Arbor Care Centers - Ord, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ord, Nebraska.
- Location
- 220 South 26th Street, Ord, Nebraska 68862
- CMS Provider Number
- 285294
- Inspections on file
- 20
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Arbor Care Centers - Ord, Llc during CMS and state inspections, most recent first.
The facility did not notify the State Agency within the required timeframe after changes in the Administrator position, as confirmed by record review and interviews with the administrator and owner. Notification forms for two separate administrator changes were submitted late, potentially affecting all 39 residents.
A resident with multiple myeloma did not consistently receive their prescribed chemotherapy medication, lenalidomide, due to repeated lapses in ordering, availability, and administration. The medication was not given according to the required 28-day cycle, with missed and delayed doses documented over several months. Staff and pharmacy interviews confirmed gaps in ordering and delivery, and there was no evidence that the prescribing oncologist was notified of these medication errors.
The facility failed to maintain sanitary conditions in food storage areas, with rodent droppings observed in multiple locations. The Food Services Supervisor acknowledged the issue and the need for more cleaning. This deficiency had the potential to affect all 32 residents.
The facility failed to maintain an effective pest control program, as evidenced by rodent droppings in food storage areas. The Food Services Supervisor acknowledged the issue, noting a lack of live mouse traps in the kitchen. The Facility Administrator was unaware of the problem, despite the facility's policy requiring an ongoing pest control program.
The facility failed to maintain a safe and clean environment, with stained carpets and ceiling tiles, a deceased bug in a light fixture, and loose flooring creating trip hazards in multiple hallways. The Maintenance Manager confirmed these issues, noting that carpets were only cleaned biannually and ceiling tiles had not been replaced after a water leak repair.
The facility failed to complete pre-employment health screenings for staff and did not adhere to hand hygiene protocols during medication administration. Additionally, staff did not follow Enhanced Barrier Precautions for residents with multidrug-resistant organisms, failing to wear gowns and gloves during high-contact care activities. These deficiencies were confirmed by facility management and observed during resident care.
The facility failed to ensure proper bathroom ventilation in three rooms, as the ventilation systems were unable to pull up a single ply of tissue, indicating inadequate ventilation. This was confirmed by the Maintenance Manager, who acknowledged the malfunction.
The facility failed to notify physicians of abnormal lab results for a resident with diabetes and out-of-range blood pressure readings for two residents with Parkinson's Disease and hypertensive heart disease. Despite having orders to notify physicians of these conditions, there was no documentation of such notifications, as confirmed by interviews with facility staff.
A resident with a history of falls and severe cognitive impairment experienced multiple falls due to inadequate fall prevention interventions. Despite the facility's policy, no new interventions were developed after a fall, and the resident was frequently left in a wheelchair instead of a regular chair as per the care plan. Additionally, the resident's mattress was not secured to the bedframe, posing a safety risk. Staff interviews revealed that fall prevention measures were not effectively communicated or implemented.
The facility failed to manage pain effectively for two residents, both experiencing chronic pain conditions. Despite receiving routine and as-needed pain medications, their pain was not adequately controlled, with frequent moderate to severe pain ratings. Staff did not notify providers about the frequent use of as-needed medications, which could have led to adjustments in pain management plans. Interviews confirmed the deficiency in communication and pain management strategies.
A facility failed to limit a PRN psychotropic medication order for a resident to 14 days as required. The resident received Lorazepam beyond the 14-day limit without a documented rationale from a physician. The oversight was noted by a consultant pharmacist, but the facility's Infection Control Coordinator was unaware of the issue until later, and a necessary note to the attending physician was not sent for review.
The facility failed to ensure clear and accurate medication labeling for two residents. One resident's insulin pen label was illegible, obscuring administration directions, while another resident's medication label did not match the physician's order. These issues were confirmed by nursing staff and the Director of Nursing.
Failure to Timely Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the State Agency within the required five working days following changes in the Administrator position, as mandated by licensure regulations. Record review showed that the Change of Administrator Notification Form for an administrator change occurring between 11/19/2025 and 11/20/2024 was not submitted to the State Agency until 12/16/2025. Similarly, for another administrator change between 6/10/2025 and 6/11/2025, the notification form was not sent until 7/12/2025. Interviews with the administrator and facility owner confirmed that both notifications were submitted outside the required timeframe. This deficiency had the potential to affect all 39 residents in the facility.
Failure to Ensure Timely Administration and Availability of Prescribed Chemotherapy Medication
Penalty
Summary
The facility failed to ensure that a resident with multiple myeloma received their prescribed medication, lenalidomide, according to the physician's orders. The medication was to be administered in a 28-day cycle, with 21 days on and 7 days off, but there were multiple documented instances where the medication was not available or not administered as ordered. Review of the Medication Administration Records (MAR) over several months revealed repeated gaps in administration, with cycles starting late, not restarting on time, or being missed entirely. There was no physician order to stop the medication at any point, and the MARs did not reflect any authorized changes to the regimen. Interviews with facility staff and the infection preventionist (IP) confirmed that the medication was only available through a specialty pharmacy, which required the facility to order the medication for each cycle individually. The IP acknowledged that the medication order would fall off the electronic system after a few months and had to be manually re-entered, which contributed to the missed doses. The pharmacy representative corroborated that there were months when no medication was ordered or delivered, and staff interviews confirmed that there were times when the medication was not available for administration. There was also a lack of documentation or receipts to show that the medication was obtained from any other source during the periods when the pharmacy did not deliver it. Additionally, there was no evidence that the resident's oncologist was notified of the medication errors, despite the ongoing issues with medication availability and administration. Staff interviews indicated inconsistent practices regarding the storage and tracking of the medication, with reports of extra medication being kept in the medication cart at times, but no clear process for ensuring continuous supply. The facility's failure to maintain a consistent supply and administration of the prescribed medication led to significant lapses in care for the resident.
Rodent Droppings Found in Food Storage Areas
Penalty
Summary
The facility failed to store food under sanitary conditions, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to the kitchen's dry storage area, where food items were stored off the floor. However, there was a 4-inch gap between the shelving and the floor, where individual food packs and wooden snap mouse traps were visible. In the main storage area, which contained a refrigerator, freezers, and dry food shelving units, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered all over the floor, with a concentration in specific areas, and sticky mouse traps were present by the delivery entryway. The FSS acknowledged awareness of the mouse droppings and stated that live mouse traps were not available in the kitchen. Additionally, the FSS admitted that more cleaning was needed. The facility's policy on dietary sanitation requires that all kitchen and dining areas be kept clean and free from rodents and other pests. The failure to adhere to these standards had the potential to affect all 32 residents of the facility.
Pest Control Deficiency in Food Storage Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodent droppings in and around the food storage areas. During an observation, the Food Services Supervisor (FSS) directed the surveyor to a kitchen area with a dry storage section where a 4-inch gap was found under the storage, containing food items and four wooden snap mouse traps. In the main storage area, which included a refrigerator, freezers, and shelving units for dry and canned food items, the floors were observed to have dried pasta, corn kernels, and a buildup of dark soiling. Mouse droppings were littered across the floor, with a concentration in specific areas, and sticky mouse traps with dead bugs were found near the delivery entryway, along with additional mouse droppings. The FSS acknowledged awareness of the mouse droppings and admitted that live mouse traps were not available in the kitchen as they were in other facility areas. The FSS mentioned that some cleaning had been done, but more was needed. The Facility Administrator (FA) was interviewed and revealed they were unaware of the rodent droppings in the dry food storage area. The facility's policy on pest control, which was undated, indicated that an ongoing pest control program should be maintained to keep the building free of insects and rodents, but this was not effectively implemented.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed in multiple hallways. In the 300 Hall, the carpet was stained and discolored, with a large dark ring extending into the hallway. The commons area near the nurse's station also had discolored areas. In the 400 Hall, ceiling tiles were stained and warped, and a deceased bug was found in a light fixture. The carpet and laminate flooring in several rooms were loose, creating trip hazards. The 500 Hall had stained ceiling tiles, and the 700 Hall had loose carpet and cracked tiles at the thresholds, with a buildup of a black, thick brown substance. The Maintenance Manager confirmed the issues, acknowledging that the ceiling tiles were warped and stained due to a previous water leak that had been repaired, but the tiles had not yet been replaced. The carpets were only cleaned twice a year by an outside company, with no interim cleaning, leading to varying degrees of staining throughout the facility. The Maintenance Manager also confirmed the presence of the bug in the light fixture and the loose and cracked flooring at the door thresholds.
Infection Control and Staff Health Screening Deficiencies
Penalty
Summary
The facility failed to complete and review pre-employment health histories for four sampled staff members, which is a critical step in ensuring that employees are free of communicable diseases before working with residents. The Business Office Manager confirmed that the Employee Health History Screen forms for the housekeeper, medication aide, dietary aide, and maintenance manager were incomplete and not reviewed by facility staff. This oversight could potentially expose residents to health risks from staff who may carry communicable diseases. During medication administration, a registered nurse failed to perform hand hygiene between resident contacts, which is a violation of the facility's hand hygiene policy. The nurse did not sanitize hands after administering medications to two residents and before preparing medications for another. Additionally, the nurse did not sanitize hands after removing gloves post-procedure when obtaining a resident's blood sugar. This lack of adherence to hand hygiene protocols increases the risk of cross-contamination and infection among residents. The facility also failed to follow Enhanced Barrier Precautions for residents known to be colonized or infected with multidrug-resistant organisms. Staff did not wear gowns and gloves during high-contact care activities for two residents, despite clear signage and policy requirements. This non-compliance was observed during transfers, toileting, and wound care, where staff had direct contact with residents without the necessary protective equipment. The Director of Nursing Services acknowledged the need for revised training to ensure staff are educated on these precautions.
Inadequate Bathroom Ventilation in Three Rooms
Penalty
Summary
The facility failed to ensure proper bathroom ventilation in three rooms, as required by licensure reference number 175NAC 12-007.04(D). During observations conducted on August 22, 2024, it was noted that the ventilation systems in the bathrooms of three specific rooms were unable to pull up a single ply of tissue, indicating inadequate ventilation. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged that the ventilation systems in these rooms were not functioning correctly and should have been able to perform the tissue test successfully.
Failure to Notify Physicians of Abnormal Lab Results and Blood Pressure Readings
Penalty
Summary
The facility failed to notify the provider of abnormal laboratory results for Resident 21, who was admitted with type two diabetes. The resident had a Hemoglobin A1C (HbA1C) test result of 9.10, which was significantly higher than the normal range of 4.80-6.00. Despite the abnormal result, there was no documentation indicating that the provider was notified or had reviewed the abnormal value. Interviews with the facility's Medical Records staff and the Director of Nursing confirmed the lack of notification and review. Additionally, the facility did not notify the physician of out-of-range blood pressure readings for Resident 24 and Resident 4. Resident 24, who was admitted with Parkinson's Disease, had several instances of systolic blood pressure readings below 100, which required physician notification according to the care plan. However, there was no documentation of such notifications. Similarly, Resident 4, who had a diagnosis of cervical spinal cord injury and hypertensive heart disease, also had multiple instances of systolic blood pressure readings below 100, with no evidence of physician notification. Interviews with the facility's Registered Nurse and Director of Nursing confirmed the absence of documentation for physician notifications regarding the out-of-range blood pressure readings for both residents. The expectation was for the nurse or charge nurse on duty to contact the physician's office and document the information in the progress notes, which was not done in these cases.
Failure to Implement Fall Prevention and Secure Mattress
Penalty
Summary
The facility failed to implement adequate fall prevention interventions for a resident, identified as Resident 25, who had a history of falls, anxiety, unsteadiness on feet, and muscle weakness. Despite the facility's policy requiring a Fall Incident and Investigation report and interdisciplinary review after a fall, no new interventions were developed following a fall on March 20, 2024, where Resident 25 and their spouse/roommate, Resident 28, fell while attempting a bathroom transfer. On August 19, 2024, Resident 25 experienced another fall under similar circumstances, yet the care plan only included an intervention to have staff assist Resident 25 back to their room from meals, which was not implemented as observed on August 21, 2024. Observations revealed that Resident 25 was frequently left in a wheelchair at the dining room table, contrary to the care plan's intervention to place them in a regular chair to prevent falls. Staff interviews confirmed that new or revised fall prevention interventions were expected but not effectively communicated or implemented. The Medication Aide-G indicated that staff often did not have time to read updates on the computer dashboard, which lacked information about Resident 25's fall and updated prevention measures. Additionally, the facility failed to ensure the mattress on Resident 25's bed was secured to the bedframe, creating a potential entrapment and fall hazard. The Maintenance Manager confirmed that the facility did not check if mattresses were secured and was unaware of devices to secure them. This oversight further compromised the safety of Resident 25, who had severe cognitive impairment and was at increased risk of falls.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, Resident 18 and Resident 21, as identified during a survey. Resident 18, admitted with multiple chronic pain-related diagnoses, frequently experienced moderate to severe pain that interfered with daily activities. Despite receiving both routine and as-needed pain medications, the resident's pain was not adequately controlled, as evidenced by frequent high pain ratings. The facility's staff did not notify the resident's provider about the frequent use of as-needed pain medication, which could have led to adjustments in the resident's pain management plan. Similarly, Resident 21, who also had chronic pain conditions, reported frequent pain that disrupted sleep and daily activities. The resident's pain was consistently rated at moderate to severe levels, and the resident often required as-needed pain medication during early morning hours. The staff did not inform the resident's provider about the frequent need for additional pain relief, which might have prompted a review and adjustment of the resident's pain management regimen. Interviews with the facility's nursing staff and the Director of Nursing confirmed that both residents' pain was not adequately controlled and that the providers had not been notified to consider changes in the pain management plans. This lack of communication and failure to adjust pain management strategies contributed to the deficiency in providing appropriate pain management for the residents.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure compliance with the regulation that PRN psychotropic medications are limited to 14 days unless re-evaluated and re-ordered by a physician. This deficiency was identified for one resident, who had an order for Lorazepam, a psychotropic medication, to be administered every 12 hours as needed for anxiety or agitation. The order, which started on 8/5/24, did not have an end date, and the medication was administered beyond the 14-day limit, specifically on the 15th day. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless a physician documents a rationale for extending the order. However, the consultant pharmacist noted the absence of a 14-day stop date in their review, and the facility's Infection Control Coordinator was unaware of this note until it was brought to their attention. Additionally, a note to the attending physician regarding the 14-day limit was not sent for review, which contributed to the oversight.
Medication Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled clearly and accurately for two residents, leading to deficiencies in medication administration. Resident 18, who was admitted with type two diabetes mellitus, received Humalog Insulin injections per a sliding scale schedule. During a medication administration observation, it was noted that the insulin pen label was illegible due to smeared ink, obscuring the resident's name and administration directions. This issue was confirmed by both the administering nurse and the Director of Nursing, indicating a failure to adhere to the facility's policy on medication labeling. Similarly, Resident 29, admitted with hypertensive heart disease, had a discrepancy between the medication label and the physician's order. The medication card label indicated Potassium Chloride 20 MEQ, while the Medication Administration Record specified Potassium Chloride ER 20 MEQ. This inconsistency was observed during medication administration and confirmed by the nurse and the Director of Nursing. The mismatch between the medication label and the physician's order highlights a failure in ensuring accurate medication labeling and administration.
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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