Adept Nursing & Rehab Of Gretna
Inspection history, citations, penalties and survey trends for this long-term care facility in Gretna, Nebraska.
- Location
- 700 Highway 6, Gretna, Nebraska 68028
- CMS Provider Number
- 285146
- Inspections on file
- 23
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Gretna during CMS and state inspections, most recent first.
Surveyors identified that the facility exceeded the acceptable medication error rate when three errors occurred out of 25 opportunities. One resident with edema missed a scheduled morning dose of torsemide 80 mg because the drug was unavailable in the medication cart, not in the medication bank, and had not yet arrived from the pharmacy. Another resident, ordered sucralfate 1 g before meals and at bedtime, received the medication after eating lunch. A third resident, ordered finasteride 5 mg once daily at 8:00 PM for urinary retention, received the dose in the early afternoon instead of at the scheduled time. Staff, including an MA, an LPN, and the DON, confirmed that these missed and wrong-time administrations constituted medication errors under facility policy.
A resident who was unable to make themselves understood and required extensive assistance with mobility and ADLs was admitted with a documented sacral pressure ulcer. Facility policy required that wound care be provided per physician orders and that a physician be notified to obtain treatment orders when none were present. Despite this, the resident’s records showed no physician order for treatment of the sacral ulcer, and an RN confirmed that the physician had not been notified and that no treatment order had been obtained.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not ensure that water temperatures for bathing and showering remained at or below 110°F, as required to prevent accidents. Multiple logs and direct observations showed water temperatures in excess of this limit in several bathhouses and tubs. Over twenty cognitively impaired residents regularly used these bathing areas, and staff confirmed the facility lacked a specific policy for tub bathing.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Staff failed to promptly assess, monitor, and implement interventions for two residents at risk for pressure ulcers, resulting in the development and worsening of pressure injuries. In both cases, wounds were not measured or treated in a timely manner, and required interventions were not initiated according to facility policy.
The facility did not provide bathing services according to the stated preferences of four residents, each of whom required significant assistance and had documented requests for two baths or showers per week. Despite varying cognitive and physical needs, these residents received fewer baths or showers than preferred, contrary to facility policy supporting resident self-determination, as confirmed by the DON.
Staff failed to promptly notify the medical practitioner of new pressure ulcers for two residents, resulting in a lack of timely treatment orders. One cognitively intact resident developed a stage 3 pressure ulcer that was not reported for further treatment, while another resident's wounds were not communicated to the practitioner until the day of the survey, contrary to facility policy.
The facility did not post daily nurse staffing information as required by its policy and federal guidelines. Observations showed that the necessary details, including the facility name, date, census, and staff hours, were missing. The DON confirmed the oversight, affecting all 44 residents.
The facility was found to have multiple environmental deficiencies in resident rooms, including scrapes on walls, stained floors, cracked sinks, and non-functioning lights. These issues were confirmed by the Maintenance Director, who noted that no active work orders were in place to address them.
The facility failed to secure residents' medications and treatments in medication carts, as observed on multiple occasions. Unlocked and unattended medication carts were found in various locations, and a Registered Nurse left a treatment cart unlocked while performing treatments. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, which was not followed.
The facility failed to obtain treatment orders for pressure ulcers for two residents. One resident had a pressure ulcer on the left lateral foot, and another had an unstageable pressure wound on the left heel. Observations and interviews confirmed the absence of treatment orders for both residents.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 opportunities, resulting in a 12% error rate. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and accepted professional standards, and specified that missed doses and wrong-time administrations are medication errors. For one resident with an order for torsemide 80 mg by mouth in the morning for edema, observation showed the medication was unavailable at the scheduled administration time. The medication aide stated they would notify the charge nurse to obtain the drug from the facility’s medication bank. The LPN later confirmed that torsemide 80 mg was not available in the medication bank, the pharmacy had been notified, and by the afternoon the medication had still not arrived, resulting in a missed dose, which was acknowledged as a medication error. Another resident had a physician’s order for sucralfate 1 g by mouth before meals and at bedtime. Observation showed the medication aide administered the sucralfate after the resident had already eaten lunch, and the aide confirmed it should have been given before the meal. A third resident had an order for finasteride 5 mg by mouth once daily, scheduled for 8:00 PM. Observation revealed that the medication aide administered the finasteride at 1:00 PM instead of the ordered 8:00 PM time. The DON confirmed that this medication should have been administered at 8:00 PM and that both missed doses and medications given at the wrong time are considered medication errors under facility policy.
Failure to Obtain Treatment Orders for Identified Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders for treatment of an identified pressure ulcer. Facility policy on Wound Treatment Management, dated 08-2025, required that wound treatments be provided in accordance with physician orders, including cleansing method, dressing type, and frequency, and that in the absence of treatment orders the licensed nurse would notify the physician to obtain such orders. Record review showed that a resident, admitted on a specified date and assessed via the MDS as unable to make themselves understood and needing partial to total assistance with mobility, ADLs, and toileting, had a sacral pressure ulcer measuring 2.0 by 1.0 cm documented on an admission/readmission assessment dated 01-09-2026. However, review of the resident’s Order Summary printed on 03-02-2026 revealed no treatment order for the sacral pressure ulcer. In an interview, an RN confirmed the resident had a sacral pressure ulcer, that the physician had not been notified, and that an order for treatment had not been obtained as required.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Safe Bathing Water Temperatures
Penalty
Summary
The facility failed to ensure that bathing and showering water temperatures did not exceed 110 degrees Fahrenheit, as required to prevent potential accidents. Multiple records and logs reviewed showed that water temperatures in various bathhouses and tubs consistently ranged from 111.4 to 116.4 degrees Fahrenheit, exceeding the facility's stated maximum safe bathing temperature. Observations conducted with the Regional Lead Maintenance confirmed that water temperatures in both the 100-hall and 200-hall bathhouses were above the 110-degree threshold. The facility's policies referenced a safe water temperature range of 98.6 to 120 degrees Fahrenheit, but staff interviews confirmed that the maximum for bathing should be 110 degrees Fahrenheit, and this standard was not met. The Resident Listing Report indicated that out of 45 residents, 22 were cognitively impaired and bathed in the bathhouses where the elevated water temperatures were recorded. Staff interviews confirmed that these residents, due to cognitive impairment, would be particularly vulnerable to the effects of excessively hot water. The facility did not have a policy specific to bathing in a tub, and the maintenance staff was responsible for checking and logging water temperatures, which were found to be above the safe limit on multiple occasions.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Facility staff failed to evaluate, monitor, and implement timely interventions for pressure ulcer prevention and wound healing for two residents. One resident, admitted with a right hip fracture and existing skin issues including a surgical incision, maceration to the sacrum, and redness on the left heel, was assessed as at risk for pressure ulcers and required pressure-relieving surfaces. Despite these risks, there was no evidence that staff implemented interventions to prevent further skin breakdown on the left heel. The resident subsequently developed a stage 3 pressure ulcer on the left heel, which worsened over time. Treatment orders were not obtained promptly, and wound care was not initiated until several days after the ulcer was identified, resulting in a decline in the wound's condition. Another resident, with moderate cognitive impairment and extensive care needs, was also identified as at risk for pressure ulcers and had interventions in place on the care plan, such as regular repositioning and pressure-reducing surfaces. However, an open area was noted on the left side of the back, and later, open wounds were observed on both the left back and sacrum. There was no documentation of wound resolution, no treatment orders for these wounds, and the wounds had not been measured or assessed as required. Staff confirmed that these wounds had not been properly evaluated or treated. The facility's own policy requires a systematic approach to pressure injury prevention and management, including prompt assessment, intervention, and monitoring. However, in both cases, staff did not follow these protocols, resulting in unaddressed and worsening pressure ulcers. The deficiencies were confirmed through record review, staff interviews, and direct observation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide bathing services in accordance with the preferences of four residents, as identified through interviews and record reviews. Each resident had documented preferences for receiving two baths or showers per week, as indicated in their care plans or preference forms. However, facility records for March and April 2025 showed that these residents did not receive the number of baths or showers they preferred. For example, one resident with severe cognitive impairment and requiring total assistance for bathing received only five baths over an eight-week period, instead of the expected sixteen. Another resident, who was cognitively intact and required extensive assistance, received only three baths over a five-week period, instead of the expected ten. Similar discrepancies were found for the other two residents, with one resident refusing a bath on one occasion, but otherwise not receiving the preferred number of showers. The residents involved had varying levels of cognitive and physical impairment, as assessed by the Minimum Data Set (MDS), and all required significant assistance with bathing and other activities of daily living. The facility's own policy emphasized the right of residents to self-determination and to make choices about their care, including bathing schedules. Despite this, the facility did not honor the residents' stated preferences for bathing frequency, as confirmed by the Director of Nursing during an interview. This failure to provide care in accordance with resident choice constitutes a deficiency in supporting resident rights and self-determination.
Failure to Notify Practitioner of New Pressure Ulcers
Penalty
Summary
Facility staff failed to notify the medical practitioner of new pressure ulcers for two residents. For one resident, staff identified a skin issue on the left heel and obtained a one-time order to wash and cover the wound, but when a Nurse Practitioner assessed the area the following day and identified it as a stage 3 pressure ulcer, no treatment orders were obtained, and the practitioner was not notified to request further treatment. The resident was cognitively intact and required varying levels of assistance with daily activities. For another resident, staff noted an open area on the left side of the back, but there were no treatment orders for this wound or for a wound on the sacrum, as confirmed by a review of the treatment administration record. The DON confirmed that the practitioner was not notified of the wound until the day of the survey. The facility's policy requires prompt notification of the practitioner and resident representative when a change in condition necessitates new or altered treatment, which was not followed in these cases.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with its policy and federal requirements to post daily nurse staffing information at the beginning of each shift. This information should include the facility name, date, current resident census, and the total number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides responsible for resident care. Observations on multiple dates revealed that the required nurse staffing information was not posted anywhere in the facility, which could potentially affect all 44 residents residing there. The Director of Nursing confirmed during an interview that the daily nurse staffing information had not been posted as required. The facility's policy, dated August 2023, mandates that this information be made readily available in a readable format to residents and visitors, updated to reflect any staff absences, and maintained for a minimum of 18 months. Despite these guidelines, the facility did not adhere to the policy, resulting in a deficiency noted by the surveyors.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as observed during an inspection. Specific issues included scrapes on walls behind beds and in bathrooms, stained areas of the floor around toilet bases, and scrapes on closet doors in multiple rooms. Additionally, there were cracked bathroom sinks, closet doors pulled off tracks, cracks in linoleum, and missing or loose transition strips between bathrooms and rooms. Some rooms also had non-functioning lights above beds, loose toilet roll holders, and ventilation covers coated with a gray fuzzy substance. These deficiencies were confirmed during an environmental tour with the Regional Director of Operations and the Maintenance Director. The Maintenance Director acknowledged the need for cleaning and repairs but confirmed that there were no active work orders for the identified concerns. The facility's census at the time was 44, with 33 occupied resident rooms, and the issues were noted in 9 of these rooms.
Failure to Secure Medications and Treatments in Medication Carts
Penalty
Summary
The facility failed to secure residents' medications and treatments in medication carts, as observed on multiple occasions. On 5/1/24 at 6:52 AM, a medication cart next to an office was found unlocked and unattended. Further observations revealed two additional unlocked and unattended carts down the 200 hall. At 7:13 AM, a Registered Nurse (RN) was seen entering a resident's room for a treatment, leaving the treatment cart unlocked in the hallway. Again, at 8:32 AM, the same RN was performing a treatment in another resident's room with the door open, leaving the treatment cart unlocked and out of view in the hallway. The RN confirmed that the cart should not be left unlocked and unattended, explaining that the cart was left unlocked when the RN went to let someone into the building without locking it first. An interview with the Administrator on 5/2/24 at 8:40 AM revealed that the facility has 15 self-ambulatory residents, 7 of whom have cognitive impairments. The Administrator confirmed that medication and treatment carts should be locked unless a nurse is actively preparing a treatment or medication. The facility's policy on medication storage mandates that all drugs and biologicals be stored in locked compartments under proper conditions, which was not adhered to in these instances.
Failure to Obtain Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility staff failed to obtain treatment orders for pressure ulcers for two residents. Resident 1 was readmitted to the facility with a pressure ulcer on the left lateral foot, but the facility did not evaluate the skin condition or obtain treatment orders. Observations revealed the presence of eschar on the left lateral foot, but no treatment orders were found in the medical records, progress notes, care plan, or medication administration records. Interviews with the RN and ADON confirmed the absence of treatment orders for the wound on Resident 1's left foot. Similarly, Resident 3 was admitted to the facility with a pressure wound on the left heel, but no treatment orders were documented. The wound was observed to be unstageable with moderate serosanguineous drainage. Interviews and record reviews confirmed that there were no orders for wound care for Resident 3's left heel. Both cases highlight the facility's failure to obtain necessary treatment orders for pressure ulcers, leading to deficiencies in care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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