Adept Nursing & Rehab Of Waverly
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Nebraska.
- Location
- 11041 North 137th St, Waverly, Nebraska 68462
- CMS Provider Number
- 285143
- Inspections on file
- 24
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Waverly during CMS and state inspections, most recent first.
Two residents with diabetes did not receive their prescribed insulin before meals as ordered, with doses given late and outside of scheduled times. LPNs and the DON confirmed the insulin was not administered according to physician orders or facility policy, and documentation showed missed or delayed doses. Facility policies and manufacturer guidelines for insulin administration were not followed, resulting in significant medication errors.
Ceiling vent covers in several common areas, including the entrance foyer, conference room, nurse's station, dining room entrance, and two hallways, were observed to have a brown fuzzy substance on them. Multiple facility leaders confirmed the vents were not clean, and there was confusion over whether maintenance or housekeeping was responsible for cleaning. No work order was in place for vent cleaning, and the issue had not been addressed despite being reported.
A resident with chronic respiratory conditions was provided oxygen therapy using a concentrator that displayed a warning light indicating substandard oxygen purity. The device was set at a higher flow rate than ordered by the provider, and staff did not immediately replace the malfunctioning equipment. The resident experienced fluctuating oxygen saturation levels and respiratory distress until the concentrator was eventually exchanged for a functioning unit.
The facility did not post daily nursing staffing information on multiple occasions, as observed on several dates. Interviews with the Administrator and HR confirmed the absence of postings and the lack of a policy for daily staffing information.
The facility failed to ensure proper handwashing practices among dietary staff, with observations showing handwashing for less than the required 20 seconds. Additionally, the kitchen environment was not maintained, with a gray fuzzy substance on vents and light fixtures, and cracked ceiling plaster. These deficiencies could affect 45 residents consuming food from the kitchen.
The facility failed to maintain a safe and clean environment, with deficiencies observed in 14 resident rooms, including malfunctioning ceiling fans, damaged walls, and missing maintenance reports. Interviews confirmed the issues and revealed a lack of policy on environmental needs.
A long-term care facility was found to have a medication error rate of 35%, affecting three residents. Errors included administering insulin without prior blood glucose testing, withholding insulin without physician parameters, and improper medication administration by an orienting nurse. The Director of Nursing confirmed these as significant errors.
The facility failed to ensure proper insulin administration for two residents, leading to significant medication errors. One resident received insulin without required blood glucose checks, and another did not receive insulin as ordered due to incorrect assumptions by staff. Additionally, a resident received medications without proper verification, breaching protocol.
A facility failed to report an abuse investigation involving a resident to the State Agency within the required 5 working days. The incident occurred on 10/22/2024, but the report was not sent until 6 working days later. The Administrator confirmed the delay, which was against the facility's policy.
A facility failed to complete an admission MDS for a resident within the required time frame. The resident was admitted, and the MDS was started but not completed within the 13-day requirement. This was confirmed by interviews with the MDS Coordinator and the DON.
A resident with a history of falls and multiple medical conditions experienced another fall, but the facility failed to implement new interventions to prevent future incidents. Despite the resident's cognitive awareness and previous fall in August, the care plan was not updated after a fall in October. The facility did not conduct an incident report or investigation, and existing interventions were not revised.
A long-term care facility failed to ensure proper use of PPE and hand hygiene in Enhanced Barrier Precautions rooms, affecting multiple residents. Staff did not wear gowns during high-contact care activities, and hand hygiene was not performed according to policy. Additionally, a resident's BiPAP filter was not cleaned or replaced as required, leading to potential cross-contamination.
The facility failed to ensure daily weights were completed according to physician's orders for four residents, despite their medical conditions requiring such monitoring. Records showed multiple instances where weights were not recorded, and interviews confirmed the oversight.
The facility failed to maintain adequate nursing staff levels, resulting in residents not receiving regular baths as per their preferences. Observations and interviews confirmed that residents were not bathed regularly due to staff shortages, with the bath aide often reassigned to other duties. The facility's staffing schedule showed multiple instances of being short-staffed, contributing to the deficiency in providing adequate bathing care.
The facility failed to monitor and document wounds for two residents, leading to a deficiency. One resident with a surgical wound and another with a diabetic foot ulcer had incomplete records regarding wound characteristics, such as tissue type, drainage, and signs of infection. Interviews confirmed the lack of comprehensive documentation, violating the facility's wound management policies.
A resident with paraplegia and spina bifida developed a pressure ulcer that was inadequately monitored and documented by facility staff. Despite interventions, weekly skin evaluations lacked necessary details, and a late entry indicated delayed wound nurse assessments. An observation revealed the ulcer's condition, and the ADON confirmed incomplete monitoring.
The facility failed to follow protocol in determining the death of two residents. A resident was mistakenly pronounced dead and sent to a funeral home, where it was discovered they were still alive. Another resident's death was not properly documented, with no evidence of vital signs assessment. These incidents highlight a critical lapse in protocol adherence, resulting in immediate jeopardy.
The facility staff failed to evaluate, implement practitioner's orders, and notify emergency medical personnel for a resident with multiple diagnoses, leading to a delay in emergency care and the resident's death. The ADON and LPN did not act promptly to send the resident to the hospital despite receiving orders from the provider.
A facility failed to safely transport a resident, resulting in the resident sliding out of their wheelchair during transport. The incident was not documented, and no safety assessments were conducted for the resident's use of the transportation van.
The facility failed to ensure staff donned and doffed required PPE for COVID-19 TBP rooms, properly sanitized COVID-19 testing surfaces, and adhered to hand hygiene and wound care protocols. Observations revealed staff entering TBP rooms without PPE, improper handling of COVID-19 test cards, and inadequate wound care practices.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that insulin was administered as ordered for two residents with diabetes, resulting in significant medication errors. For one resident, the care plan identified a risk for blood sugar alterations and required insulin administration before meals. However, the resident's electronic medication record showed that NovoLOG insulin, scheduled for 6:30 AM, was not administered until 9:19 AM, after the resident had already eaten breakfast. Additionally, the Basaglar insulin, also ordered for the morning, was not documented as given. Interviews with the LPN and DON confirmed that the insulin was not administered within the ordered parameters, and the resident confirmed not receiving insulin prior to eating. For the second resident, who also had a diagnosis of diabetes and was independent in daily activities, the treatment administration record indicated an order for Insulin Aspart to be given before meals at 6:30 AM. The electronic medication record showed that the insulin was administered at 7:58 AM, which was after the scheduled time. The LPN confirmed the late administration, and the DON verified that the insulin was not given as ordered. Observations confirmed that the resident was eating breakfast in the dining room during this period. Facility policies required insulin to be administered in accordance with physician orders, coordinated with mealtimes, and in compliance with the six rights of medication administration. Manufacturer guidelines for NovoLOG specified that the medication should be taken 5-10 minutes before eating. The failure to administer insulin as ordered and within the specified timeframes for both residents constituted significant medication errors, as confirmed by staff interviews and documentation review.
Failure to Clean and Sanitize Ceiling Vent Covers in Common Areas
Penalty
Summary
The facility failed to ensure that ceiling ventilation covers in multiple common areas were cleaned and sanitized, as required by their Routine Cleaning and Disinfection policy. Observations on two consecutive days revealed that flat ceiling vents in the entrance foyer, conference room, above the nurse's station, at the entrance to the dining room, and at the ends of two halls all had a brown fuzzy substance on them. These findings were confirmed during walkthroughs with the Regional Maintenance Director, Regional Director of Operations, and the Administrator. Interviews with facility leadership revealed confusion regarding responsibility for cleaning the vents. The Regional Maintenance Director stated that maintenance was not assigned to clean the vents, considering it a housekeeping concern, and noted that the contracted cleaning company had not addressed the issue despite being notified. The Administrator, however, confirmed that maintenance was responsible for vent cleaning and acknowledged the vents should have been clean. There was no work order in the system for maintenance to complete this task at the time of the observations. The deficiency had the potential to affect all 46 residents in the facility.
Failure to Ensure Proper Functioning and Use of Oxygen Concentrator
Penalty
Summary
A resident with a history of COPD, chronic respiratory failure, pneumonia, and nicotine dependence required continuous oxygen therapy to maintain oxygen saturation above 90%, as ordered by the attending physician. The most recent physician order specified oxygen at 2 liters per minute (l/m) at all times. The resident was moderately cognitively impaired and dependent on staff for several activities of daily living. The care plan and medical records indicated the need for continuous oxygen, but did not specify the exact setting in the care plan. On multiple occasions, the resident's oxygen concentrator was observed to be malfunctioning, as indicated by a yellow warning light on the device, which, according to the manufacturer's manual, signified that the machine was producing substandard oxygen purity and required immediate attention. Despite this warning, the resident continued to receive oxygen from the malfunctioning concentrator, and the device was set at 4 l/m, which was not in accordance with the most recent physician order of 2 l/m. The resident's oxygen saturation levels fluctuated, with some readings below the target threshold, and the resident exhibited signs of respiratory distress, including rapid, shallow breathing and difficulty speaking. Staff interviews confirmed awareness of the malfunctioning equipment and the discrepancy between the ordered and delivered oxygen flow rates. The oxygen concentrator was not replaced until after the issue was brought to the attention of the Director of Nursing. The resident's condition improved after the concentrator was exchanged for a functioning device, but the deficiency centered on the failure to ensure the oxygen concentrator was operating properly and that oxygen was administered according to the provider's orders.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of nursing staffing information was current and complete, which had the potential to affect all residents. Observations on December 2nd, 3rd, and 4th, 2024, revealed missing postings for the daily census sheet. Interviews with the Administrator and Human Resources confirmed the absence of these postings for the specified dates. Additionally, the Administrator admitted that the facility did not have a policy in place for daily nursing staffing posting.
Deficiencies in Handwashing and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure proper handwashing practices among dietary staff, which is crucial to prevent foodborne illnesses. Observations revealed that a cook, referred to as Cook-A, consistently performed handwashing for less than the required 20 seconds before and after handling food and changing gloves. This was confirmed by both Cook-A and the facility's Registered Dietician (RD) during interviews. Additionally, a dietary aide was observed washing hands for only 14 seconds after handling dirty dishes. The facility's handwashing guidelines clearly state that handwashing should be performed for at least 20 seconds to prevent the spread of bacteria. The facility also failed to maintain a clean and safe kitchen environment. Observations noted that the kitchen ceiling ventilation covers, light fixtures, and walls were not in safe condition, with a gray fuzzy substance present around vents and on light fixtures. The ceiling plaster was bubbled and cracked, and there was a large crack in the wall above the food preparation sink. These conditions were confirmed by the RD, who acknowledged the need for repairs and cleaning. The deficiencies in handwashing practices and kitchen maintenance had the potential to affect 45 residents who consumed food from the kitchen.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during an environmental tour. The surveyors identified issues in 14 resident rooms, including malfunctioning ceiling fans covered in a gray fuzzy substance, holes in drywall, and walls with missing paint. Additionally, there was a strong smell of urine in one room, a broken plastic nightlight cover, a missing door frame side, a missing call light cord in a bathroom, and a heater/air conditioner unit with missing wall sections allowing cold air to enter the building. The presence of a flyswatter hanging on a hallway wall and multiple screws, nails, and hooks without decor in the hallways further contributed to the unkempt environment. Interviews with the facility Administrator (ADM) and Corporate Nurse (CN) confirmed the environmental concerns and revealed that the TELS system, intended to monitor maintenance issues, did not have corresponding reports for the identified deficiencies. The ADM acknowledged the need for repairs and cleaning but also disclosed that the facility lacked a policy on environmental needs. These findings indicate a systemic failure to address and document maintenance issues, compromising the residents' right to a safe and comfortable living environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with observations revealing a 35% error rate. This deficiency affected three residents, including Resident 21, who was administered insulin without prior blood glucose testing as required by the physician's order. The nurse responsible for administering the insulin confirmed the oversight, and the Director of Nursing acknowledged it as a significant medication error. Resident 10, who has a history of type 2 diabetes and other medical conditions, did not receive the prescribed Insulin Lispro due to a nurse's incorrect decision to withhold it based on blood glucose levels, despite the absence of such parameters in the physician's order. The nurse confirmed the error, and the Director of Nursing recognized it as a significant medication error. Resident 199 was administered medications by a nurse who did not dispense them, violating the facility's medication administration policy. The nurse was still in orientation and lacked access to the medication administration record, leading to a failure to verify the six rights of medication administration. The Director of Nursing confirmed that this was inappropriate practice.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure the proper administration of insulin for two residents, leading to significant medication errors. Resident 21, who has a history of uncontrolled type 2 diabetes, COPD, and other conditions, was administered insulin without checking blood glucose levels as required by the physician's orders. On one occasion, insulin was given when the blood glucose level was below the specified threshold, and on another occasion, the nurse failed to check the blood glucose level before administering insulin, which was later found to be above the threshold. Resident 10, who also has type 2 diabetes and other medical conditions, did not receive insulin as ordered due to the nurse's incorrect assumption that insulin should be withheld if blood glucose levels were below 100 mg/dl, despite no such parameter being specified in the orders. This led to multiple instances where insulin was not administered as prescribed, including when blood glucose levels were within the range that required insulin administration according to the sliding scale order. Additionally, there was a failure in following the six rights of medication administration for another resident, Resident 199. An LPN dispensed medications and handed them to an RN, who was still orienting and did not have access to the medication administration record (MAR), to administer. The RN did not verify the medications against the MAR or check the six rights before administration, leading to a breach in medication administration protocol.
Delayed Reporting of Abuse Investigation
Penalty
Summary
The facility failed to ensure that an abuse investigation involving a resident was reported to the State Agency within the required timeframe. The facility's policy mandates that the Administrator must confirm the initial report was received by government agencies and report the investigation results within 5 working days of the incident. However, the investigation of potential staff-to-resident abuse, which occurred on 10/22/2024, was not emailed to the State Agency until 10/29/2024, which was 6 working days after the event. This delay was confirmed by the Administrator during an interview, acknowledging the failure to meet the 5 working day requirement.
Failure to Complete Admission MDS Timely
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) for one of the sampled residents, identified as Resident 196, within the required time frames. Resident 196 was admitted on October 21, 2024, and the MDS was initiated on November 6, 2024, but not completed. This delay was confirmed through interviews with the Minimum Data Set Coordinator and the Director of Nursing on December 4, 2024. According to the CMS's RAI Version 3.0 Manual 2024, the MDS Completion Date must be no later than 13 days after the resident's entry date, which was not adhered to in this case.
Failure to Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident, identified as Resident 10, who had a history of falls. The resident, who was cognitively aware with a BIMS score of 13, had multiple medical diagnoses including hemiplegia, hemiparesis, congestive heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease. Despite these conditions and a previous fall in August 2024, the facility did not update the resident's care plan with new interventions following another fall on October 22, 2024. The existing intervention of using a wedge under the resident in bed, which was implemented after the August fall, was not revised or supplemented with additional measures after the October incident. The facility's failure to document and investigate the fall on October 22, 2024, further contributed to the deficiency. Interviews with the Director of Nursing and the Administrator confirmed that no incident report or investigation was conducted for the fall, and no new fall prevention strategies were implemented. Observations revealed that the resident was found on the floor beside the bed, and although the resident was assessed with no new injuries, the lack of a new intervention to prevent future falls was evident. The facility's Incident and Accidents policy, which emphasizes the need for immediate interventions and corrective actions, was not adhered to in this case.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) in an Enhanced Barrier Precautions (EBP) room for a resident requiring such precautions due to an ostomy, pressure injury, and urinary catheters. During an observation, a registered nurse (RN) performed wound care without donning a gown, which is required for high-contact care activities in EBP rooms. The RN confirmed the omission of the gown during an interview, and the Director of Nursing (DON) acknowledged that the expectation for PPE use includes wearing gloves, gowns, and face shields if necessary during wound care. Additionally, the facility did not ensure proper hand hygiene was performed by staff during care for two residents. One resident with a urinary indwelling catheter and a knee wound did not receive care with the required hand hygiene standards. The RN performed hand hygiene for less than the required 20 seconds and did not wear a gown during wound care. The DON confirmed the expectations for hand washing and PPE use were not met. Another resident's catheter care was observed with similar deficiencies, where nurse aides did not perform hand hygiene adequately and used the same gloves to handle clean wipes, which was confirmed as inappropriate by the DON. The facility also failed to maintain the cleanliness of a resident's BiPAP machine, specifically the disposable filter, which was observed to be dark gray and coated with a fuzzy substance. The resident confirmed that the filter had not been cleaned or replaced, and the DON acknowledged the oversight. The facility's policy required the replacement of disposable filters twice monthly, which was not adhered to, leading to the deficiency.
Failure to Monitor Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that daily weights were completed according to physician's orders for four residents. The facility's Weight Monitoring policy required a weight monitoring schedule to be developed upon admission and, if clinically indicated, to monitor weights daily. However, the records for Residents 1, 3, 5, and 6 showed that daily weights were not consistently recorded as ordered by their physicians. Resident 1, who had diagnoses including Acute Systolic Heart Failure and Morbid Obesity, was supposed to have daily weights taken in the morning. However, only one weight was recorded during their stay. Similarly, Resident 3, with conditions such as CHF and brain cancer, was ordered to have daily weights before breakfast, but multiple dates were missing from the records. Resident 5, diagnosed with Schizoaffective Disorder and COPD, also had missing weight records despite the physician's order for daily weights before breakfast. Resident 6, who had Paranoid Schizophrenia and COPD, was also supposed to have daily weights taken before breakfast, but the records showed numerous dates where weights were not recorded. Interviews with the facility's Regional Clinical Nurse confirmed that the weights for these residents were not taken daily as required by the physician's orders. The failure to adhere to the weight monitoring schedule as per physician's orders constitutes a deficiency in the facility's care practices.
Inadequate Staffing Leads to Bathing Deficiency
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the bathing needs of residents, as evidenced by the lack of regular bathing for four sampled residents. The facility's policy stated that residents should receive showers as per request or according to the facility's schedule, but a review of the Bath QAPI revealed that residents were not receiving the minimum of two baths per week. Interviews with staff, including a Nursing Assistant, Medication Aide, and Registered Nurse, confirmed that the facility was short-staffed, leading to the bath aide being reassigned to other duties, resulting in incomplete bathing tasks. Resident 3, who was cognitively intact and required substantial assistance with bathing, reported receiving only one bath in the previous 30 days. Observations noted the resident's hair was greasy, indicating inadequate personal hygiene care. Similarly, Resident 4, who was dependent on staff for bathing, had not been offered a bath in the previous 30 days, and observations showed the resident's hair was greasy and unkempt. Interviews with family members confirmed the lack of sufficient staff to provide regular bathing. The facility's staffing schedule revealed multiple instances of being short-staffed across various shifts, with no scheduled bath aide on certain days. The Director of Nursing confirmed the absence of bathing logs and acknowledged that bathing preferences were not being completed. The facility's assessment identified specific staffing needs, but the actual staffing levels did not meet these requirements, contributing to the deficiency in providing adequate bathing care for residents.
Deficiency in Wound Monitoring and Documentation
Penalty
Summary
The facility failed to adequately monitor and document the condition of wounds for two residents, leading to a deficiency in care. Resident 5, who was admitted with a history of septicemia, diabetes, and osteomyelitis, had a surgical wound on the left heel that required regular monitoring and documentation as per the comprehensive care plan. However, the facility's records showed a lack of detailed documentation regarding the wound's characteristics, such as tissue type, color, drainage, signs of infection, and peri-wound skin condition, across multiple weekly evaluations and progress notes. Similarly, Resident 8, who was admitted with cellulitis, septicemia, and diabetes, had a diabetic foot ulcer and other open lesions that required careful monitoring. Despite the care plan's directives for weekly skin checks and wound monitoring, the facility failed to document essential details about the wounds, including measurements and signs of infection, in the weekly skin evaluations and progress notes. Observations during wound care revealed that measurements were not taken, and the documentation was incomplete. Interviews with the LPN and the Assistant Director of Nursing confirmed the lack of comprehensive wound documentation for both residents. The facility's policies on wound treatment management and skin assessment were not adhered to, resulting in incomplete records and a failure to meet professional standards of quality care for the residents' wounds.
Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility staff failed to adequately monitor and document the condition of a pressure ulcer for a resident, identified as Resident 10, who was admitted to the facility with significant medical conditions including paraplegia and spina bifida. The resident had functional limitations in the range of motion to both lower extremities and required total assistance with bed mobility and transfers. The resident was identified with an unstageable pressure ulcer that was not present upon admission, and the facility provided pressure-reducing devices and other interventions. Despite these interventions, the facility's documentation was lacking. The resident's weekly skin evaluations from mid-June to the end of July did not include necessary details such as wound observation, measurements, type of tissue, color of the wound bed, drainage, signs and symptoms of infection, condition of peri-wound skin, and odor. A late entry in the progress notes indicated that the resident was seen by a wound nurse on two occasions, but the documentation was not timely or comprehensive. An observation in early August revealed that the resident's sacral ulcer was not actively draining but had slough and rolled wound edges, with surrounding skin reddened. The Assistant Director of Nursing confirmed that the monitoring of the pressure ulcer was not completed for the resident, indicating a deficiency in the facility's care and documentation practices.
Failure to Properly Determine Death of Residents
Penalty
Summary
The facility failed to follow proper protocol in determining the death of two residents, leading to significant deficiencies. In the case of Resident 1, the resident was pronounced dead by RN-A without a complete assessment of vital signs, as required by the facility's protocol. The RN did not obtain a blood pressure reading and failed to have a second licensed nurse verify the absence of vital signs. Consequently, the resident was mistakenly sent to a funeral home, where it was discovered that the resident was still alive. For Resident 2, there was no documented evidence that an assessment was completed to determine the absence of vital signs at the time of death. The nursing progress notes lacked documentation of the vital signs assessment, and the Record of Death was not completed according to the facility's process. This oversight indicates a failure to adhere to the established procedures for confirming a resident's death. These incidents highlight a critical lapse in the facility's adherence to its own protocols for determining death, resulting in immediate jeopardy. The lack of proper assessment and verification of vital signs in both cases underscores the need for strict compliance with established procedures to ensure accurate determination of death and appropriate handling of residents' bodies.
Removal Plan
- Immediate Corrective Actions included the RN on duty was suspended pending an investigation to determine processes and procedures were followed to determine end of life. The RN was educated by the DON or designee and followed by suspension.
- The DON or designee began educating current staff and agency staff on the following processes: The process for determining the death of a resident with an updated guidance tool. Change of condition.
- At Morning Stand up the leadership team will discuss any new hires and agency staff, to verify that they were educated in the above procedures. This will be audited by the Administrator/DON or designee.
- The updated guidance tool will be utilized on suspected deaths.
- All new staff will be educated by DON or designee on the above processes during orientation to the building.
- Education will continue until clinical staff are educated prior to their next scheduled shift on the processes listed above. This will be completed by the DON or designee.
- All staff will be re-educated on the process listed above during the all-staff meeting by the DON or designee.
Failure to Implement Practitioner's Orders and Notify Emergency Medical Personnel
Penalty
Summary
The facility staff failed to evaluate, implement practitioner's orders, and initiate notification of emergency medical personnel for a change in condition for one resident. The resident had multiple diagnoses, including pulmonary hypertension, congested heart failure, atrial fibrillation, venous insufficiency, essential hypertension, and altered mental status. The resident's advanced directive indicated a wish to receive CPR. On the day of the incident, the resident experienced discomfort related to an indwelling catheter, which was addressed by the Assistant Director of Nursing (ADON). Shortly after, the resident became unresponsive, and the ADON was informed of the resident's condition change and instructed to send the resident to the hospital by the provider. However, the resident was not sent to the hospital promptly, and CPR was initiated only after the resident became dusky and unresponsive. Emergency Medical Services (EMS) arrived and continued CPR, but the resident expired shortly after. Interviews with the family member, facility staff, and the Advanced Practice Registered Nurse (APRN) revealed that the ADON was aware of the resident's condition change and had received orders to send the resident to the hospital. The Licensed Practical Nurse (LPN) on duty did not follow the facility policy and failed to notify the provider of the resident's condition. The ADON and LPN did not act promptly to send the resident to the hospital, resulting in a delay in emergency care. The Director of Nursing (DON) confirmed that the provider should have been called when the resident's blood pressure was critically low and that the resident should have been sent to the hospital as per the APRN's orders. The facility's policy on Medical Emergency Response was not followed, as the nurse did not stay with the resident, designate a staff member to announce a Code Blue, or call 911 immediately. The facility's abatement plan included suspending the LPN pending investigation, educating current and agency staff on the relevant policies, and ensuring all new staff receive education on these policies during orientation.
Removal Plan
- LPN-A did not follow the facility policy and was suspended pending the outcome of the facility investigation
- began educating current staff and agency staff on the policies listed below
- education will continue until all staff are educated on policies listed below
- all staff will be reeducated on the policies listed below during the all-staff meeting
- Medical Emergency Response- calling 911 immediately
- CPR Policy
- Change of condition
- all new staff will be educated on the above policies during orientation to the building
- all new agency staff will be educated on the above policies during general orientation to the building
Failure to Safely Transport Resident
Penalty
Summary
The facility failed to safely transport a resident, resulting in the resident sliding out of their wheelchair during transport. On 1/31/2024, Van Driver-E transported Resident 1 to a hospital appointment. While on the interstate, another vehicle crossed into the facility van's lane, causing Van Driver-E to slam on the brakes. Resident 1 informed the driver that they were sliding out of the wheelchair and ended up sitting on the foot pedals. Van Driver-E pulled off the interstate to check on Resident 1 and observed that the right restraint belt had pulled out of the floor mount latch. The driver then continued to the hospital, where emergency room staff called the local Fire and Rescue to assist in lifting Resident 1. The resident was evaluated in the emergency room and was found to have a knee contusion and neck strain but did not sustain injuries from sliding out of the wheelchair to the floor in the van. The facility's records did not document the van incident or any assessment of Resident 1 upon their return to the facility. Additionally, there was no documentation indicating that the facility evaluated Resident 1 for safety within the transportation van. Interviews with Resident 1's family members confirmed the incident, and the Therapy Director revealed that no safety assessments were completed for residents using the transportation van. The Regional Director also confirmed the lack of safety assessments for the transportation van for Resident 1.
Failure to Follow PPE, Sanitization, and Wound Care Protocols
Penalty
Summary
The facility failed to ensure staff donned and doffed the required PPE when entering a resident's room marked for transmission-based precautions (TBP) for COVID-19. Observations revealed that staff members, including a Licensed Practical Nurse (LPN) and Nursing Assistants (NAs), entered or leaned into TBP rooms without wearing the necessary PPE such as masks, gowns, gloves, and eye protection. Interviews with the staff indicated a lack of awareness or adherence to the TBP protocols, which was confirmed by the Director of Nursing (DON). This failure had the potential to affect all 49 residents in the facility, as the facility census was 49 at the time of the surveyor's visit. The facility also failed to ensure proper sanitization and handling of COVID-19 testing surfaces and materials. Observations showed that a Registered Nurse (RN) placed COVID-19 test cards on unsanitized surfaces and did not use barriers to prevent cross-contamination. Additionally, the RN did not wait the required 15 minutes before reading the test results, instead reading them prematurely. The DON confirmed that the RN should have sanitized the surfaces and waited the full 15 minutes before reading the test results. Furthermore, the facility did not adhere to proper hand hygiene and wound care protocols. An LPN was observed performing wound care on a resident with vascular wounds without changing gloves or performing hand hygiene between different wound sites. The LPN used the same towel to dry multiple wounds and did not change gloves between handling different body parts. The DON confirmed that the LPN should have performed hand hygiene and changed gloves between each wound site and when moving from one foot to the other.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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