Callaway Good Life Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Callaway, Nebraska.
- Location
- 600 West Kimball Street, Callaway, Nebraska 68825
- CMS Provider Number
- 285200
- Inspections on file
- 16
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Callaway Good Life Center, Inc during CMS and state inspections, most recent first.
The facility did not consistently record refrigerator, freezer, or food temperatures, and failed to label or date food items as required. Staff were observed not following proper hand hygiene or food safety practices, and some foods were served below recommended temperatures. Residents reported that hot foods were often not warm enough, and the dietary manager confirmed incomplete temperature logs and lack of Serve Safe training among staff.
A resident reported that personal items, including a candle warmer and a welcome sign, were taken from their room without notification, and mail was opened by staff. The DON and ADM confirmed that these incidents were not reported to the state as required by facility policy, and staff avoided cleaning the resident's side of the room due to fear of accusations. The facility failed to follow its own procedures for reporting allegations of abuse and misappropriation of property.
The facility failed to ensure safe food handling and preparation practices, as observed during meal services. Dietary Aides did not change gloves between tasks, leading to potential cross-contamination. A Dietary Aide improperly prepared meatballs without following a recipe, resulting in incorrect ingredient measurements and cooking methods. Interviews revealed staff were unaware of proper food handling procedures, contrary to the facility's policy to minimize foodborne illness risk.
The facility failed to ensure that three nurse aides completed the required 12 hours of continuing education. Nurse Aide M completed 2.37 hours, Nurse Aide N completed 1.63 hours, and Nurse Aide O completed 4 hours from January 2024 to February 2025. The DON confirmed the deficiency.
The facility failed to maintain operational ventilation systems in bathrooms of rooms 7, 8, 9, 10, 11, 14, 15, and 19, affecting 13 residents. Observations showed that the ventilation systems were not functional, as evidenced by a lack of air draw when tested with toilet paper. The Administrator confirmed the issue, acknowledging that the ventilation should be working.
The facility failed to complete a comprehensive annual assessment for a resident within the required 366-day period and did not conduct a quarterly assessment for another resident every 92 days as mandated. These lapses were confirmed by the MDS coordinator and the Administrator.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly documented as receiving insulin injections, while another was inaccurately coded as taking an anticoagulant. These errors were confirmed by the MDS coordinator and attributed to an LPN who is no longer completing MDS assessments.
A resident was found to be using two antifungal medications, Ketoconazole Cream and Nystatin Powder, on the same area of the body, contrary to recommendations. The resident self-applied Nystatin Powder, while nursing staff applied Ketoconazole Cream at night. Interviews confirmed the concurrent use, and the DON acknowledged that both medications should not be used on the same area, indicating a failure to ensure the resident's drug regimen was free from unnecessary medications.
A resident was prescribed Seroquel for depression, despite not having a diagnosis of schizophrenia or bipolar disorder, which are the indicated uses for the medication. The facility's policy requires compliance with regulatory requirements for medication use, but the prescribed use did not align with these indications. This was confirmed by the DON during an interview.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 7%. An RN did not follow the facility's policy of priming insulin pens with 2 units before each use, affecting two residents. The RN believed priming was only needed when the pen was first opened, leading to incorrect insulin administration. The DON confirmed the policy deviation.
A resident was found to have Nystatin Powder stored insecurely in their room, accessible to others. The resident had a physician order to self-administer the medication but lacked a completed self-administration assessment. The DON confirmed the medication should have been stored securely.
Failure to Ensure Safe Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards, as required by policy and regulation. Multiple observations and record reviews revealed that refrigerator and freezer temperatures were not consistently recorded, with numerous dates missing entries for both morning and evening checks. Food temperature logs were also incomplete, with sporadic documentation and several meals lacking any recorded temperatures. Additionally, there were instances where food items in the refrigerators were not labeled or dated, including nacho cheese, turkey, and dessert cups, contrary to facility policy requiring all food to be appropriately dated and labeled for proper rotation and safety. Staff interviews and direct observations highlighted further lapses in food safety and hygiene practices. One cook was observed handling food without following proper hand hygiene between glove changes and did not wash tomatoes before slicing them for meal preparation. Another dietary aide was seen handling cleaning equipment and then preparing coffee without washing hands. Staff also had difficulty locating a food thermometer, and when found, it was not consistently used to check food temperatures prior to serving. The dietary manager confirmed that temperature logs were incomplete and that neither the manager nor other dietary staff had completed Serve Safe training at the time of the survey. Residents reported that hot foods were often not served at appropriate temperatures, especially when delivered to rooms, with one resident specifically noting that food was not very warm when served on a tray. Observations confirmed that food items such as oven-baked French fries were served below recommended temperatures. The dietary manager, who was also responsible for environmental services and housekeeping, expressed feeling overwhelmed and was unsure of proper dietary department procedures, further contributing to the deficiencies in food safety and handling.
Failure to Report Allegations of Misappropriation and Abuse
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of resident property within the required time frame, as outlined in its own Abuse and Neglect Reporting policy. One resident reported multiple concerns, including staff opening mail, missing clothing, personal items being taken without consent, and feeling targeted by facility administration. The resident specifically noted that a candle warmer was taken from the room on two separate occasions without notification, and a welcome sign was also removed and later returned. The resident expressed feeling picked on and unable to communicate honestly with the Administrator. Interviews with facility staff confirmed that the candle warmer was removed from the resident's room by Environmental Services staff due to it being considered a fire hazard, but the resident was not informed at the time of removal. Staff also acknowledged that the resident's side of the room had not been cleaned for several days due to fear of being accused of theft. The Business Office Manager admitted to accidentally opening the resident's mail. Despite these incidents and the resident's grievances, the Director of Nursing and Administrator did not report the allegations to the state as required by policy. The facility's policy mandates immediate reporting of suspected abuse, neglect, exploitation, or misappropriation of property, including notification to appropriate authorities within specified time frames. However, the Administrator and Director of Nursing chose not to report the incidents, even after internal discussions and confirmation that items were taken from the resident's room without consent or notification. The lack of timely reporting and communication with the resident regarding the removal of personal property constituted a failure to protect the resident from the wrongful use of belongings and money.
Improper Food Handling and Preparation Practices
Penalty
Summary
The facility failed to prepare and serve food in a safe manner, as observed during multiple meal services. Dietary Aides were seen wearing gloves while handling food, but they did not change gloves between different tasks, such as handling food, opening refrigerators, and managing dietary cards. This practice was observed over several days, indicating a consistent failure to maintain proper hygiene standards. Additionally, the Dietary Aides did not wash their hands between glove changes, further increasing the risk of cross-contamination. During meal preparation, a Dietary Aide was observed cooking meatballs without following a recipe, leading to improper ingredient measurements and cooking methods. The aide used a knife to cut into raw ground beef, some of which was frozen, and attempted to thaw it in a microwave, which is not an appropriate method. The meat was not cooked to the correct internal temperature initially, and the aide did not measure seasonings or follow the recipe's egg requirements. Furthermore, the aide did not check the temperatures of other foods, such as peas and potatoes, before serving them. Interviews with the Dietary Manager revealed that the staff was not fully aware of the proper food handling procedures, including the necessity of temping all foods and the inappropriateness of thawing meat in a microwave. The facility's policy on food handling emphasized minimizing the risk of foodborne illness through proper hygiene, cooking, and food storage practices, but these were not adhered to during the observed meal services. This deficiency had the potential to affect all residents consuming meals prepared in the facility's kitchen.
Deficiency in Nurse Aide Continuing Education Hours
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides completed the required continuing education hours. The facility census was 28. A review of the facility's Course Completion History documents revealed that Nurse Aide M completed only 2.37 hours, Nurse Aide N completed 1.63 hours, and Nurse Aide O completed 4 hours of continuing education from January 1, 2024, to February 10, 2025. During an interview, the Director of Nursing confirmed that these nurse aides had not met the minimum requirement of 12 hours of continuing education annually, as required by the facility's standards.
Non-Functional Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in several rooms, specifically rooms 7, 8, 9, 10, 11, 14, 15, and 19. This deficiency affected the bathrooms used by 13 residents out of a total facility census of 28. Observations conducted on multiple occasions revealed that the ventilation systems in these bathrooms were not functional, as demonstrated by the inability of a 1-ply square of toilet paper to adhere to the ventilation cover, indicating no air draw. The Administrator confirmed the non-functionality of the ventilation system during an interview, acknowledging that the system should be operational.
Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure a comprehensive resident assessment was completed annually for one resident and a quarterly assessment was completed every 92 days for another resident. Specifically, Resident #8 did not have a comprehensive assessment completed within the required 366-day period, as the last assessment was completed on 01/27/2023, and no subsequent assessment was scheduled as of 02/06/2025. This was confirmed by the facility's Minimum Data Set (MDS) coordinator and the Administrator, who acknowledged the lapse in meeting the regulatory guidelines for annual assessments. Additionally, Resident #4 did not receive a quarterly assessment within the required 92-day interval. The last quarterly assessment was completed on 10/10/2023, and the next comprehensive assessment was not conducted until 07/01/2024, resulting in a gap of 265 days without a quarterly assessment. This oversight was also confirmed by the MDS coordinator and the Administrator, who recognized the failure to adhere to the regulatory requirements for quarterly assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their medical records. For Resident #8, the Quarterly MDS inaccurately documented that the resident received insulin injections daily during the look-back period. However, a review of the Medication Administration Record for the same period revealed that the resident was actually receiving Victoza, a non-insulin injectable medication, rather than insulin. This error was confirmed by the facility's MDS coordinator during an interview. Similarly, Resident #25's Quarterly MDS was incorrectly coded to indicate that the resident was taking an anticoagulant medication. Upon reviewing the Medication Administration Record, it was found that the resident was receiving Aspirin, a nonsteroidal anti-inflammatory medication, instead of an anticoagulant. This discrepancy was also confirmed by the MDS coordinator. Both errors were attributed to the same LPN, who was no longer responsible for completing MDS assessments at the facility.
Failure to Ensure Resident's Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications, as evidenced by the concurrent use of two antifungal medications on the same area of the resident's body. Resident #25 had physician orders for Ketoconazole External Cream 2% to be applied topically at bedtime and Nystatin External Powder to be applied every morning and at bedtime under the right breast. The resident self-applied the Nystatin Powder when experiencing redness and itchiness, while the nursing staff applied the Ketoconazole Cream to the same area at night. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed the simultaneous use of both medications on the same area, which was not recommended. The Director of Nursing acknowledged that both medications should not be used on the same area, indicating a failure to ensure the resident's drug regimen was free from unnecessary medications.
Incorrect Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that an antipsychotic medication was prescribed with the correct diagnosis for a resident. Specifically, Resident #3 was receiving Seroquel, an antipsychotic medication, for a diagnosis of depression, despite not having a diagnosis of schizophrenia or bipolar disorder, which are the indicated uses for Seroquel. This discrepancy was identified during a review of the resident's physician orders and confirmed by the Director of Nursing during an interview. Resident #3 was admitted to the facility with diagnoses including Alzheimer's Disease, Dementia, and Altered Mental Status, but not depression. The resident's Quarterly Minimum Data Set indicated daily use of an antipsychotic medication. The facility's policy on Behavioral Assessment Intervention and Monitoring states compliance with regulatory requirements related to medication use, yet the prescribed use of Seroquel for depression did not align with the approved indications for the medication.
Medication Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 7% during a survey. This deficiency affected two residents out of six observed medication administrations. The issue was identified during the administration of insulin using insulin pens. The facility's policy required that insulin pens be primed with 2 units before each use, but this procedure was not followed by the registered nurse (RN) administering the medication. During the observation, the RN did not prime the insulin pens before administering doses to two residents. The RN mistakenly believed that priming was only necessary when the pen was first opened. This misunderstanding led to the incorrect administration of insulin doses to the residents. The Director of Nursing confirmed that the facility's policy was to prime the insulin pens with 2 units before each use, indicating a deviation from the established protocol by the RN.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were securely stored, affecting one resident out of three sampled. During an observation, a bottle of Nystatin Powder with a pharmacy label was found on the over-bed table and later on the back of the toilet in the resident's shared bathroom. The resident stated that the doctor had approved them to keep the medication in their room and apply it independently. However, the resident denied receiving any staff education on keeping the medication secure and out of reach of others. The Director of Nursing confirmed that the resident had a physician order to self-administer the Nystatin powder and to keep it in their room. However, a self-administration of medication assessment was not completed to ensure the resident was safe to self-administer and store the medication. The DON acknowledged that all medications should be stored securely and confirmed that the observed storage locations were not secure, as they were accessible to other residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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