Butte Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Butte, Nebraska.
- Location
- 210 Broadway, Butte, Nebraska 68722
- CMS Provider Number
- 285180
- Inspections on file
- 14
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Butte Senior Living during CMS and state inspections, most recent first.
A facility failed to prevent cross-contamination during wound care for a resident with stage III pressure ulcers. The LPN did not adhere to hand hygiene protocols, used contaminated scissors, and placed supplies on bed linens. The resident, admitted with pressure ulcers and a history of infections, was not placed on enhanced barrier precautions until weeks later. The LPN also failed to change gloves between dressing changes and did not wear gloves during resident transfer, violating infection control policies.
The facility failed to ensure the Dietary Manager had the necessary credentialing, as required by regulations. A review of the DM's personnel file showed no evidence of completed training, and an interview confirmed the lack of required education and certification. The DM was enrolled in a course to obtain the necessary credentials, and a Registered Dietician visited the facility bi-weekly. This deficiency potentially affected food service for 26 residents.
The facility failed to maintain proper kitchen sanitation and food handling practices, affecting 26 residents. A dietary staff member used hand sanitizer instead of washing hands and handled food with bare hands. Observations revealed unsanitary conditions, including dusty fans, unlabeled frozen food, and a dirty microwave and ice machine.
The facility failed to provide adequate toileting and incontinence care for four residents who required substantial assistance with daily activities. One resident was not offered toileting assistance for over nine hours, resulting in a heavily soiled brief. Another resident was not checked for incontinence for four hours, leading to bowel and bladder incontinence. Staffing challenges were cited as a reason for not adhering to care plans that specified toileting assistance at specific times.
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in inadequate care and supervision. A resident with severe cognitive impairment was not offered toileting assistance for over nine hours, leading to a heavily soiled incontinence brief. Another resident with a history of wandering and falls required frequent 1:1 or 2:1 staff supervision, which was not adequately provided, impacting the care of other residents. Multiple residents experienced delayed toileting assistance, resulting in soiled incontinence products, and a resident experienced multiple falls due to inconsistent implementation of care plan interventions.
The facility failed to follow infection control protocols, leading to potential cross-contamination. Staff neglected hand hygiene and glove changes during resident care and did not clean mechanical lifts between uses. Enhanced Barrier Precautions were not implemented for a resident with MRSA history, as required.
The facility failed to report an incident where two cognitively impaired residents were seen kissing, which was not reported to the State Agency as required by the facility's abuse policy. Both residents had severe cognitive impairments and were unaware of the inappropriateness of their actions. The incident was reported internally but not to Adult Protective Services or the Department of Health and Human Services.
The facility failed to update care plans for two residents with severe cognitive impairments after an incident where they were observed kissing. Despite the incident being reported, the care plans did not include interventions related to this behavior. Interviews confirmed the care plans were not revised to address the incident.
The facility failed to prevent falls for two residents with severe cognitive impairments, leading to repeated incidents and injuries. Despite interventions like motion sensors and appropriate footwear, the facility did not consistently implement new measures or determine causal factors. Interviews confirmed the facility's shortcomings in fall prevention and management practices.
A survey revealed an 8% medication error rate in an LTC facility, exceeding the acceptable 5%. Errors included an LPN preparing an incorrect insulin dose for a diabetic resident due to not checking the MAR, and an MA failing to ensure a resident consumed Miralax, yet documenting it as given. The facility's policy on medication administration was not followed.
A nurse aide, not certified in Nebraska, administered oxygen to a resident, which is outside the scope of practice for CNAs. The facility's job description did not include oxygen administration as a responsibility, and the DON confirmed the NA was not qualified for this task.
Failure to Implement Infection Control Measures During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care and did not implement enhanced barrier precautions for a resident with multiple pressure ulcers. The facility's policies on standard precautions and enhanced barrier precautions were not adhered to, as observed during a wound care procedure. The LPN involved did not perform hand hygiene before putting on clean gloves and after removing soiled gloves, which is a critical step in preventing infection. Additionally, the LPN used contaminated scissors to cut tape and placed wound care supplies directly on the resident's bed linens, further increasing the risk of infection. The resident involved was admitted with stage III pressure ulcers on the left hip, thigh, and shoulder. The resident had a history of non-traumatic brain dysfunction, pneumonia, dementia, and malnutrition, and was dependent on staff for personal care. The resident's pressure ulcers were present upon admission and had shown signs of infection, as indicated by the need for multiple courses of antibiotics. Despite these conditions, the resident was not placed on enhanced barrier precautions until several weeks after admission, which was a significant oversight by the facility. During the observed wound care procedure, the LPN failed to change gloves between dressing changes for different wound sites and did not perform hand hygiene between these tasks. The LPN also did not wear gloves when assisting in transferring the resident, which is a requirement under enhanced barrier precautions. These actions and inactions contributed to the deficiency, as they did not align with the facility's infection control policies and increased the risk of cross-contamination and infection for the resident.
Dietary Manager Lacks Required Credentialing
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary credentialing to meet regulatory requirements for their position. This deficiency was identified through a review of the facility's job description for the Director of Dining Services, which was revised on 7/18/24, and required the DM to perform duties in accordance with current federal and state regulations. The job description also stipulated that the DM should meet current requirements established by regulatory agencies or be enrolled in a class to meet such requirements. However, a review of the DM's personnel file revealed no evidence of completed required training. An interview with the DM confirmed that they did not have the education, credentialing, or certification required for the position. The DM acknowledged enrollment in a class/course to obtain the necessary education and credentials. Additionally, it was noted that a Registered Dietician visited the facility every other week, but there was no other staff employed at the facility with the required qualifications. This deficiency had the potential to affect the food service provided to 26 residents who were served food from the kitchen.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food handling practices, which had the potential to affect all 26 residents who consumed food prepared in the facility's kitchen. Observations revealed that a dietary staff member, identified as DC-J, did not wash hands with soap and water as required, instead using hand sanitizer before handling food. DC-J used bare hands to handle food items such as bread and cheese, and later used gloved hands to touch various kitchen surfaces and utensils without changing gloves, violating the facility's policy on bare hand contact with food and glove use. Further inspection of the kitchen revealed several sanitation issues, including plastic scoops left inside flour and sugar bins with handles touching the food, a dusty fan blowing over a storage area, a chest freezer with frost and ice accumulation, and repackaged food items in the freezer that were not labeled or dated. Additionally, the microwave had a heavy layer of food splatter, and the ice machine had a significant build-up of lime deposits and dust. The facility's kitchen cleaning checklist indicated that these areas should have been cleaned regularly, but there was no evidence that the cleaning had been completed.
Failure to Provide Adequate Toileting Assistance
Penalty
Summary
The facility failed to provide adequate assistance with toileting and incontinence care for four residents who required substantial to maximal assistance with activities of daily living. Resident 11, who had severe cognitive impairment and was frequently incontinent, was not offered toileting assistance or checked for incontinence from 7:30 AM until 5:00 PM, resulting in a heavily soiled urinary incontinence brief. The care plan for Resident 11 specified assistance with toileting before and after meals, midafternoon, at bedtime, and as needed, but this was not adhered to due to staffing challenges. Resident 7, who was dependent on staff for all transfers and toileting, was not offered toileting care from 6:30 AM until 10:33 AM, during which time the resident was found to be incontinent of both bowel and bladder. The care plan required assistance with toileting before and after meals, but this was not provided. Similarly, Resident 3, who required maximal assistance with toileting hygiene, was not checked for incontinence from 7:00 AM until 2:15 PM, resulting in a heavily soiled pull-up. The care plan for Resident 3 also specified assistance with toileting at specific times, which was not followed. Resident 6, who required maximal assistance for toileting hygiene, was not offered toileting care from 9:00 AM until 2:00 PM, resulting in a soiled pull-up. The care plan for Resident 6 required assistance with toileting before and after meals, midafternoon, at bedtime, and as needed, but this was not provided. Interviews with staff confirmed that the residents were not toileted as per their care plans due to staffing levels, leading to prolonged periods without toileting assistance and resulting in incontinence issues.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of several residents, resulting in inadequate care and supervision. Resident 11, who has severe cognitive impairment and requires substantial assistance with toileting, was not offered toileting assistance for over nine hours, leading to a heavily soiled incontinence brief. Similarly, Resident 7, who is dependent on staff for toileting and is always incontinent, was not provided with timely toileting care, resulting in incontinence of both bowel and bladder. Staff interviews confirmed that the lack of sufficient staffing made it difficult to meet the residents' toileting needs in a timely manner. Resident 77, with severe cognitive impairment and a history of wandering and falls, required frequent 1:1 or 2:1 staff supervision due to exit-seeking and aggressive behaviors. The facility's staffing levels were inadequate to provide the necessary supervision, impacting the ability to meet the needs of other residents. The ongoing behaviors of Resident 77 necessitated significant staff attention, which diverted resources from other residents, further highlighting the staffing deficiencies. Resident 22 experienced multiple falls over several months, with interventions either not being implemented or delayed. The resident's delusions and hallucinations contributed to the falls, and the facility did not consistently implement care plan interventions to prevent these incidents. Additionally, Resident 3 and Resident 6, both with severe cognitive impairments and incontinence issues, were not provided with timely toileting assistance, resulting in soiled incontinence products. The Director of Nursing confirmed that the current staffing levels were insufficient to maintain toileting schedules, prevent falls, and address resident behaviors effectively.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, leading to potential cross-contamination among residents. Observations revealed that staff members, including nursing assistants and medication aides, consistently neglected to perform hand hygiene before and after resident care, as well as during glove changes. This was evident in multiple instances where staff entered resident rooms, provided incontinence care, and administered medications without washing hands or using hand sanitizer. Additionally, staff often failed to change gloves between dirty and clean tasks, further increasing the risk of contamination. The use of mechanical lifts for resident transfers also highlighted lapses in infection control practices. Staff did not clean or disinfect the sit-to-stand mechanical lifts between uses for different residents, despite the facility's policy requiring such measures to prevent microorganism transmission. This oversight was confirmed by the Director of Nursing and the Administrator, who acknowledged that the lifts were used for multiple residents and should have been cleaned after each use. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a history of Methicillin-resistant Staphylococcus Aureus (MRSA), as required by their care plan. The absence of EBP measures, such as the use of gowns and gloves during high-contact care activities, was noted during several observations. The Director of Nursing confirmed that EBP should have been in place for this resident, indicating a failure to follow established infection control protocols.
Failure to Report Incident Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an incident involving two residents to the State Agency, as required by their abuse policy. The incident occurred when Resident 3, who had severe cognitive impairment and a diagnosis of non-traumatic brain dysfunction and dementia, was seen kissing another resident, Resident 23, who also had severe cognitive impairment and a diagnosis of Alzheimer's Disease and non-Alzheimer's Dementia. Both residents were unaware of the inappropriateness of their actions due to their cognitive impairments. The staff separated the residents and monitored them to prevent further interaction, and the incident was reported internally to the Administrator and charge nurse by the Social Services Director. Despite the internal reporting, the facility did not report the incident to Adult Protective Services (APS) or the Department of Health and Human Services (DHHS) as required by their policy. The facility's policy mandates that any act against a vulnerable adult, including inappropriate sexual conduct, must be reported to APS. The Administrator confirmed during an interview that the incident was not reported to the State Agency. The failure to report this incident represents a deficiency in adhering to the facility's abuse policy and state regulations.
Failure to Update Care Plans for Residents with Behavioral Incidents
Penalty
Summary
The facility failed to review and revise the care plan interventions related to behaviors for two residents with severe cognitive impairments. Resident 3, diagnosed with non-traumatic brain dysfunction, non-Alzheimer's dementia, and unspecified dementia with behavioral disturbances, was involved in an incident on 10/14/24 where they were observed kissing another resident, Resident 23, in the living room. Both residents were cognitively unaware of the inappropriateness of their actions. Despite the incident being observed and reported by the Social Services Director, the care plan for Resident 3, last revised on 10/10/24, did not include any interventions related to this behavior. Similarly, Resident 23, who has severe cognitive impairment and a history of kissing a male resident, did not have their care plan updated to reflect the incident on 10/14/24. The care plan, last revised on 10/10/24, included instructions for staff to redirect the resident by explaining the behavior was not acceptable. However, there was no documentation of interventions related to the incident with Resident 3. Interviews with the MDS Coordinator and the Administrator confirmed that the care plans for both residents were not updated to include behavior interventions following the incident.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to adequately address and prevent falls for two residents, leading to repeated incidents and injuries. Resident 22, with severe cognitive impairment and a history of falls, experienced numerous falls over several months. Despite interventions such as a scoop mattress, motion sensors, and appropriate footwear, the facility did not consistently implement new interventions or determine causal factors for the falls. The resident continued to experience delusions and hallucinations, contributing to the falls, and there was a delay in medication reviews and adjustments. Resident 77, also with severe cognitive impairment and a history of falls, experienced multiple falls without adequate identification of causal factors or development of new interventions. The resident was found on the floor multiple times, and although interventions such as gripper socks and lowering the bed were eventually implemented, they were not consistently applied. The facility's failure to revise and implement effective fall prevention measures contributed to the ongoing risk of falls for this resident. Interviews with the Director of Nursing confirmed the facility's shortcomings in implementing new interventions and determining causal factors for falls. The facility's risk management policy required incidents to be reported, investigated, and reviewed, but this was not effectively carried out for Residents 22 and 77. The lack of adequate supervision and timely intervention adjustments resulted in repeated falls and injuries, highlighting deficiencies in the facility's fall prevention and management practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an 8% error rate observed during a survey. This was based on 25 opportunities for medication administration, where two errors were identified. The facility's policy on medication administration, which emphasizes adherence to the 5 Rights of medication administration and the use of the Medication Administration Record (MAR), was not followed in these instances. One of the errors involved a resident with diabetes who was dependent on staff for all activities of daily living and required daily insulin injections. During a medication pass, an LPN prepared to administer an incorrect dose of insulin to the resident. The LPN failed to check the MAR before preparing the insulin dose, relying instead on a typewritten note that led to the preparation of 3 units instead of the correct 6 units for the resident's blood glucose level. The error was identified and corrected only after intervention by a surveyor. Another error involved a resident who was prescribed Miralax to prevent constipation. An MA prepared the correct dose of Miralax and delivered it to the resident but did not ensure the resident consumed it. The MA then inaccurately documented the medication as administered. The Director of Nursing confirmed that staff are required to witness the complete consumption of all medications and that the MAR should be used to ensure accurate medication administration.
Unqualified Staff Administering Oxygen
Penalty
Summary
The facility failed to ensure that qualified staff were administering oxygen to a resident, leading to a deficiency. During an observation, a nurse aide (NA) was seen assisting a resident with toileting and then turning on the resident's oxygen concentrator and placing a nasal cannula on the resident. This action was performed despite the NA not being certified to administer or manage oxygen in Nebraska, as confirmed by the NA herself and the Director of Nursing (DON). The NA had a Medication Aide Certification in Minnesota but was not certified in Nebraska, which would require retesting. The facility's job description for Certified Nursing Assistants (CNAs) did not include the administration or provision of medications or oxygen as part of their responsibilities. The DON confirmed that the NA was not qualified or trained to administer or interrupt the flow of oxygen. This incident highlights a failure in ensuring that staff had the appropriate competencies to care for residents, specifically in the administration of oxygen, which is outside the scope of practice for a CNA without the necessary certification.
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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