Arbor Care Centers-countryside Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Nebraska.
- Location
- 703 North Main Street, Madison, Nebraska 68748
- CMS Provider Number
- 285207
- Inspections on file
- 25
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Arbor Care Centers-countryside Llc during CMS and state inspections, most recent first.
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.
Staff failed to consistently use Enhanced Barrier Precautions, including gowns and gloves, during high-contact care for residents with wounds, indwelling devices, or MDROs, and did not follow proper hand hygiene or equipment cleaning protocols. Observations included improper cleaning and storage of a CPAP machine, omission of gowns during catheter and toileting care, and failure to perform hand hygiene at required intervals.
A resident with dementia, bladder incontinence, and self-care deficits following a hip fracture did not receive bathing assistance at least weekly as required. Bathing records showed intervals of up to 13 days between baths, despite the resident's dependence on staff for ADLs and the facility's policy to provide bathing services based on individual needs.
The facility did not complete required post-fall assessments and documentation after a resident experienced an unwitnessed fall with injury, and also failed to consistently follow physician's orders for wound care treatments for another resident, with multiple missed or undocumented treatments confirmed by the DON.
Two residents with multiple chronic conditions and cognitive impairment were neither offered nor given the pneumococcal vaccine, and there was no documentation in their medical records to show the vaccine was offered, administered, or declined, as confirmed by facility staff.
The facility did not meet the requirement of having an RN on duty for 8 hours daily, as there was no RN coverage on three consecutive days in November 2024. This was confirmed by the DON during an interview.
The facility did not follow its policy to address pharmacist recommendations for two residents' medication regimens. A resident's recommendations for dose reductions and medication clarifications were not forwarded to the provider timely, and another resident's medication stop date requests were not addressed. The facility lacked evidence of timely communication and resolution of these issues.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with MRDOs, as a nurse aide did not wear a gown during high-contact care activities. Additionally, the facility lacked ongoing evidence of antibiotic surveillance, with only one month of data available from the past 13 months, as confirmed by the Infection Preventionist.
A resident with a history of falls and medical conditions requiring supervision was frequently left unattended in a wheelchair, contrary to their care plan. Despite being dependent on staff for transfers and mobility, the resident was observed alone multiple times, attempting to get up and calling for help. Staff interviews confirmed the resident's needs, and the DON acknowledged the failure to follow the fall prevention plan, leading to the deficiency.
A facility failed to ensure a resident's long-term antibiotic use had a clinical rationale or ordered duration, violating its Antibiotic Stewardship Program. The resident, dependent on assistance and frequently incontinent, was on Nitrofurantoin Macrocrystal since 2020 for chronic cystitis prevention. The Infection Preventionist confirmed no ongoing infection surveillance or antibiotic use review, leading to the deficiency.
A facility failed to follow its Antibiotic Stewardship Policy by not providing stop dates or documented clinical rationale for a resident's ongoing antibiotic use. The resident, who required substantial assistance and was frequently incontinent, was on a scheduled antibiotic for chronic cystitis prevention. The Medication Administration record showed the resident was taking Nitrofurantoin Macrocrystal daily since 2020 without a defined duration. The IP-RN confirmed the lack of ongoing infection surveillance or antibiotic use review per the facility's ASP.
The facility failed to evaluate adverse findings in criminal background checks for three staff members, compromising resident protection. Despite policies requiring screening for abuse, neglect, and exploitation histories, the facility did not investigate criminal findings for certain staff, including charges of possession, driving offenses, and shoplifting. The Administrator confirmed the lack of adherence to hiring policies and absence of documented investigations into these findings.
The facility did not comply with its policy to post daily nurse staffing information, which includes the facility's name, date, census, and total hours worked by nursing staff. Observations and record reviews showed no postings were made from December 2 to December 3, 2024, and none were completed over the past 30 days. An RN consultant confirmed the postings were not done.
A facility failed to investigate and report a potential exploitation case involving a resident who was cognitively intact but had delusions and multiple medical conditions. The resident was involved with potential scammers and requested to cash a Social Security check. Despite the Social Service Director contacting APS and the police, no investigation was completed or submitted to the State Agency as required.
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 Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) and proper cleaning protocols. Observations revealed that staff did not consistently use gowns and gloves during high-contact care activities for residents who were either colonized or infected with multidrug resistant organisms (MDROs), had wounds, or had indwelling medical devices. For example, during toileting assistance for one resident and catheter care for another, staff either omitted the use of gowns or failed to perform hand hygiene at appropriate intervals. In several instances, staff were unaware of residents' EBP status or did not follow the policy for donning personal protective equipment during high-contact care. Additionally, the facility did not ensure proper cleaning and storage of resident care equipment, such as CPAP machines. Multiple observations showed a resident's CPAP mask and tubing left on the floor or improperly stored, and staff confirmed that cleaning was not performed according to facility policy or CDC guidelines. This failure to clean and store equipment as required increased the risk of cross-contamination and infection. Hand hygiene practices were also not consistently followed. Staff were observed failing to perform hand hygiene before and after glove use, after removing gloves, and between clean and soiled tasks. These lapses occurred during wound care, catheter care, and incontinent care for multiple residents. Interviews with staff and the infection preventionist confirmed that these practices were not in line with facility policy, which requires hand hygiene at specific intervals during resident care.
Failure to Provide Timely Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide bathing assistance to a resident with dementia, bladder incontinence, and self-care deficits following a recent hip fracture. The resident was dependent on staff for activities of daily living, including bathing, and was unable to bear weight on the left leg. According to the resident's care plan, staff were required to assist with bathing. However, a review of bathing records showed that the resident was not bathed at least weekly, with intervals of up to 13 days between baths. The Director of Nursing confirmed that there was no evidence the resident received bathing assistance at the required frequency, despite the facility's policy to provide bathing services according to individual needs and preferences.
Failure to Complete Post-Fall Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate follow-up evaluations and condition assessments after a resident experienced a fall. Specifically, after a resident slipped and fell in their room, initial documentation indicated the resident was alert, denied hitting their head, and had no visible injuries. However, the following morning, red drainage was observed on the resident's right cheek and shirt, which the resident confirmed was related to the fall. Interviews with facility staff, including the DON and Administrator, confirmed that required neurological assessments, vital signs, and post-fall evaluations were not completed or documented as per facility policy, despite the fall being unwitnessed and resulting in an injury. Additionally, the facility did not follow physician's orders for the treatment of a foot ulcer for another resident. Review of the Treatment Administration Record (TAR) over several months revealed multiple instances where wound care treatments were not signed off as completed, and in some cases, treatments were marked as not done due to the resident sleeping, which was confirmed by the DON as not appropriate. The lack of documentation and completion of ordered treatments indicated that staff were not consistently following physician's orders for wound care.
Failure to Offer or Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide evidence that two residents were up to date with, or had been offered, pneumococcal vaccinations as required by facility policy. According to the policy, all residents should be offered onsite pneumococcal vaccinations annually by October 1. Record review showed that one resident with heart failure, high blood pressure, kidney disease, and moderate cognitive impairment, and another resident with anemia, high blood pressure, diabetes, Alzheimer's disease, dementia, depression, chronic lung disease, and severe cognitive impairment, had not received or been offered the pneumococcal vaccine. There was no documentation in either resident's medical record indicating the vaccine was offered, administered, or declined. Interviews with facility staff confirmed that these residents were not offered the vaccination as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage daily, as mandated by licensure reference number 175 NAC 12-006.04(F). A review of the nurse's schedule for November 2024 revealed that there was no RN coverage on November 1st, 2nd, and 3rd. This deficiency was confirmed during an interview with the Director of Nursing (DON) on December 5th, 2024, at 10:00 AM, where the DON acknowledged the absence of RN coverage on the specified dates.
Failure to Address Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to adhere to its policy of addressing pharmacist recommendations for medication regimen reviews for two residents. For Resident 1, the pharmacist recommended a sleep assessment and dose reductions for Risperdal and Zoloft, as well as a clarification for the use of Nitrofurantoin. Despite these recommendations, there was no evidence that the facility forwarded these to the provider in a timely manner or that the recommendations were addressed according to the facility's policy. The provider did not indicate agreement with the recommendations, and there was no documented response for the Nitrofurantoin clarification. Similarly, for Resident 27, the pharmacist noted the need for a stop date for Ativan and requested a review of two insomnia medications. The provider documented the rationale for the antianxiety medications but did not respond to the insomnia medication review or the stop date request. The facility did not ensure these recommendations were sent to the provider again in a timely manner, and there was no evidence that the identified irregularities were addressed as per the facility's policy.
Failure to Implement Enhanced Barrier Precautions and Maintain Antibiotic Surveillance
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of Multi-Drug-Resistant Organisms (MRDOs) during the care of two residents. Resident 20 required substantial assistance with dressing, transfers, and hygiene, and had skin ulcers and a pressure ulcer. Despite being on EBP for wounds, a nurse aide assisted the resident with toileting and hygiene without wearing a gown, only using gloves. Similarly, Resident 25, who had an active MRDO wound and required moderate assistance, was also assisted by the same nurse aide without the use of a gown, contrary to the care plan that required gown and glove use for high-contact activities. The facility also failed to maintain ongoing evidence of antibiotic surveillance. The Infection Preventionist confirmed that the facility lacked evidence of conducting ongoing and real-time surveillance of infections or reviewing antibiotic use as per their Antibiotic Surveillance plan. The facility was only able to provide one month of infection surveillance data from the past 13 months, indicating a significant lapse in their infection control and prevention program.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for a resident, identified as Resident 27, who was at risk due to their medical conditions, including Non-Traumatic Brain Dysfunction, Dementia, Anxiety, and Depression. The resident was dependent on staff for assistance with transfers and wheelchair mobility. Despite having a care plan that required the resident not to be left alone in their room while in a wheelchair, observations over several days revealed that the resident was frequently left unattended. This lack of supervision occurred even though the resident had a history of falls, including two falls with no injury and two with minor injuries since the last assessment. Observations documented multiple instances where the resident was left alone in their room while seated in a reclining wheelchair, attempting to get up independently, and calling out for assistance. Interviews with nursing assistants confirmed that the resident required a mechanical lift for transfers and was dependent on staff for mobility. The Director of Nursing acknowledged that staff failed to adhere to the fall intervention plan, which increased the risk of further falls. The facility's failure to provide adequate supervision and follow the established fall prevention procedures led to the deficiency identified in the report.
Failure to Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's long-term use of an antibiotic had a clinical rationale for continued use or an ordered duration of use. The facility's Antibiotic Stewardship Program (ASP) policy, revised in March 2023, mandates that all antibiotic prescriptions include a specific dose, duration, and indication for use. However, a review of the resident's care plan and medication administration record revealed that the resident was on a scheduled antibiotic, Nitrofurantoin Macrocrystal, since December 2020, without a defined duration for its use. The resident, who required substantial assistance with daily activities and was frequently incontinent, was receiving the antibiotic for the prevention of chronic cystitis, a condition characterized by chronic bladder inflammation without active infection. During an interview, the facility's Infection Preventionist Registered Nurse (IP-RN) confirmed that there was no evidence of ongoing and real-time surveillance of infections or a review of antibiotic use in accordance with the facility's Antibiotic Surveillance plan. This lack of oversight and adherence to the ASP policy led to the deficiency, as the resident's antibiotic regimen did not comply with the facility's requirements for monitoring and documenting the use of antibiotics, including specifying the duration of use.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Policy, as evidenced by the lack of stop dates or documented clinical rationale for ongoing antibiotic use for a resident. The facility's Antibiotic Stewardship Program (ASP), revised in March 2023, is part of the infection prevention and control program aimed at optimizing infection treatment and reducing adverse events from antibiotic use. The Infection Preventionist (IP), under the Director of Nursing's (DON) oversight, leads the ASP, with support from the Medical Director, Consultant Pharmacist, and attending Physicians. The policy mandates that all antibiotic prescriptions include a specific dose, duration, and indication for use. A review of a resident's records revealed that the resident, who required substantial assistance with daily activities and was frequently incontinent, was on a scheduled antibiotic for chronic cystitis prevention. The resident's Medication Administration record showed they were taking Nitrofurantoin Macrocrystal daily since December 2020, but there was no defined duration for this antibiotic order. During an interview, the IP-RN confirmed the facility lacked evidence of ongoing and real-time infection surveillance or antibiotic use review per their ASP, and the resident's antibiotic order lacked a defined duration.
Failure to Evaluate Criminal Backgrounds of Staff
Penalty
Summary
The facility failed to evaluate adverse findings regarding criminal background checks for three out of five sampled staff members, which compromised the protection of residents from potential abuse. The facility's policy on Abuse, Neglect, and Exploitation outlined the need for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation, including conducting background, reference, and credential checks. However, the facility did not adhere to these policies, as evidenced by the lack of investigation into the criminal background findings of certain staff members. Specifically, the criminal background checks for a Nurse Aid (NA)-M revealed findings of careless driving, possession of marijuana, and driving under suspension; NA-N had findings of possession of controlled substances, transporting a child while intoxicated, driving under suspension, shoplifting, and attempt of a felony; and a Medication Aid (MA)-O had findings of driving under the influence of alcohol. The facility's failure to investigate these findings and determine the suitability of these individuals for employment was confirmed during interviews with the facility Administrator. The Administrator admitted that hiring decisions were finalized through Human Resources after reviewing background checks, but there was uncertainty about how the facility recorded the review of these checks or the conclusions of the hiring decisions. Furthermore, the Administrator confirmed that the facility had not followed its hiring and HR policy related to criminal background checks and had no documented evidence that the findings on the criminal history checks were further investigated to determine if the employees were appropriate or suitable for positions on the nursing staff.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which is essential for transparency and accountability in resident care. The facility's policy, dated January 2024, mandates that a Nurse Staffing Sheet be posted daily, including details such as the facility's name, date, census, and total actual hours worked by licensed and unlicensed nursing staff. This information should be displayed prominently for residents and visitors. However, observations on December 2 and December 3, 2024, revealed no staff postings throughout the facility. Record reviews further indicated a lack of evidence for staff postings from December 2 to December 3, 2024, and no postings were completed over the past 30 days. An interview with an RN consultant confirmed that the Nurse Staff Posting had not been completed or posted.
Failure to Investigate and Report Potential Exploitation
Penalty
Summary
The facility failed to investigate an allegation of potential abuse, misappropriation, or exploitation concerning a resident and did not submit the results of the investigation to the State Agency as required. The facility's policy mandates that all suspected acts of abuse, neglect, exploitation, or misappropriation of resident property be promptly reported and thoroughly investigated, with a written report submitted to the State Agency within five working days. However, despite the Social Service Director (SSD) and the Director of Nursing (DON) being aware of the resident's interactions with potential scammers and the resident's request to cash a Social Security check, no investigation was conducted or reported to the State Agency. The resident involved was cognitively intact but had delusions and was diagnosed with osteomyelitis, gas gangrene, major depressive disorder, anxiety, and diabetes. The resident was also identified as having a diabetic foot ulcer and a surgical wound. The SSD and DON were aware of the resident's potential exploitation by scammers, as the resident had been buying Apple cards to send to them. Despite the SSD contacting Adult Protective Services (APS) and the local police on the recommendation of the State Ombudsman, the facility did not complete or submit a written investigation to the State Agency within the required timeframe.
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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