Adept Nursing & Rehab Of Sutherland
Inspection history, citations, penalties and survey trends for this long-term care facility in Sutherland, Nebraska.
- Location
- 333 Maple Street, Sutherland, Nebraska 69165
- CMS Provider Number
- 285141
- Inspections on file
- 24
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Sutherland during CMS and state inspections, most recent first.
A resident with Parkinson's Disease, traumatic brain injury, and schizo-affective disorder was not properly assessed for elopement risk, leading to two incidents where the resident exited the facility without staff knowledge or assistive devices. The care plan was not updated after these events, and required incident documentation and reassessment were not completed, resulting in a deficiency.
The facility did not complete required competency assessments for eight out of nine sampled staff, including medication aides, nurse aides, RNs, and LPNs. This failure was confirmed by the DON and affected all residents in the facility.
A resident with multiple diagnoses, including Parkinson's Disease and a history of traumatic brain injury, exited the facility without staff knowledge or their assistive device on two occasions. Despite care plans requiring supervision and interventions for safety, no incident report or investigation was completed for the first elopement, and required notifications to the administrator, APS, and the state agency were not made for either event. The DON confirmed that facility policy was not followed.
A resident with cognitive impairment and a recent hip surgery experienced ongoing moderate to severe pain that was not adequately managed, as staff failed to consistently assess, document, and implement both pharmacological and non-pharmacological interventions. Despite available PRN pain medications and care plan directives, staff did not administer medications as needed, did not document non-pharmacological measures, and did not notify the physician or revise the pain management plan when interventions were ineffective. Staff interviews confirmed these lapses in pain management and communication.
A resident with cognitive impairment and a history of hip surgery experienced ongoing moderate to severe pain that was not relieved by PRN Tylenol and Tramadol. Despite repeated documentation of ineffective pain control, staff did not notify the physician as required by facility policy and state regulations. Nursing staff and the DON confirmed that physician notification should have occurred when pain was not controlled.
A resident with a history of stroke, chronic pain syndrome, opioid abuse, anxiety, and depression experienced ongoing pain that was documented in their MDS assessment, including a pain rating of 8/10 and frequent limitations in daily activities. Despite these findings and a triggered CAA for pain, the facility did not include a pain management focus in the care plan until prompted by surveyors, as confirmed by both nursing staff and the DON.
A resident with dementia and moderate cognitive impairment experienced ongoing pain and behavioral symptoms. Staff administered psychotropic medications such as Ativan and Seroquel without consistently assessing for underlying causes or attempting non-pharmacological interventions, despite facility policy requiring these steps. Documentation showed pain was often unmanaged, and staff did not notify the provider about ongoing pain before obtaining psychotropic medication orders. The DON confirmed that expected protocols were not followed, resulting in unnecessary use of psychotropic medications.
The facility failed to properly store and label refrigerated food items, as observed during a kitchen tour. Unlabeled and undated items included salad mix, shredded carrots, and various opened bottles of dressings and juices, some showing spoilage. The Dietary Manager confirmed these items should have been labeled and discarded if not compliant with the facility's food safety policy. Additionally, a half-empty bottle of Diet Coke, likely belonging to an employee, was improperly stored in the residents' food refrigerator.
A facility failed to accurately code the MDS for a resident with pressure ulcers, resulting in a deficiency. The resident, admitted with Type 2 Diabetes Mellitus and an unstageable pressure ulcer, had discrepancies in their MDS documentation. The MDS inaccurately recorded zero unstageable pressure ulcers upon admission, despite the presence of pressure ulcers noted in the weekly wound assessment. The MDS/Care Plan Coordinator confirmed the incorrect coding.
A facility failed to develop a comprehensive care plan for a resident with chronic respiratory failure, COPD, heart failure, and diabetes. The resident required varying levels of assistance for ADLs, but the care plan lacked specific interventions for these needs. The DON confirmed the care plan was not comprehensive, failing to meet regulatory standards.
A resident with COPD was not administered oxygen according to the physician's order of 1 LPM. Observations showed the oxygen concentrator set at 2 LPM. Staff interviews revealed a lack of awareness of the correct order, leading to improper respiratory care.
A facility failed to follow infection control protocols during catheter care for a resident on Enhanced Barrier Precautions. Two nurse aides did not perform proper hand hygiene or change gloves after cleaning a soiled area, and they did not wear the required PPE. Interviews confirmed these lapses, highlighting a deficiency in infection control practices.
The facility did not develop baseline care plans within 48 hours of admission for two residents, as required. One resident had conditions including depression and COPD, while another had atrial flutter and respiratory failure. The DON confirmed the delay in completing the care plans.
A resident with multiple health conditions fell during a transfer, but the facility failed to update the care plan with the fall details or new interventions. The resident's transfer method was changed post-fall, but this was not documented. The DON confirmed the care plan was not updated as per facility protocol.
A resident with dementia and constipation did not receive prescribed interventions for constipation, resulting in multiple episodes of no bowel movements over several days. The facility's MAR showed no documentation of administered laxatives, and there were no progress notes on the resident's condition. The DON confirmed the lack of a written bowel management policy and the failure of nursing staff to implement the existing process.
A facility failed to maintain a medication error rate below 5%, with a 16% error rate observed. Errors included incorrect administration of Advair Diskus, Azelastine HCL Solution, and Alendronate Sodium, as well as delayed blood glucose monitoring for a resident with asthma and allergies. These errors were confirmed by the MA and DON.
A resident was injured when a shower chair tipped over due to inadequate safety checks and lack of staff education on its use. The resident preferred using a shower chair for transport to the bath house, but the facility did not assess the safety of this practice or educate staff on potential risks, leading to an incident where the chair's wheels caught on a threshold, causing the resident to fall.
The facility failed to provide adequate grooming assistance to three residents, resulting in unkempt hair, unshaved facial hair, and long, jagged toenails. Despite care plans and facility policies, staff did not consistently meet the residents' grooming needs.
A facility failed to accurately code dialysis treatment on the MDS for a resident with End Stage Renal Disease, despite the resident receiving dialysis three times a week. The DON confirmed that the MDS assessments should have indicated the dialysis treatment, but they did not on three separate occasions.
The facility failed to update a resident's care plan to reflect the discontinuation of daily dressing changes and the removal of stitches after the removal of a right subclavian catheter. The care plan still indicated the need for daily dressing changes and the presence of stitches, despite these no longer being applicable.
The facility failed to follow physician orders to remove a dressing from a resident's AV fistula site and document the condition of the site. The resident, dependent on renal dialysis, had an undated dressing observed on multiple occasions, and the required monitoring and documentation were not consistently completed.
Facility staff failed to perform proper wound care for two residents, leading to potential cross-contamination and infection. The LPNs did not set up clean fields or establish areas for soiled supplies, and the DON confirmed a lack of staff training and accessible policies.
Failure to Assess and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess a resident for elopement risk, did not provide appropriate interventions to prevent elopement, and did not implement new interventions after repeated incidents. The resident in question had a history of Parkinson's Disease, traumatic brain injury, and schizo-affective disorder, and was admitted with a care plan that allowed for independent outdoor activity. Despite documentation indicating the resident required supervision or assistance with mobility, the admission assessment incorrectly stated the resident was not at risk for elopement, as it was believed the resident could not exit the facility independently. The resident was able to leave the facility without staff knowledge or the use of assistive devices on two separate occasions. On one occasion, the resident exited the building without signing out or notifying staff, and on another, the resident was found by police sitting in the road outside the facility. After the first incident, the resident was not reassessed for elopement risk, and no incident or accident report was completed as required by facility policy. The care plan was not updated to reflect the resident's actual risk or to implement new interventions after these events. Interviews with the DON confirmed that the initial assessment was inaccurate and that the resident's known history of independent exits from previous living situations was not properly considered. The facility's failure to reassess the resident after the first elopement, to complete required documentation, and to update the care plan or implement further interventions directly contributed to the repeated elopement incidents.
Failure to Complete Staff Competency Assessments
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had completed required competency assessments to demonstrate proficiency in the care and services they provide to residents. Record reviews revealed that eight out of nine sampled staff members, including medication aides, nurse aides, registered nurses, and licensed practical nurses, did not have documented competencies on file. These staff members had been hired at various times, but none had completed competency evaluations either upon hire or annually as required. Interviews with staff and the Director of Nursing confirmed that the necessary competency assessments had not been conducted for these individuals. The Director of Nursing acknowledged that staff should have completed competencies both at the time of hire and on an annual basis, but this process was not followed. The lack of completed competencies had the potential to affect all residents in the facility, which had a census of 41 at the time of the survey.
Failure to Investigate and Report Resident Elopement Incidents
Penalty
Summary
The facility failed to investigate and report possible incidents of abuse or neglect for one resident, as required by both facility policy and regulatory standards. Specifically, a resident with diagnoses including Parkinson's Disease, a history of traumatic brain injury, and schizo-affective disorder exited the facility without staff knowledge or their assistive device on two separate occasions. On one occasion, the resident was found by police sitting in the road outside the facility without having signed out or notified staff. Documentation showed that the resident was cognitively intact and had expressed a strong preference for going outside, but care plans required supervision and specific interventions for mobility and safety. Despite these incidents meeting the facility's definition of elopement, no incident report or investigation was completed for the first occurrence, and the required notifications to the administrator, Adult Protective Services, and the state regulatory agency were not made for either event. The Director of Nursing confirmed that these incidents constituted elopement and acknowledged that facility policy was not followed, as neither an immediate investigation nor timely reporting occurred as mandated.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of cognitive impairment, dementia, a recent hip fracture and surgery, and other comorbidities. Despite documented orders and a care plan that included both pharmacological and non-pharmacological interventions for pain, staff did not consistently assess, implement, monitor, or revise pain management strategies as required. The resident frequently exhibited moderate to severe pain, both verbally and through non-verbal indicators such as restlessness, facial grimacing, and behavioral outbursts, yet there was repeated lack of documentation and evidence that appropriate interventions were provided. Records showed that the resident often had available PRN pain medications, such as Tylenol and Tramadol, which were not administered despite ongoing reports of pain. Non-pharmacological interventions, although listed in the care plan, were rarely documented as being attempted or implemented. When pain medications were administered and found to be ineffective, there was no evidence that staff consistently followed up with additional interventions or notified the physician in a timely manner. The resident's pain management regimen was not reassessed or adjusted despite ongoing reports of ineffective pain control and persistent pain behaviors. Interviews with staff, including nursing assistants, RNs, and the DON, confirmed that pain was not adequately managed and that staff did not always follow the facility's pain management policy. There were also missed opportunities to communicate pain management concerns to the physician or rounding providers, and staff did not consistently assess for pain when the resident exhibited behaviors that could be related to pain. The deficiency was further substantiated by the DON's confirmation of multiple instances where interventions were not implemented or documented, and where follow-up with the physician did not occur as expected.
Failure to Notify Physician of Ineffective Pain Management
Penalty
Summary
The facility failed to notify a resident's physician of ongoing, inadequately controlled pain, as required by both facility policy and state regulations. The resident in question had a history of cognitive communication deficit, dementia, transient ischemic attack, and a hip joint replacement, and was admitted with orders for PRN Tylenol and Tramadol for pain management. Despite repeated documentation in the medical record of moderate to severe pain persisting after administration of these medications, there was no evidence that the physician was notified of the ineffective pain control during multiple instances over a period of several weeks. Facility policies required staff to inform the physician when pain was not adequately controlled and to consider revising the pain regimen. The resident's care plan also included interventions to evaluate the effectiveness of pain treatment and to report pain not at or below the resident's acceptable level to the physician. Progress notes repeatedly documented moderate to severe pain after PRN medications were given, with specific pain scores ranging from 5/10 to 10/10, and noted that both PRN Tylenol and Tramadol were ineffective at times. Despite these findings, there was no documentation that the physician was notified of the ongoing pain or that pain management was discussed, except for one instance where the physician was notified of behavior but not specifically about pain management. Interviews with nursing staff and the DON confirmed that the physician should have been notified when pain was not controlled by PRN medications, and that this notification did not occur as required. The deficiency was identified through record review and staff interviews, which established that the facility did not follow its own policies or regulatory requirements regarding physician notification for ineffective pain management.
Failure to Develop and Implement Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing pain management for a resident with a history of stroke, chronic pain syndrome, opioid abuse, anxiety, and depression. Upon admission, the resident's Minimum Data Set (MDS) assessment indicated the presence of ongoing pain, with the resident rating their pain as 8 out of 10. The assessment also revealed that pain occasionally interfered with sleep, rarely affected therapy, and frequently limited daily activities. The Care Assessment Area (CAA) for pain was triggered, indicating the need for a care plan focus on pain management. Despite these findings, a review of the resident's care plan showed that no focus area for pain had been included as of several weeks after admission. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the care plan did not address pain management until the day of the surveyor's inquiry, despite the resident's ongoing pain and relevant diagnoses. This omission was not in accordance with the facility's policy, which requires the development of a person-centered care plan with measurable objectives and timeframes for all identified needs.
Failure to Assess Underlying Causes Before Psychotropic Medication Use
Penalty
Summary
The facility failed to assess and evaluate the underlying causes of behavioral symptoms in a resident prior to initiating or continuing psychotropic medications, as required by both facility policy and regulatory standards. The resident in question had a history of cognitive impairment, dementia, and pain, and was admitted with multiple diagnoses including a cognitive communication deficit and a history of hip replacement. Despite documented moderate pain and behavioral symptoms, there was no evidence that staff consistently attempted non-pharmacological interventions or thoroughly assessed for underlying causes, such as pain, before administering psychotropic medications. Record reviews revealed that the resident experienced ongoing pain, with frequent reports of high pain scores and observable nonverbal indicators such as restlessness, facial expressions, and protective postures. Staff administered PRN pain medications, but documentation showed these were often ineffective, and there was a lack of follow-up or additional interventions to address the resident's pain. Behavioral incidents, including physical and verbal outbursts, were managed with psychotropic medications like Ativan and Seroquel, but there was no evidence that staff attempted non-pharmacological interventions or notified the provider about the resident's ongoing pain prior to obtaining these medication orders. Interviews with staff and the DON confirmed that the resident's behaviors could have been related to uncontrolled pain and that expected protocols, such as assessment during behavioral episodes, implementation of non-pharmacological interventions, and physician notification, were not followed. The facility's failure to identify and address the underlying causes of the resident's behaviors, particularly pain, led to the unnecessary use of psychotropic medications without adequate attempts at alternative interventions.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and labeling practices, as observed during a kitchen tour. Several refrigerated items were found unlabeled and undated, including bulk bags of salad mix, shredded carrots, and various opened bottles of salad dressings and juices. Some of these items, such as the salad mix, showed signs of spoilage, with lettuce turning brown and carrots becoming mushy with liquid in the bag. Additionally, a squirt bottle of ranch dressing was found with an uncovered spout, and a partially used bottle of soy sauce was opened and not dated. These observations indicate a failure to comply with the 2017 Nebraska Food Code, which requires food held for more than 24 hours to be clearly marked with a consumption or discard date. The Dietary Manager confirmed during an interview that the items should have been labeled with an open date and discarded if not labeled as required. The facility's policy on food safety requirements mandates that refrigerated items be labeled, dated, and covered in tight containers, which was not followed in this instance. Furthermore, the interview revealed that the salad dressings should be discarded within 30-60 days of being opened, and the presence of a half-empty bottle of Diet Coke, likely belonging to an employee, was improperly stored in the residents' food refrigerator. These lapses in food safety practices had the potential to affect all 39 residents who consumed food from the facility's kitchen.
Incorrect MDS Coding for Pressure Ulcers
Penalty
Summary
The facility failed to correctly code the Minimum Data Set (MDS) for a resident's pressure ulcers, leading to a deficiency. Resident 24, who was admitted with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and an unstageable pressure ulcer on the left heel, had discrepancies in their MDS documentation. The quarterly MDS inaccurately recorded that the resident had zero unstageable pressure ulcers upon admission, despite the presence of pressure ulcers on the right buttock, left buttock, and left heel as noted in the weekly wound assessment. An interview with the MDS/Care Plan Coordinator confirmed that the MDS section M was incorrectly marked, failing to accurately reflect the resident's condition.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 97, who was admitted with multiple diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, and diabetes. The resident's admission Minimum Data Set (MDS) indicated varying levels of assistance required for activities of daily living (ADLs), such as substantial assistance for toileting, bathing, and personal hygiene, total assistance for lower body dressing, and moderate assistance for transfers. Despite these needs, the care plan for Resident 97 lacked specific interventions to address these ADLs, with only a general intervention for therapy to screen, evaluate, and treat as needed. The deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan was not comprehensive and did not include specific interventions detailing the amount of assistance required for each ADL. This oversight in the care planning process resulted in a failure to adequately document and plan for the resident's needs, as required by the facility's policy and regulatory standards.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen according to the prescriber's orders for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted with a care plan that included an intervention for oxygen therapy as ordered by the physician. The physician's order, dated 12/17/2024, specified continuous oxygen at 1 Liter Per Minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the resident's portable oxygen concentrator was set to 2 LPM, contrary to the prescribed order. Interviews with facility staff indicated a lack of awareness and understanding of the resident's oxygen order. A Medication Aide was unsure of the order and needed to consult with a Registered Nurse (RN). The RN initially believed the order was for 2 LPM but confirmed after checking that it was indeed for 1 LPM. This discrepancy in oxygen administration was identified during observations and interviews, highlighting a failure in following the physician's orders for the resident's respiratory care.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during catheter care for a resident. Observations revealed that two nurse aides, NA-C and NA-D, did not perform hand hygiene or change gloves after cleansing a visibly soiled area before proceeding with perineal and catheter care. The resident was on Enhanced Barrier Precautions due to their catheter, which required the use of personal protective equipment (PPE) such as gowns and masks during high-contact care activities. However, the nurse aides did not wear the required PPE while providing care. Interviews with the nurse aides confirmed the lapses in protocol. NA-C acknowledged that they did not perform hand hygiene for the recommended 20 seconds or change gloves after cleaning a soiled area, and they did not track their scrub time. NA-D also confirmed the failure to wear the required gown and mask and the inadequate hand hygiene practices. The facility's policy on Enhanced Barrier Precautions was not followed, leading to a deficiency in infection control practices.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents, as required by their policy. Resident 9 was admitted with diagnoses including depression, repeated falls, difficulty swallowing, and Chronic Obstructive Pulmonary Disease. However, the baseline care plan for this resident was signed more than 48 hours after admission. Similarly, Resident 96, who was admitted with conditions such as atrial flutter, acute and chronic respiratory failure, difficulty in walking, depression, high blood pressure, and a history of falls, also had a baseline care plan signed beyond the 48-hour requirement. The Director of Nursing confirmed that the baseline care plans for both residents were not completed within the stipulated timeframe.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident following a fall, as required by regulatory standards. The resident, who has a history of amyotrophic lateral sclerosis, unspecified osteoarthritis, hereditary and idiopathic neuropathy, muscle wasting and atrophy, and generalized muscle weakness, experienced a fall during a transfer from the toilet to a wheelchair. Despite the fall occurring, the care plan was not updated to reflect the incident or to include new interventions to prevent future falls. The resident reported feeling their legs giving out before the fall and expressed concerns to staff, which were not heeded. After the fall, the resident's method of transfer was changed from using a walker and wheelchair to a Hoyer lift, but this change was not documented in the care plan. The Director of Nursing confirmed that the care plan was not updated with the fall details or new interventions, which is a deviation from the facility's standard process following a fall.
Failure to Administer Constipation Interventions
Penalty
Summary
The facility failed to provide necessary interventions for constipation for a resident diagnosed with dementia and constipation. The resident was admitted on 8/3/2023 and had severe cognitive impairment, requiring moderate assistance with toileting. The care plan included interventions such as administering medication as ordered, monitoring response to medication, and reporting irregularities in bowel patterns to the physician. Despite these interventions, the resident experienced multiple episodes of constipation, with no bowel movements recorded for several days in October, November, and December 2024. The Medication Administration Record (MAR) showed no documentation of the administration of prescribed laxatives, Milk of Magnesia and Bisacodyl, during these periods of constipation. Additionally, there were no progress notes regarding the resident's constipation or any interventions taken. Interviews with the Director of Nursing (DON) revealed that the facility lacked a written bowel management policy, and the existing process was not being utilized effectively by the nursing staff. The DON confirmed the absence of interventions and progress notes for the resident's constipation, which was expected to be completed.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 16% error rate observed during a survey. This was based on 26 medication opportunities, where 4 errors were identified, affecting one resident out of a sample of three. The errors included improper administration of medications and failure to follow prescribed protocols. Specifically, the medication aide (MA-A) did not ensure that the resident rinsed their mouth after using Advair Diskus, administered an incorrect dosage of Azelastine HCL Solution by giving two sprays per nostril instead of one, and did not administer Alendronate Sodium 30 minutes before breakfast as required. Additionally, the blood glucose monitoring was not conducted before meals as prescribed. The resident involved had a medical history that included asthma, allergies, and a need for blood glucose monitoring. The errors in medication administration were confirmed through interviews with the MA-A and the Director of Nursing (DON), who acknowledged the discrepancies in the administration of the medications and the failure to adhere to the prescribed timing and dosage instructions. The DON confirmed that the nasal spray was administered incorrectly, the mouth rinse was omitted, the timing for Alendronate was not followed, and the blood sugar checks were delayed, all contributing to the medication error rate exceeding the acceptable threshold.
Failure to Ensure Safety in Bath Chair Use
Penalty
Summary
The facility failed to implement necessary safety checks, education, or hazard assessments for the use of a bath chair, affecting Resident 4. Interviews with staff revealed that Resident 4 preferred to be transported in a shower chair from their room to the bath house, contrary to the usual practice of using a wheelchair. Despite feeling safety concerns, Bath Aide C continued to use the shower chair without reporting these concerns to maintenance or management. On 09/20/2024, an incident occurred where Resident 4 fell forward from the shower chair when its wheels caught on the floor threshold, resulting in the resident being taken to the hospital. The care plan for Resident 4 did not include any safety goals or interventions for handling the resident in the shower chair. Interviews with the Facility Administrator and the Director of Nursing confirmed that no assessments were conducted to ensure the resident's safety when using the bath/shower chair, and no education on the associated safety risks was provided to the staff. The facility's protocol for resident bathing did not address the specific safety concerns related to the use of shower chairs, contributing to the incident.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate assistance with grooming to three residents, leading to deficiencies in personal hygiene. Resident 1, who had moderate cognitive impairment and required extensive assistance with personal hygiene, was observed multiple times with unkempt hair and food debris on their clothing. Despite the care plan indicating the need for substantial assistance, the resident's grooming needs were not met consistently. Resident 12, who required setup or clean-up assistance for personal hygiene, was observed with long grey facial hair on multiple occasions. Although the resident preferred to have their facial hair shaved off and received baths twice a week, the staff failed to shave the resident's facial hair as per the facility's grooming policy. Interviews with the resident and staff confirmed that the grooming assistance was not provided as required. Resident 15, who had cognitive deficits and was dependent on staff for personal hygiene, was observed with long, thick, yellow, and jagged toenails, with one toenail split down the middle. Despite the facility's policy to offer nail trimming during baths, the resident's toenails were not trimmed. Interviews with the DON and an LPN confirmed the condition of the resident's toenails and the lack of proper grooming care. The resident expressed their inability to trim their own toenails and the desire for assistance, which was not provided by the staff.
Failure to Accurately Code Dialysis on MDS
Penalty
Summary
The facility failed to accurately code dialysis treatment on the Minimum Data Set (MDS) for a resident diagnosed with End Stage Renal Disease and Dependence on Renal Dialysis. The resident was admitted to the facility and received dialysis treatment on Mondays, Wednesdays, and Fridays at a dialysis center. Despite this, the MDS assessments completed on three separate occasions did not indicate that the resident was receiving dialysis treatment in Section O, as required by federal regulations and the facility's policy on MDS 3.0 Completion. The Director of Nursing (DON) confirmed during an interview that the resident had been receiving dialysis treatment prior to their admission and that all MDS assessments since admission should have reflected this treatment. However, the MDS assessments dated 12/1/23, 1/16/24, and 1/23/24 failed to indicate dialysis treatment in Section O. This oversight was identified through a record review and interview process, highlighting a lapse in the facility's adherence to accurate and comprehensive resident assessments.
Failure to Revise Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident with End Stage Renal Disease (ESRD) and dependence on renal dialysis. The resident was admitted with a right subclavian catheter, which was removed on 12/20/2023, and initially had an order for daily dressing changes to the catheter removal site. However, this order was discontinued on 2/1/2024. Despite the discontinuation, the resident's care plan still indicated the need for daily dressing changes and the presence of stitches, which were no longer applicable. An interview with the Director of Nursing (DON) confirmed that the resident no longer had stitches or an order for daily dressing changes, yet the care plan had not been updated to reflect these changes. This discrepancy was identified during a record review on 2/14/2024. The facility's policy mandates that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment, which was not adhered to in this case.
Failure to Follow Physician Orders and Document AV Fistula Care
Penalty
Summary
The facility failed to adhere to the physician's order to remove the dressing from a resident's arteriovenous (AV) fistula site four hours after dialysis treatment and to document the condition of the site. The resident, who was admitted with End Stage Renal Disease and dependence on renal dialysis, had an undated dressing on their AV fistula site, which was observed on multiple occasions. The Treatment Administration Record (TAR) for January and February 2024 showed multiple instances where the required monitoring and documentation of the AV fistula site were not completed as ordered. Additionally, the facility's policy on Hemodialysis Access Care was not followed, as there was no documentation of the condition of the dressing or observations post-dialysis in the resident's medical record. During an interview, the Director of Nursing (DON) confirmed that the dressing was likely applied the day before and that there was no date on the dressing. The facility's failure to remove the dressing and document the condition of the AV fistula site as required affected the resident's care. The resident's care plan also indicated the need for regular assessment of the AV shunt for bruit and thrill, which was not consistently documented in the TAR. This lack of adherence to physician orders and facility policy led to the deficiency noted in the report.
Inadequate Wound Care Practices
Penalty
Summary
The facility staff failed to perform wound care in a manner that prevents potential cross-contamination and infection. For Resident 2, who had a stage III pressure ulcer on the sacral region, the LPN did not set up a clean field for wound care supplies and placed dressing supplies on the resident's bed. The LPN also used soiled gauze and gloves to open a wound dressing package and did not sanitize the top of a storage bin that had visible moist spots from the old dressing. The LPN confirmed they did not follow the facility's Clean Dressing Change policy and did not establish an area for soiled products to be placed. For Resident 9, who required daily suprapubic catheter care, the LPN also failed to set up a clean field and placed wound treatment supplies on the resident's bed. The LPN did not use a trashcan or trash bag for soiled supplies and placed them on the bed. The LPN confirmed they did not follow the facility's Clean Dressing Change policy and was not aware of the facility's policy and procedure for wound care. The LPN mentioned that the resident's bed table was full of items, and they did the best they could with the available resources. The Director of Nursing (DON) revealed that they had not completed any competencies or skills checklists on staff caring for residents with wounds. Additionally, there was no accessible binder or manual with policies and procedures at the nurse's station, and the policies could not be accessed electronically. The DON had to contact the company that took over the facility to request policies and procedures, indicating inconsistency in policy availability and staff training.
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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