Adept Nursing & Rehab Of South Sioux City
Inspection history, citations, penalties and survey trends for this long-term care facility in South Sioux City, Nebraska.
- Location
- 3501 Dakota Avenue, South Sioux City, Nebraska 68776
- CMS Provider Number
- 285076
- Inspections on file
- 22
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of South Sioux City during CMS and state inspections, most recent first.
A resident with multiple serious diagnoses, including ESRD, heart failure, cellulitis, hepatic encephalopathy, and morbid obesity, experienced progressive changes in condition, including loss of appetite, refusal of all meals, lethargy, weakness, and an SpO2 of 88%, followed by findings of a pale appearance and a bright red, edematous, warm, and tender stump that was later diagnosed as cellulitis. Despite a facility policy requiring prompt physician notification for significant changes in condition, the MD was not notified until the following day when the stump changes were observed and the resident was then sent to the ED. Separately, the same resident’s weight increased from 390 to 415 pounds over a short period, representing a significant weight gain without a prescribed weight‑gain regimen, and there was no evidence that the physician was notified of this weight change.
A resident with CHF, atrial fibrillation, hypertension, and renal insufficiency was not weighed as ordered on two consecutive days after admission, despite physician orders for daily weights to monitor the effects of diuretic therapy. Both the ADON and DON confirmed the omission.
A resident with severe cognitive impairment and an ear infection experienced a delay in treatment due to the facility's failure to promptly notify a physician of a change in condition. Despite attempts to contact the resident's medical practitioner and an alternate, there was no follow-up documentation or response until an antibiotic was ordered days later.
The facility experienced significant delays in responding to residents' call lights due to a shortage of pagers and walkie-talkies. A resident with a history of cerebral infarction and a fracture waited over two hours for assistance after activating the call light, with several other instances of delayed responses noted. Staff interviews confirmed the lack of necessary equipment, and the facility's call light monitoring system was inadequate, contributing to the deficiency.
A resident with a bleeding wound on blood thinners experienced a significant delay in receiving care due to a call light not being answered for over two hours. Despite the facility's expectation for call lights to be answered within 15-20 minutes, the resident's call light was not addressed until a family member intervened. The resident's care plan included monitoring the wound, but there was a lack of timely documentation and intervention, leading to a deficiency in care.
The facility's kitchen was found to have multiple food safety and sanitation deficiencies, affecting 48 of 49 residents. Observations included undated and unlabeled food items, frost buildup on the freezer door, and dirty surfaces in the dishwashing area. The kitchen preparation area had dust and grease buildup, and the flooring was uncleanable due to unsealed patches. These issues were confirmed by the Certified Dietary Manager, indicating a failure to comply with Nebraska Food Code regulations.
The facility failed to maintain a clean and comfortable environment, with stained carpets, a strong urine smell in a room, and dusty ventilation covers. Additionally, a shared toilet lacked doors, and a privacy curtain was missing, compromising resident privacy.
Facility staff failed to perform hand hygiene after glove changes during care for two residents, leading to potential cross-contamination. Observations showed that staff placed washcloths in the sink and used them without barriers, and did not perform hand hygiene between glove changes. Interviews confirmed these practices contradicted facility policies, and the DON acknowledged the risk of cross-contamination.
The facility failed to provide timely written notification of hospital transfers for a resident and their representative, and did not notify the Ombudsman for two residents. One resident was transferred twice without receiving a bed hold notice, and the Ombudsman was not informed of another resident's hospital transfers. The Social Services Director and Designee confirmed these lapses.
The facility failed to provide written bed hold notices to two residents during hospital transfers, as required by policy. One resident was transferred twice without receiving a notice, and another resident did not receive notices for two of their transfers. The Social Services Director confirmed these omissions.
A facility failed to accurately complete a PASARR for a resident admitted with Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. The PASARR Level 1 screening incorrectly assessed the resident as having no diagnosis of SMI or ID/RC. The Social Services Director confirmed the inaccuracy, noting that a Level 2 screen was necessary based on the resident's diagnoses.
A resident with multiple health conditions did not receive timely skin evaluations and treatments as per the prescribed schedule. The resident's records showed missing documentation for skin assessments, and evaluations revealed worsening skin maceration. Despite treatment orders for skin breakdown prevention, there was inconsistent documentation and adherence to the treatment schedule.
A facility failed to follow the prescribed wound care treatment for a resident's left heel ulcer. The treatment administration record indicated a daily skin prep order, but a nurse applied Betadine instead. The DON confirmed the treatment should have been skin prep, and the nurse was unaware of the current order.
A resident with severe cognitive impairment and multiple health conditions experienced a fall due to the facility's failure to implement recommended interventions. Staff were observed transferring the resident without using Dycem to prevent slipping, despite it being documented in the care plan. Interviews revealed staff were unaware of this intervention.
A resident with moderately impaired cognition was prescribed Novasource renal formula at a specific rate, but it was administered via gravity without a physician's order. Nursing staff, including an LPN and RN, were unaware of the correct formula, rate, and flush amount, and the DON confirmed the lack of a physician's order for gravity administration.
A facility failed to identify and monitor specific behaviors for a resident receiving psychotropic medications. Despite the resident being cognitively intact and having multiple diagnoses, including bipolar disorder, the facility did not document targeted behaviors in the resident's medical records or care plan. This was confirmed by the DON, indicating non-compliance with the facility's policy on psychotropic medication use.
Failure to Notify Physician of Change in Condition and Significant Weight Gain
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician of significant changes in condition, including symptoms related to cellulitis and a substantial weight gain. The facility’s own “Notification of Changes” policy required prompt physician consultation and notification of the resident and representative for significant physical changes, deterioration in health status, or circumstances requiring alteration of treatment. The resident had multiple serious diagnoses, including alcohol cirrhosis of the liver, anemia, end stage renal disease, depression, cellulitis, hepatic encephalopathy, morbid obesity, and heart failure. The MDS dated 2/18/26 documented that the resident’s cognition was intact, the resident reported feeling down or depressed, and had a weight of 411 pounds with a weight gain of 5% or more in the last month or 10% or more in the last six months, without being on a prescribed weight gain regimen. Nursing progress notes showed that on 11/28/25 staff documented that the resident did not look good, had loss of appetite, did not eat breakfast, and was very drowsy. Throughout that day, the resident refused lunch and dinner due to poor appetite, reported feeling tired with little energy, remained lethargic and weak, and refused hospitalization when suggested by staff. Later that evening, the resident’s oxygen saturation was documented at 88%, and there was no further documented assessment after 9:53 PM until 10:30 AM the next day, when the resident was noted to be pale with flushed cheeks and a left stump that was bright red, edematous, warm, and tender; only then was the physician notified and the resident sent to the emergency room, where the resident was admitted for cellulitis. Additionally, weight records showed an increase from 390 pounds on 2/3/26 to 412 pounds on 2/10/26 (a 22‑pound, 6% gain in one week), and then 415 pounds on 2/12/26, with no evidence that the physician was notified of this significant weight gain.
Failure to Complete Ordered Daily Weights for Resident on Diuretic Therapy
Penalty
Summary
The facility failed to follow physician's orders for a resident who had multiple significant health conditions, including atrial fibrillation, congestive heart failure (CHF), hypertension, and renal insufficiency. The resident was prescribed a diuretic for CHF and had admission orders for daily weights for four days, followed by weekly weights for four weeks, to monitor the effects of the medication. Record review showed that the resident's daily weights were not completed on two consecutive days as ordered. This was confirmed by both the Assistant Director of Nursing and the Director of Nursing, who acknowledged that the required weights were not obtained on the specified dates.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, leading to a delay in treatment. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 4, required extensive assistance with daily activities. On October 7, 2024, the resident exhibited a fever of 101.5 degrees and had tenderness and drainage from the left ear, suggesting an ear infection. The facility attempted to contact the resident's medical practitioner, who was unavailable, and was advised to reach out to an alternate practitioner. Despite the resident's ongoing symptoms, there was no documentation of follow-up actions on October 8, 2024, and no response was received from the alternate practitioner by October 9, 2024. A fax was sent to the original medical practitioner, but the facility did not receive a response until October 10, 2024, when an antibiotic was finally ordered. The facility administrator confirmed that there was a delay in treatment and acknowledged that the facility should have contacted the practitioner again the following day if no response was received.
Delayed Response to Call Lights Due to Equipment Shortage
Penalty
Summary
The facility failed to ensure that staff were promptly notified of residents' calls for assistance, as evidenced by multiple instances of delayed response times to call lights. Resident 3, who was cognitively intact and had a history of cerebral infarction and a fracture, experienced significant delays in receiving assistance. On one occasion, Resident 3 activated the call light at 6:27 AM due to bleeding from a scratch and waited over two hours without a response, eventually requiring a family member to intervene. The call light log showed several other instances where Resident 3's calls went unanswered for extended periods, ranging from 23 to 114 minutes. Further review of call light activity reports for other residents revealed similar issues. Resident 2 experienced delays ranging from 22 to 65 minutes, while Resident 1 had call light response times ranging from 28 to 44 minutes. Observations indicated that the facility's call light monitoring system was inadequate, with monitors placed in locations not visible to staff working in various hallways. Staff interviews confirmed that they lacked pagers or walkie-talkies, which hindered their ability to promptly respond to call lights. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the shortage of pagers and walkie-talkies, which contributed to the delayed response times. The Administrator was unaware of the pager shortage and confirmed that staff had to leave their work areas to check call light monitors. The facility's expectation was for call lights to be answered within 15-20 minutes, but the current system and equipment shortages made it difficult to meet this standard, leading to the identified deficiency.
Delayed Response to Resident's Bleeding Wound
Penalty
Summary
The facility staff failed to provide timely care for a resident with a change in the condition of a wound. The resident, who was cognitively intact, had a cat scratch on the right forearm that was bleeding. Despite activating the call light at 6:27 AM, the resident waited for over two hours without receiving assistance, leading to the involvement of a family member who arrived at the facility to find help. The call light was not answered until 8:21 AM, which was significantly longer than the facility's expected response time of 15-20 minutes. The resident's medical history included a cerebral infarction and a fracture of the left fibula, and they were on blood thinners, which contributed to the bleeding issue. The care plan included monitoring the wound and reporting any abnormalities, but there was a lack of documentation and timely intervention when the wound continued to bleed. The resident's progress notes indicated multiple instances of bleeding and dressing changes, but there was no documentation on one of the days, and the provider was not contacted promptly. Interviews with facility staff revealed that the LPNs were not aware of the call light being on due to a lack of communication devices like pagers or walkies. The Director of Nursing confirmed that the provider should have been contacted earlier, and additional monitoring should have been conducted after the initial bleeding was noted. The delay in responding to the call light and the lack of timely medical intervention contributed to the deficiency in care provided to the resident.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in their kitchen, which had the potential to affect 48 of the 49 residents who consumed meals prepared there. During an initial kitchen tour, several deficiencies were observed, including an open and undated gallon of milk in the walk-in refrigerator, visible frost and ice buildup on the walk-in freezer door, and unlabeled and undated food items such as frozen egg patties or waffles, sandwiches, meat salad, and sour cream. Additionally, the dry storage area had boxes sitting on the floor, an open bag of lemonade drink mix, and an open bag of cocoa powder. The dishwashing area was found to have a dirty steel metal grate with dust, food debris, and grease buildup, as well as oxidized deposits on the dishwasher. Further observations revealed additional issues, such as unlabeled and undated food items like sour cream, hot dogs, and cottage cheese. The kitchen preparation area had dust, dirt, and grease buildup in the seams of the linoleum flooring, and the ice machine lid had a flakey substance. The dry storage room floor had dried food debris, and the kitchen flooring had unsealed patches, making it an uncleanable surface. These findings were confirmed by the Certified Dietary Manager, who acknowledged the need for cleaning, repair, and correction of the listed items. The Nebraska Food Code regulations were referenced, highlighting the requirement for nonfood-contact surfaces to be easily cleanable and for food to be stored in a manner that protects it from contamination.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility staff failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed during an environmental tour. The carpets in the center hallway, south hallway, and the common area between the 400 north and south hallways were found to have irregularly shaped discolored blotches and streaked linear lines, indicating high traffic use and lack of proper maintenance. Additionally, a strong urine smell was detected in one of the rooms, with the Maintenance Director confirming that the odor originated from the floor. This suggests inadequate cleaning and sanitation practices in the facility. Further observations revealed that the ventilation covers in rooms 310, 402, and 405 were covered with a gray, fuzzy substance resembling dust, indicating a lack of regular cleaning. Moreover, a shared toilet between certain rooms lacked doors, compromising the privacy of the residents. A privacy curtain was also missing on one side of a shared toilet in another room, as confirmed by the Maintenance Director. These findings highlight the facility's failure to ensure a homelike environment and respect the residents' right to privacy.
Failure in Hand Hygiene and Cross-Contamination Prevention
Penalty
Summary
The facility staff failed to perform proper hand hygiene after glove changes during peri care, catheter care, and wound care, leading to potential cross-contamination. Observations revealed that Nurse Assistant (NA) D and NA E did not perform hand hygiene after glove changes while providing care to Resident 1, who required maximal assistance due to conditions such as heart failure, diabetes, schizophrenia, and morbid obesity. NA D placed washcloths in the sink, which were then used without a barrier, and failed to perform hand hygiene after removing soiled gloves. Similarly, NA E did not change gloves or perform hand hygiene after handling potentially contaminated items. In another instance, NA E and Registered Nurse (RN) A provided personal and wound care to Resident 21, who was a carrier of Methicillin Resistant Staph Aureus (MRSA) and required maximal assistance. Both staff members placed washcloths in the sink basin and used them without performing hand hygiene between glove changes. RN A used washcloths from the sink basin to clean various body areas and applied powder without changing gloves or performing hand hygiene, which could lead to cross-contamination. Interviews with the staff confirmed the failure to perform hand hygiene and the inappropriate use of the sink basin for washcloths, which contradicted the facility's policies on perineal care and hand hygiene. The Director of Nursing acknowledged that these practices could cause cross-contamination and confirmed that hand hygiene should have been performed after glove changes.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer to the hospital for Resident 252 and their representative, as well as failed to notify the Office of the State Long-Term Care Ombudsman for both Resident 252 and another resident. Resident 252 experienced a fall and was transferred to the hospital twice without receiving a bed hold notice at the time of transfer or shortly thereafter. The Social Services Director confirmed that the facility did not provide the required notifications to the resident or their representative. Additionally, the facility did not notify the Ombudsman of Resident 1's hospital transfers on two separate occasions. The Social Service Designee confirmed that the Ombudsman was not informed of these transfers. The facility's policy requires that residents and their representatives be informed of the bed hold option at the time of emergency transfer, with written details provided as soon as possible, which was not adhered to in these cases.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed hold to two residents during their transfers to the hospital. Resident 252 experienced a fall and was transferred to the hospital twice, once at night and once the following day, without receiving a bed hold notice at either time. The facility's policy requires that residents or their representatives be informed of the bed hold option at the time of emergency transfer, with written details provided as soon as possible. However, the Social Services Director confirmed that no such notification was given to Resident 252 or their representative during these transfers. Similarly, Resident 1 was transferred to the hospital multiple times, but the facility did not provide a bed hold notice for two of these transfers. The facility's policy mandates that a written notice specifying the duration of the bed hold policy and information about the resident's return to the next available bed be provided at the time of transfer. An interview with the Social Services Director confirmed that Resident 1 and their representative did not receive the required bed hold notices for the specified hospital transfers.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening Resident Review (PASARR) for a resident, identified as Resident 34, who was admitted with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. The PASARR Level 1 screening form dated July 12, 2023, incorrectly assessed the resident as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). This inaccuracy was confirmed during an interview with the Social Services Director, who acknowledged that based on the resident's admission diagnoses, a PASARR Level 2 screen should have been completed. The facility's policy on coordinating assessments with the PASARR program was in place but not followed in this instance.
Failure to Conduct Timely Skin Evaluations and Treatments
Penalty
Summary
The facility staff failed to conduct timely skin evaluations and provide wound treatments according to the prescribed schedule for a resident. The resident, who was admitted with diagnoses including morbid obesity, alcoholic cirrhosis, and an above-knee amputation, required maximal assistance for personal hygiene and was dependent on staff for transfers. Despite having intact cognition, the resident's electronic health record showed missing documentation for skin assessments on specific dates, and subsequent evaluations revealed worsening skin maceration in multiple areas. Additionally, there was a failure to adhere to the treatment schedule for skin breakdown prevention. The treatment administration record indicated orders for twice-daily application of house powder and Nystatin powder to prevent fungal infections and soreness. However, observations confirmed that treatments were not consistently documented, and the facility's wound treatment management policy emphasized the importance of following physician orders and documenting treatments. The Director of Nursing confirmed the lack of skin assessments after a certain date, highlighting a lapse in the facility's adherence to care protocols.
Failure to Implement Ordered Wound Care Treatment
Penalty
Summary
The facility failed to implement the ordered treatment for a resident's wound care, specifically for a left heel ulcer. The treatment administration record for June 2024 indicated an order for daily skin prep on the resident's left heel, dated 6/5/2024. However, on 6/26/2024, a registered nurse (RN-A) was observed applying Betadine to the resident's left heel instead of the prescribed skin prep. During an interview, the Director of Nursing confirmed that the treatment should have been performed as ordered, and RN-A admitted to not being aware of the current order for the resident's left heel.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent recurring falls for a resident with severe cognitive impairment and multiple health conditions, including End Stage Renal Disease, Heart Failure, Diabetes Mellitus, and Depression. The resident required varying levels of assistance for daily activities and had previously experienced a fall while being transported in a wheelchair. The interdisciplinary team identified the cause of the fall as the resident sitting on a lift sling during transport and recommended using Dycem to prevent slipping. During an observation, staff members were seen transferring the resident into a wheelchair without using the Dycem as instructed. Interviews with the staff involved revealed they were unaware of the intervention to place Dycem under the wheelchair cushion and between the sling and the resident. The Director of Nursing confirmed that the intervention was documented in the resident's care plan, but it was not followed by the staff.
Failure to Follow Physician's Orders for Tube Feeding Administration
Penalty
Summary
The facility failed to adhere to physician's orders for the administration of tube feeding for a resident identified as having moderately impaired cognition. The resident was prescribed Novasource renal formula to be administered at a rate of 65 milliliters per hour for 12 hours. However, during an observation, it was found that the resident's tube feeding was being administered via gravity, with no indication of the rate or duration of administration. The gravity set bag was dated from the previous day and contained an unidentified formula, with 50 milliliters remaining. Interviews with the nursing staff, including an LPN and an RN, revealed a lack of knowledge regarding the formula being used, the prescribed rate, and the necessary flush amount after feeding. Both nurses were unable to locate a physician's order for administering the tube feeding by gravity. The Director of Nursing also confirmed the absence of a physician's order for this method of administration and was unaware that the tube feeding was being conducted in this manner.
Failure to Monitor Targeted Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that targeted behaviors were identified and monitored for a resident receiving psychotropic medications. Specifically, Resident 4, who was cognitively intact and had multiple diagnoses including bipolar disorder, was prescribed Lithium Carbonate and Risperidone. However, the facility did not document specific behaviors to be monitored in the resident's medical records, care plan, or medication administration records. This lack of documentation was confirmed during an interview with the Director of Nursing. The facility's policy on the use of psychotropic medications requires that the indications for medication use, as well as the effects on the resident's well-being, be evaluated and documented. Despite this policy, the facility did not adhere to these guidelines for Resident 4, as there were no specific target behaviors identified or monitored. This oversight was noted in the resident's care plan and other medical records, which lacked documentation of the resident's response to the medications and progress towards therapeutic goals.
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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