented assessments or interventions for the resident's constipation during the specified periods.
Failure to Manage Pain for Resident
Penalty
Summary
The facility staff failed to manage complaints of pain for Resident 192, who was admitted with multiple fractures and other medical conditions. Upon admission, Resident 192 reported excruciating pain, which was rated as a 10 on a scale of 0-10. Despite the resident's severe pain, no pain medication was administered until the following day. The resident's baseline care plan indicated a pain management regimen, but the facility did not provide the necessary medications promptly, nor did they utilize non-pharmacological pain interventions as documented in the care plan. Interviews with staff revealed that the facility had protocols for ensuring timely medication delivery, including using a backup pharmacy and an emergency drug box containing pain management medications. However, these protocols were not followed in Resident 192's case. The resident did not receive any doses of prescribed pain medications on the day of admission, and the first doses were only administered in the early hours of the following day, despite the resident's reported pain levels of 9 and 8. The facility's pain management policy requires a systematic approach to recognizing, assessing, treating, and monitoring pain. This includes evaluating the resident for pain upon admission and managing pain consistent with the care plan and professional standards. The facility failed to adhere to this policy, as evidenced by the lack of timely pain medication administration and the absence of documented non-pharmacological pain management interventions for Resident 192. The Director of Nursing confirmed that medications to control pain should be provided to those who are prescribed and in need, which did not occur in this instance.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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