Adept Nursing & Rehab Of North Platte
Inspection history, citations, penalties and survey trends for this long-term care facility in North Platte, Nebraska.
- Location
- 510 Centennial Circle, North Platte, Nebraska 69101
- CMS Provider Number
- 285094
- Inspections on file
- 22
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of North Platte during CMS and state inspections, most recent first.
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.
Two residents experienced significant medication errors when ordered drugs were not available or not initiated as required. One resident with dental pain and infection had an antibiotic ordered by a dentist and faxed to the pharmacy, but the order was never entered into the electronic record, and the first dose was not given as scheduled. Another resident with Type 2 DM had a standing weekly Ozempic injection order, but the last administering nurse did not reorder the medication after the prior dose, leaving no dose available on the next due date. These failures occurred despite facility policies requiring timely initiation of new medications and reordering when supplies were low.
Multiple deficiencies were identified in dietary services, including improper labeling and storage of food items, failure of staff to wear required beard covers, storage of clean utensils near chemicals, handling of ready-to-eat foods without gloves, and use of a handwashing sink for food preparation water. These actions were inconsistent with facility policy and food safety codes, potentially affecting all residents.
A resident's discharge record lacked the required recapitulation summary of their stay, as the facility's process did not include this documentation and the SSD was unaware of the regulatory requirement.
A resident with moderate cognitive impairment was found to have bed canes in use without documentation or care plan inclusion, despite facility policy requiring clinical indication for such equipment. The resident was unaware of the reason for the bed canes, and the ADON confirmed the omission in the care plan.
A resident admitted after ankle surgery for osteomyelitis and cellulitis did not have wound care orders or a documented weight-bearing status upon admission. The dressing was not changed or assessed, and staff were unclear about mobility restrictions, resulting in a lack of appropriate wound care and guidance.
Two residents experienced significant weight loss due to the facility's failure to provide necessary assistance and interventions during meals. Despite care plans indicating nutritional risk and the need for prompting or set-up help, staff did not consistently assist or cue residents, and meal intake was often poorly documented. Providers and the dietitian were not promptly notified of ongoing weight loss, and staff lacked clear guidelines for addressing inadequate food intake.
A resident with multiple medical conditions and total dependence on staff for care was repeatedly observed in bed, wearing the same soiled gown, with unkempt hair and without proper assistance for daily activities. Staff interviews confirmed that required morning and evening cares, including dressing and grooming, were not provided as expected, and the resident was not assisted to get out of bed despite being alert and not actively dying.
Two nurse aides did not don the required PPE, except for gloves, while providing high-contact perineal and catheter care to a resident with a urinary catheter, despite an EBP sign on the door and knowledge of the facility's infection control policy. Both the aides and the DON confirmed that the required PPE should have been used during this care.
The facility failed to identify causative factors and implement interventions for falls for three residents and did not develop interventions for a resident at risk for elopement. One resident with vascular dementia experienced multiple falls without appropriate interventions, leading to hospitalizations. Another resident with severe cognitive impairment had repeated falls without causative factors being identified or appropriate interventions. A third resident's fall lacked root cause analysis and interventions, while a resident at risk for elopement had no care plan focus or interventions, and staff were unaware of the risk.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing pain management, assistance with daily activities, and specific medical needs such as ostomy and dialysis care. These omissions were identified through record reviews, observations, and interviews, highlighting a lack of updated and complete care plans for residents with various medical conditions.
The facility failed to administer medications at the correct times for three residents, resulting in a medication error rate of 12%. A resident received Novolog after starting a meal, another received glipizide while eating, and a third received Prostat late due to a request. These errors were confirmed by staff interviews.
The facility failed to prevent cross-contamination by leaving clean linen carts uncovered and unattended during laundry distribution. Additionally, a resident's nebulizer mask was not cleaned or stored properly, as it was found with residue and undated, contrary to the facility's policy.
A facility failed to accurately code a resident's MDS, indicating full dependency for transfers, while observations and staff interviews showed the resident required limited to extensive assistance from one staff member. The MDS Coordinator was unsure why the resident was coded as dependent, despite documentation showing otherwise.
A resident did not have a TSH lab test completed as ordered by the physician. The resident was admitted in November 2023 and had an order for an annual TSH test starting in September 2022. Despite having a medication order for Levothyroxine, the last TSH lab was conducted in September 2022, and no further tests were found. The DON confirmed the oversight.
A facility failed to follow its dialysis care policy for a resident, as there was no documentation of required assessments for the AV graft site or dialysis catheter. Interviews revealed that nursing staff did not routinely check dialysis sites or document assessments, as confirmed by the DON. This resulted in a lack of necessary assessments and documentation for the resident's dialysis care.
A facility failed to provide a clinically valid rationale for continuing a psychotropic medication for a resident. The facility's policy requires gradual dose reductions unless contraindicated. A pharmacist recommended a dosage reduction for the resident's sertraline, but the physician claimed it was contraindicated without a valid clinical reason. The DON confirmed the rationale was not clinical.
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.
Failure to Ensure Timely Initiation and Continuation of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to timely initiation and continuation of ordered medications. Facility policy required that medications be obtained and administered in a timely manner, with new orders to be started within 24 hours unless otherwise specified, and that nurses reorder medications when six or fewer doses remained. Despite this, the process for entering and obtaining medications from the pharmacy did not function as intended, resulting in missed doses for two residents. For one resident admitted with dental pain and infection, a dentist evaluated the resident and prescribed Augmentin to be given twice daily for 10 days, with the medication to be delivered by the pharmacy. The LPN on duty documented faxing the new antibiotic order to the pharmacy on the day of the dental visit. The following morning, when the resident complained of significant jaw pain and stated they had not received the antibiotic, the LPN confirmed there was no antibiotic listed in the resident’s electronic orders and contacted the pharmacy. The pharmacy reported the medication was at the facility, but the order had not yet been entered into the medical record, and the resident had not received the first dose the day it was ordered. For another resident with a primary diagnosis of Type 2 Diabetes Mellitus, the Medication Administration Record showed an ongoing order for Ozempic 2 mg to be injected once weekly at 7:00 AM. On the scheduled administration date, the LPN was unable to locate the Ozempic on the medication cart or in the medication storage room and confirmed that the injection due that morning could not be given. The LPN later verified that the last person who administered the weekly Ozempic dose had not reordered the medication when the previous dose was given, contrary to facility practice for once-weekly medications. The DON confirmed that the last nurse to administer the Ozempic was responsible for reordering it and that this had not occurred, resulting in a missed scheduled dose.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. In the kitchen, concentrated juice containers were not labeled with open dates, and some items were kept past their recommended shelf life, contrary to facility policy and manufacturer guidelines. Additionally, syrup and juice products were found with expired or missing open dates, and the Dietary Manager confirmed these items were not safe or suitable for resident use. Staff in the kitchen, including the Dietary Manager, cooks, and dietary aides, were observed not wearing beard covers despite having facial hair, which was inconsistent with facility policy requiring hair restraints for staff with facial hair longer than a quarter inch. Clean grill cleaning tools were stored in an uncovered pan next to cleaning chemicals under a sink used for dirty dishes, violating both facility policy and the Nebraska Food Code regarding the separation of clean and dirty items and the storage of toxic materials. Further, a cook was observed handling ready-to-eat food, such as sandwich buns, with bare hands instead of wearing gloves, despite facility policy mandating glove use for direct contact with ready-to-eat foods. Water for food preparation and the steam table was dispensed from a handwashing sink, which is prohibited by the Nebraska Food Code, and staff were unaware of this requirement. These actions and inactions had the potential to affect all residents in the facility.
Failure to Document Required Recapitulation Summary at Discharge
Penalty
Summary
The facility failed to document a recapitulation, which is a complete summary of a resident's stay from admission to discharge, for a resident who initiated their own discharge. Record review showed that the discharge summary and plan of care for this resident did not include the required recapitulation summary. During an interview, the Social Service Director confirmed that the recapitulation summary was not part of the facility's discharge process and that they were unaware of the regulatory requirement for this documentation.
Failure to Include Repositioning Bars in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing the use of repositioning bars for a resident with moderate cognitive impairment. Record review showed that the facility's policy requires positioning rails to be used only when clinically indicated. The resident was observed with two bed canes on the bed, but there was no documentation in the care plan regarding their use. The resident was unaware of the reason for the bed canes and stated they were present upon admission. The Assistant Director of Nursing confirmed that the care plan did not include the use of bed canes, despite their presence and the resident's assessed needs.
Failure to Assess Wound and Obtain Wound Care Orders
Penalty
Summary
The facility failed to assess a wound and obtain appropriate wound care orders for a resident who was admitted following right ankle surgery for osteomyelitis and cellulitis. Upon admission, there was no documentation of wound care orders or clarification of the resident's weight-bearing status in the physician orders. The resident reported that their dressing had not been changed since arrival and that no one had examined the wound. Nursing staff confirmed that no dressing change or wound assessment had occurred since admission, and there was no order specifying the resident's weight-bearing status. Further interviews revealed uncertainty among staff regarding the resident's transfer status, with some believing the resident was non-weight bearing but lacking confirmation. The Rehab Services Director later produced hospital discharge paperwork indicating a non-weight bearing order, but this information had not been incorporated into the facility's orders or communicated to the care team. As a result, the resident did not receive the necessary wound care or clear guidance on mobility restrictions as required by their condition and post-surgical needs.
Failure to Implement Interventions to Prevent Resident Weight Loss
Penalty
Summary
The facility failed to implement appropriate interventions to prevent significant weight loss in two residents, despite clear evidence of nutritional risk and inadequate food and fluid intake. For one resident with dementia, records showed a 12.1% weight loss over three months, with the care plan identifying nutritional risk and requiring prompting, cueing, and set-up assistance for meals. Observations revealed that this resident was not assisted during meals, was seated too far from the table, and consumed less than 25% of their food at lunch without staff intervention. Additionally, there was no evidence that the facility contacted a provider or dietitian regarding the resident's ongoing weight loss, and meal intake documentation was incomplete for several meals. Another resident, admitted with a femur fracture, experienced a 5.9% weight loss in one month. The care plan required dietitian evaluation and set-up or clean-up assistance with eating. However, documentation showed frequent meal refusals or minimal intake, and staff did not consistently provide assistance or cueing during meals. Observations indicated that the resident was left with a meal tray out of reach and in a poor eating position for over an hour without staff intervention. The provider was not notified of the weight loss, and the dietitian did not review the resident's case during a recent consultation. Interviews with staff revealed a lack of clear guidelines for addressing poor meal intake and inconsistent understanding of which residents required assistance. Staff relied on care plans and meal slips for information but did not consistently offer or provide assistance when residents were not eating. The facility's approach to addressing poor intake and weight loss was described as case-by-case, with no evidence of timely or effective interventions for the residents identified in the report.
Failure to Assist Dependent Resident with Activities of Daily Living
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, admitted with diagnoses including acute kidney failure, COPD, muscle weakness, repeated falls, and anxiety, was documented as requiring set-up assistance with eating and being dependent for all other cares such as dressing, bathing, toileting, and transferring. Observations over two days showed the resident remained in bed, wearing the same soiled hospital gown, with disheveled hair and an unkempt appearance. The resident's oxygen tubing was repeatedly found draped over the abdomen and not in use, despite the concentrator being on. The bedside table was noted to be unclean at one point. The resident reported not being assisted to get up for meals and indicated that staff did not get them up, stating there was "no need to." Interviews with staff confirmed that the resident was totally dependent on staff for care and that expectations included assisting all residents with morning and evening cares, including dressing, grooming, and getting out of bed. Staff acknowledged that the resident was not actively dying and was alert enough to get out of bed, but had not been assisted to do so. The DON confirmed that the resident should not be left in a gown for staff convenience, that daily care and documentation of refusals were required, and that a more rigorous repositioning schedule should be implemented if the resident chose to remain in bed. The failure to provide these required cares constituted a deficiency in meeting the resident's needs for assistance with ADLs.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Nurse aides failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing high-contact care to a resident with a urinary catheter. The EBP policy, dated 4/1/24, required the use of gowns, gloves, and masks during high-contact activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care. During an observation, two nurse aides transferred a resident from a wheelchair to a bed using a hoyer lift and performed perineal and catheter care. Although an EBP sign was posted on the resident's door, indicating the need for PPE, the aides only wore gloves during care and did not don the required gowns or masks. Interviews with both nurse aides confirmed their knowledge of the EBP policy and its requirements, as well as their awareness that the resident was on EBP due to the urinary catheter. Both acknowledged that they should have applied the required PPE prior to providing care. The Director of Nursing also confirmed that staff are expected to use PPE for all high-contact care activities and that the aides did not follow this expectation during the observed incident.
Failure to Address Fall and Elopement Risks
Penalty
Summary
The facility failed to identify causative factors and implement new interventions for falls for three residents and did not develop interventions for one resident at risk for elopement. Resident 1, who had vascular dementia and repeated falls, experienced multiple falls without appropriate interventions being implemented. The facility's policy did not include identifying causative factors of falls, and the care plan for Resident 1 lacked updates after falls, leading to repeated incidents and hospitalizations. Resident 4, with severe cognitive impairment and repeated falls, also experienced multiple falls without causative factors being identified or appropriate interventions being implemented. The facility's failure to identify causative factors and implement suitable interventions resulted in repeated falls for Resident 4, with some interventions being duplicates or inappropriate for the identified causes. Resident 3, with moderate cognitive impairment and repeated falls, had a fall where the root cause analysis and interventions were not completed. Additionally, Resident 5, who was at risk for elopement, was not provided with a care plan focus, goals, or interventions related to elopement, and staff were unaware of the resident's risk and the presence of a Wanderguard.
Removal Plan
- Fall assessment upon admission
- Elopement assessment upon admission
- Environmental check for Residents 3 and 4 to ensure room is free of clutter and fall hazards, with new interventions implemented as indicated
- Resident 5 Wander guarded location and functionality order to monitor was placed on the TAR and Care Plan updated to reflect elopement risk
- All staff present will be educated regarding fall prevention, root cause analysis, and elopement, and all other staff will be educated prior to working their next shift
- A Fall Risk assessment will be completed on all HC residents, and any resident identified as at risk for falls will have appropriate interventions implemented and care plan updated
- An Elopement assessment will be completed on all HC residents, and any resident identified as at risk for elopement will have appropriate interventions implemented and care plan updated
- Fall Care Plan created upon admission and reviewed quarterly and as indicated by Fall assessment score
- Residents at risk for falls will have fall care plans (baseline initially) and comprehensive care plan with interventions in place
- With each fall, a post fall assessment will be completed, and a root cause analysis will be completed to determine the cause of the fall, and appropriate interventions will be added to prevent a recurrence
- Residents at high risk for elopement as identified by the Elopement assessment score will be provided a wander guard, they will be added to the elopement binder, and an order for monitoring the device will be placed in the orders (location and functionality) every day and night shift
- Risk for elopement will be placed on the care plan with interventions
- Staff will be educated on the location of the Elopement book at the nurse's station, a reminder sign will be added to the staff bulletin board, and a list posted on the facility bulletin board in PCC
- Falls will be reviewed daily in Daily Clinical
- Administrator or Designee will utilize the fall review checklist to audit fall review, Root Cause analysis, and intervention implementation
- Falls will be reviewed weekly in Risk meeting to ensure interventions are effective and if not, new interventions will be implemented
- Administrator or Designee will audit fall review in risk
- Elopement assessment scores will be reviewed upon admission in Daily Clinical
- Administrator or Designee will audit Elopement assessment scores to ensure appropriate interventions are in place
Deficiencies in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, as evidenced by record reviews, observations, and interviews. Resident 22's care plan did not address their pain management needs, despite having multiple diagnoses related to pain and receiving various pain medications. The care plan lacked interventions for both routine and as-needed medications, which was acknowledged by the facility leadership as an issue of outdated information. Resident 48's care plan was incomplete, missing critical information regarding assistance needs for activities of daily living such as eating, ambulation, dressing, personal hygiene, and bathing. Similarly, Resident 54's care plan did not include necessary details about assistance needs for eating, toileting, dressing, personal hygiene, or bathing, despite the resident's documented requirements for such assistance. Additional deficiencies were noted for other residents. Resident 28's care plan did not address the limited range of motion and need for positioning devices for their left hand, which was observed to be closed and without protective devices. Resident 29's care plan lacked documentation of their ostomy care, despite the presence of an ostomy bag and the resident's acknowledgment of staff care. Lastly, Resident 30's care plan did not include focus or interventions for dialysis, even though the resident had a diagnosis of End Stage Renal Disease and was receiving dialysis care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered at the correct times for three residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of less than 5%. Resident 10 was supposed to receive Novolog 15 minutes before meals, but it was administered after the resident had already started eating. Similarly, Resident 21 was to receive glipizide 30 minutes before meals, but it was given while the resident was eating. These errors were confirmed through interviews with the staff involved. Additionally, Resident 11 was supposed to receive Prostat at 9:00 AM, but it was administered late at 11:54 AM because the resident requested it be given at lunch. This deviation from the prescribed schedule was also confirmed by the medication aide. These instances highlight the facility's failure to adhere to medication administration schedules as per physician orders, contributing to the high medication error rate.
Infection Control Deficiencies in Laundry and Nebulizer Equipment
Penalty
Summary
The facility failed to distribute residents' laundry in a manner that prevented potential cross-contamination. Observations revealed that the Laundry Supervisor (LS) distributed clean laundry without using protective coverings. The LS left the clean linen cart uncovered and unattended while delivering laundry to resident rooms, which was against the facility's Infection Prevention and Control Program policy. This policy required that clean linen be delivered on covered carts with the covers down to prevent the spread of infection. Additionally, the facility did not ensure the cleanliness of nebulizer equipment for Resident 29, who had a diagnosis of lobar pneumonia and was at risk for respiratory issues. The nebulizer mask was observed to be unassembled, undated, and with dry whitish residue on the inside, indicating it was not cleaned as per the facility's Nebulizer Therapy Policy. This policy required the nebulizer mask to be cleaned with soap and water after each use and stored properly. The Director of Nursing confirmed the mask's condition and acknowledged that it did not meet the facility's expectations for cleanliness and storage.
Inaccurate MDS Coding for Resident Assistance Level
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for one resident was accurately coded to reflect the current level of assistance required. Specifically, Resident 13's MDS indicated that the resident was dependent on staff for transfers, meaning the helper does all the effort, or that two or more helpers are required. However, observations and interviews revealed discrepancies in this assessment. During an observation, a nurse aide assisted Resident 13 in transferring from bed to wheelchair, with the resident actively participating by sitting up and scooting to the edge of the bed. Interviews with staff indicated that Resident 13 required limited to extensive assistance from one staff member for transfers, rather than being fully dependent. The MDS Coordinator, responsible for completing Section GG of the MDS, relied on interviews with nurse aides and information from the therapy department. The coordinator also mentioned using a new assessment tool available in the electronic medical record system. Despite these resources, the coordinator was unsure why Resident 13 was coded as dependent, suggesting that behaviors requiring two staff assistance might have influenced the coding. However, the facility's documentation for the months leading up to the survey consistently showed that Resident 13 required only limited to extensive assistance from one staff member for transfers.
Failure to Complete Annual TSH Lab Test for Resident
Penalty
Summary
The facility failed to ensure that a resident had laboratory tests completed as per the physician's order. Resident 5, who was admitted to the facility on November 14, 2023, had a physician's order for an annual Thyroid-stimulating hormone (TSH) lab test. The order was documented in the Treatment Administration Review (TAR) for June 2023, with a start date of September 15, 2022. Additionally, the Medication Administration Review (MAR) for June 2023 included an order for 75 mcg of Levothyroxine to be administered daily, indicating a need for thyroid management. However, a review of the resident's medical chart revealed that the last TSH lab results were dated September 16, 2022, and no subsequent TSH labs were found. The Director of Nursing (DON) confirmed in an interview on June 24, 2024, that the TSH lab had not been completed since September 16, 2022.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to adhere to its policy for providing safe and appropriate dialysis care for a resident requiring such services. The policy, dated 8/1/23, mandates that the dialysis access site be checked before and after dialysis treatments, with the dialysis graft auscultated every shift for patency by listening for a bruit/thrill. Additionally, external dialysis catheters should be assessed every shift to ensure the catheter dressing is intact and not soiled. However, a review of Resident 30's records from 3/2/24 to 6/25/24 revealed no documentation of assessments for the bruit/thrill of the AV graft site, monitoring for signs or symptoms of infection, drainage, or dressing status for the resident's two dialysis access sites, or the application of ointment prior to dialysis. Interviews conducted with Resident 30 and facility staff further confirmed these deficiencies. Resident 30 reported that nursing staff did not routinely check the dialysis sites, listen for a bruit/thrill, or remove the dressing upon return to the facility. A Registered Nurse acknowledged that nursing staff are responsible for assessing dialysis sites and documenting these assessments, but the Director of Nursing confirmed the absence of such documentation in the treatment record or nurses' notes for Resident 30. This lack of adherence to the facility's dialysis care policy resulted in a failure to provide the necessary assessments and documentation for the resident's dialysis care.
Failure to Provide Clinical Rationale for Psychotropic Medication Continuance
Penalty
Summary
The facility failed to obtain a clinically valid rationale for the continuance of a psychotropic medication for one resident. The facility's policy on the use of psychotropic medication, last revised on 4/24/2023, requires residents to receive gradual dose reductions unless clinically contraindicated. A review of the Minimum Data Set (MDS) for the resident, who was cognitively intact with a Brief Interview for Mental Status score of 14, revealed an order for sertraline 100 mg. The pharmacist identified the need for a dosage reduction, but the physician responded that a reduction was clinically contraindicated without providing a valid clinical rationale. An interview with the Director of Nursing confirmed that the rationale provided was not clinical.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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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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