Beatrice Health And Rehabilitaion
Inspection history, citations, penalties and survey trends for this long-term care facility in Beatrice, Nebraska.
- Location
- 1800 Irving Street, Beatrice, Nebraska 68310
- CMS Provider Number
- 285130
- Inspections on file
- 21
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beatrice Health And Rehabilitaion during CMS and state inspections, most recent first.
A deficiency was found when a cook failed to perform hand hygiene for the required 20 seconds and did not wash hands before donning gloves while preparing and serving food. The Certified Dietary Manager confirmed these actions were not in line with facility policy, potentially affecting all residents.
Staff failed to follow proper hand hygiene and infection control procedures during catheter and perineal care for two residents, including not performing hand hygiene before and after glove use, using contaminated gloves to remove wipes from containers, and placing a catheter drainage bag above bladder level during a transfer. These actions were confirmed by staff interviews and were not in accordance with facility policies.
The facility failed to maintain the cleanliness of vents in multiple resident rooms, with a thick brown buildup of debris observed. The Maintenance Director confirmed the lack of a policy or procedure for vent checks or cleaning, and the Housekeeping Supervisor confirmed that vents were not on the cleaning list.
The facility failed to maintain the indwelling catheter drainage bag below bladder level during toileting and catheter care for a resident with neuromuscular dysfunction of the bladder and overactive bladder. The catheter drainage bag was observed above bladder level for 20 minutes, confirmed by nursing assistants and the Director of Nursing.
A resident's medications were administered late due to the resident visiting with their spouse. The Medication Aide did not inform the charge nurse about the delay, contrary to facility policy. The Director of Nursing confirmed the need for timely administration and communication with the charge nurse.
The facility failed to maintain mechanical ventilation in resident bathrooms in rooms 38, 39, 40, 47, and 48. Observations and interviews confirmed non-functioning vents and a lack of policy, procedure, and documentation for vent function checks.
The facility failed to obtain a physician's order for a CPAP for a resident with Obstructive Sleep Apnea. The resident had been using the CPAP nightly since admission, but no order was documented in the records, and it was not listed on the eMAR. The Director of Nursing confirmed the oversight.
The facility failed to ensure a resident was free from unnecessary medications by not attempting a gradual dose reduction (GDR) for psychotropic medications, despite the resident showing no documented behaviors, hallucinations, delusions, or signs of depression for several months. Interviews with the DON confirmed no GDRs were completed in the last year, and the facility's policy requiring GDR and behavioral intervention was not followed.
The facility failed to perform proper hand hygiene during wound care for one resident and catheter care for another. Staff did not change gloves or perform hand hygiene between tasks, and hand washing was insufficient. These lapses were confirmed during interviews with the staff involved and the Director of Nursing.
Failure to Ensure Proper Hand Hygiene in Kitchen
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure proper hand hygiene practices in the kitchen, as required to prevent the spread of foodborne illness. During meal preparation, the cook was observed performing hand hygiene with soap and water for less than the facility's required 20 seconds on multiple occasions. Additionally, the cook was seen donning gloves without performing hand hygiene beforehand, specifically before serving breakfast plates to staff for resident service. These actions were not in accordance with the facility's Infection Control Prevention and Control Program-Hand Hygiene Policy, which mandates hand hygiene before handling food and before donning gloves. The Certified Dietary Manager confirmed that the cook should have performed hand hygiene for at least 20 seconds and before putting on gloves. The facility's policy also specifies the use of alcohol-based hand rub or soap and water before and after handling food. The failure to follow these procedures had the potential to affect all 55 residents in the facility, as proper hand hygiene is considered the primary means to prevent the spread of infection.
Failure to Follow Hand Hygiene and Infection Control During Catheter and Perineal Care
Penalty
Summary
Staff failed to perform proper hand hygiene and infection control practices during catheter and perineal care for two residents. In one instance, two nurse aides provided catheter care to a resident with multiple diagnoses, including neuromuscular dysfunction of the bladder and multiple sclerosis, without performing hand hygiene before donning gowns and gloves. During the procedure, contaminated gloves were repeatedly used to remove cleansing wipes from the container, and hand hygiene was not performed after glove removal. The catheter drainage bag was also placed at or above the level of the bladder during a transfer, contrary to facility policy and physician orders. Both nurse aides confirmed in interviews that these actions were not in accordance with proper infection control procedures. In another case, two nurse aides performed catheter and perineal care for a resident with an indwelling catheter and multiple medical conditions, including fractures and chronic respiratory failure. Although hand hygiene was performed before donning gowns and gloves, one aide repeatedly reached into the wipes package with soiled gloves and failed to change gloves or perform hand hygiene between cleaning different body areas. The same soiled gloves were used to apply barrier cream to both the buttocks and the labia/groin folds without changing gloves or performing hand hygiene in between. The aide confirmed in an interview that these actions were not appropriate and did not follow infection control protocols. Facility policy reviews revealed that hand hygiene is required before and after handling invasive devices, after removing gloves, and after contact with blood or bodily fluids. Policies also specify that gloves do not replace hand hygiene and that the drainage bag should be kept below the level of the bladder. The Director of Nursing confirmed in interviews that the observed practices did not align with facility policies and expectations for infection prevention and control.
Failure to Maintain Cleanliness of Vents
Penalty
Summary
The facility failed to maintain the cleanliness and condition of vents in multiple resident rooms, specifically rooms 7, 16, 17, 29, 33, 38, 39, 40, 47, and 48. During an environmental tour, a thick brown buildup of debris was observed on the outside of vents in these rooms. The Maintenance Director confirmed the presence of the debris and revealed that there was no policy or procedure for vent checks or cleaning. Additionally, there was no monthly tracking or documentation of vent checks or cleaning. The Housekeeping Supervisor confirmed that vents in resident bathrooms were not included in the cleaning or checking list.
Improper Positioning of Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the indwelling catheter drainage bag below bladder level during toileting and catheter care for a resident diagnosed with neuromuscular dysfunction of the bladder and overactive bladder. During an observation, nursing assistants were seen completing catheter care while the resident was seated on the toilet with the catheter drainage bag positioned on a transfer device above the bladder level for a total of 20 minutes. Interviews with the nursing assistants and the Director of Nursing confirmed that the catheter bag was improperly positioned above the bladder level during this time.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer the correct medication within the prescribed time frame for one resident. During an observation, a Medication Aide (MA) administered multiple medications to a resident at 12:30 PM, which were due no later than 11:00 AM. The MA acknowledged that the medications were late and attributed the delay to the resident visiting with their spouse. The MA also mentioned that medications are given in block times and should be administered within a specific time frame to ensure proper separation between doses. However, the MA did not inform the charge nurse about the delay as required by the facility's policy. The Director of Nursing (DON) confirmed that the MA should have informed the charge nurse about the late medications and sought assistance if needed. The facility's policy states that medications must be administered within one hour before or after their prescribed time. The DON also mentioned that the facility would need to contact the physician to adjust the medication times. The physician was later informed about the late administration of Carbidopa-Levodopa, and an order was obtained to hold the afternoon dose and give the evening dose as scheduled.
Failure to Maintain Mechanical Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to maintain mechanical ventilation in residents' bathrooms located in rooms 38, 39, 40, 47, and 48. During an environmental tour, it was observed that the vents in these rooms were not functioning. Interviews with the Maintenance Director confirmed the non-functioning vents and revealed that there was no policy or procedure for vent function checks, nor was there any tracking or documentation of such checks. Additionally, the Housekeeping Supervisor confirmed that vents in the resident bathrooms were not on the list to be cleaned or checked.
Failure to Obtain Physician's Order for CPAP
Penalty
Summary
The facility failed to obtain a physician's order for a CPAP for Resident 70, who had a diagnosis of Obstructive Sleep Apnea. Observations on 4/17/24 revealed a CPAP machine assembled and sitting on the bedside table in Resident 70's room. The resident confirmed during an interview that they had been using the CPAP every night since admission. However, a review of the resident's records, including the Hospital Admission Physician orders and the Minimum Data Set (MDS), showed no documented physician order for the CPAP or its settings, and it was not listed on the eMAR. The Director of Nursing confirmed in an interview on 4/23/24 that the admission physician orders did not include a CPAP order and acknowledged that one should have been obtained. The facility's Physician Orders Policy, revised in January 2018, mandates that medications, treatments, or related orders must be transcribed accurately and verified via a double-check system process. This policy was not followed in the case of Resident 70, leading to the deficiency.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not attempting a gradual dose reduction (GDR) for psychotropic medications. The resident, who was admitted on 05/09/2020, had multiple diagnoses including Major Depressive Disorder, Delusional Disorders, Vascular Dementia with Behavioral Disturbance, Anxiety Disorder, Schizoaffective Disorder, Depression, and Unspecified Psychosis. Despite the resident showing no documented behaviors, hallucinations, delusions, or signs of depression for the months of February, March, and April of 2024, no GDRs were attempted between 05/31/2023 and 03/31/2024. Additionally, there were no notes from the in-house psychiatric physician since 01/18/2023, and the facility's policy required GDR and behavioral intervention unless clinically contraindicated. Interviews with the Director of Nursing (DON) confirmed that no behaviors were documented for the resident during the specified months and that no GDRs had been completed in the last year. The facility's failure to document and attempt GDRs, despite the resident's stable condition and lack of target behaviors, led to the deficiency. The facility's psychotropic medication policy, dated 12/2023, was not followed, resulting in the resident continuing on psychotropic medications without necessary evaluations and reductions.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene during wound care for one resident and catheter care for another resident. During wound care, a registered nurse (RN) gathered supplies without performing hand hygiene, sanitized hands, applied gloves, and then touched various surfaces before and after cleansing the resident's wound. The RN did not change gloves or perform hand hygiene after cleansing the wound and before applying a moisture barrier. Additionally, the RN performed hand washing for only 12 seconds instead of the required 30 seconds. The RN confirmed these lapses in hand hygiene during an interview. During catheter care, two nursing assistants (NAs) sanitized their hands, donned gowns and gloves, and then entered the resident's bathroom. One NA wiped the resident's groin and catheter insertion site without changing gloves or performing hand hygiene between tasks. The other NA applied barrier cream to the resident's buttocks without removing gloves or performing hand hygiene. Both NAs confirmed these lapses in hand hygiene during interviews. The Director of Nursing stated that the expectation for catheter care is to perform hand hygiene after cleansing the groin and before performing catheter care.
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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