Chimney Rock Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Bayard, Nebraska.
- Location
- 106 East 13th Street, Bayard, Nebraska 69334
- CMS Provider Number
- 285260
- Inspections on file
- 27
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Chimney Rock Villa during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe and sanitary bathing environment, with significant structural damage and debris present in the shower room used by multiple residents with complex medical needs. The facility was aware of the damage but had no plan to repair it, directly affecting residents' right to a safe and homelike environment.
The facility did not designate a full-time DON for an extended period, despite staffing documentation and interviews confirming that no RN was officially assigned to this role. An RN assisted with DON duties but was not formally appointed, potentially affecting all residents.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
The facility did not assign the Infection Preventionist role to a qualified staff member other than the DON. The DON was responsible for both the infection prevention and control program and their regular duties, with no documentation of hours spent on infection preventionist tasks, despite a census of 35 residents.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, as observed by surveyors.
A resident's MDS assessments were incorrectly coded to indicate hypoglycemic medication use, despite Medication Administration Records showing no such medications were given during the observation periods. This error was confirmed by an RN during review.
A resident with a known left-hand contracture and multiple neurological diagnoses was admitted without the contracture being documented or addressed in the care plan. Despite clear functional limitations and staff awareness of the contracture, no interventions or therapy were implemented to prevent worsening, and the resident reported no staff assistance with the affected hand.
The facility did not develop or implement new interventions to prevent further falls after multiple residents experienced repeated falls, some resulting in serious injuries such as fractures and head trauma. Despite documented cognitive impairment and mobility issues, care plans were not updated with appropriate fall prevention strategies following these incidents, and required reporting procedures were not followed.
A resident with multiple comorbidities and recent hip surgery did not receive consistent monitoring or wound care as ordered, including lapses in documentation, delayed clarification of dressing change frequency, and missed wound care interventions. The incision was left uncovered at times, and wound assessments were not performed or recorded as required, leading to concerns from the orthopedic surgeon and subsequent hospital admission.
The facility did not ensure its QAPI program identified and addressed a recurring pattern of resident falls, including some with major injuries, over several months. Despite multiple falls being documented in incident lists and discussed in meetings, there was no evidence that these incidents were recognized as a concern or that any corrective action plans were developed or implemented, as required by facility policy.
A resident with dementia and a history of falls suffered an un-witnessed fall resulting in a fractured pelvis and required hip replacement. The facility did not report the serious injury to the State Agency within the required two-hour window and failed to submit a five-day investigative report, as confirmed by the administrator.
The facility failed to ensure proper food storage, temperature control, and hand hygiene practices. Observations revealed expired food items, improper storage, and unsafe food temperatures. Staff members were also observed not performing hand hygiene between glove changes and when assisting multiple residents, despite being aware of the protocol.
The facility failed to maintain resident dignity during meal services as staff engaged in personal conversations with each other instead of interacting with residents. Observations showed nurse aides either sitting or standing near residents without including them in conversations, contrary to the facility's policy. Interviews confirmed the staff's awareness of the expectations to interact with residents and be seated while assisting them.
The facility failed to develop comprehensive care plans for four residents, omitting critical health information such as COPD diagnosis, accurate weight and BMI, fluctuating toileting assistance, and severe cognitive impairment with weight loss. These omissions were confirmed by the DON and DM, indicating a lack of adherence to person-centered care planning policies.
A facility failed to accurately assess a resident's nutritional status on their admission MDS. The assessment incorrectly indicated significant weight loss and a mechanically altered diet, while medical records showed no weight loss and a regular diet. The Dietary Manager confirmed the inaccuracies in the MDS.
The facility failed to update care plans for two residents, leading to inaccuracies in their care. One resident's care plan did not reflect the required assistance with ADLs, while another resident's care plan lacked documentation of a necessary nutritional intervention following significant weight loss. These discrepancies were confirmed by the DON.
A resident with severe cognitive impairment was administered Coreg, a hypertension medication, against prescriber's orders in an LTC facility. The medication was given despite the resident's blood pressure and pulse being below the specified parameters on multiple occasions, as confirmed by the DON.
A facility failed to ensure a physician's order was in place for a resident's oxygen therapy, leading to an incorrect oxygen flow rate. The resident, with moderately impaired cognition and COPD, was using oxygen set at 1.5 LPM without a documented order. Interviews confirmed the absence of an order in the EHR, despite a pulmonologist's directive for 2 LPM. Facility policy required verification and documentation of such orders, which was not followed.
The facility did not ensure antibiotics prescribed to two residents had a stop date or treatment duration, violating their Antibiotic Stewardship policy. One resident with Multiple Sclerosis was on Keflex for prophylaxis, and another with Alzheimer's was on an antibiotic eyedrop for pink eye, both lacking specified treatment durations.
A medication aide crushed a resident's potassium chloride extended release medication, which should not be crushed, due to a lack of guidance in the facility's policy and the medication order. The aide was unaware of the restriction, leading to a significant medication error.
The facility failed to employ a full-time dietician or have a certified Food Service Director, affecting 29 residents. The dietician was employed for only six hours a month, and the Food Service Director was not yet certified. The facility assessment indicated a need for a Food Service Director, and the job description required accredited dietetic training and registration.
A resident with a diagnosis of seizures was administered an incorrect dose of Keppra due to a Medication Aide not following the five rights of medication administration. The prescribed dose was 1,000 mg in the morning, but the resident received 1,500 mg instead.
A facility failed to perform proper hand hygiene, change gloves, and use a sanitary surface during catheter care for a resident with Multiple Sclerosis. The LPN did not follow the facility's hand hygiene and catheter care policies, including not sanitizing the overbed table used for the procedures.
Unsafe and Unsanitary Bathing Environment Maintained for Residents
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike bathing environment for its residents. Observations of the 200 hall shower room revealed significant structural damage, including missing wall tiles, broken drywall with exposed wood studs and pipes, and an area covered with torn paper and clear tape. The floor in front of the damaged wall also had broken and missing tiles, exposing rough cement and creating uneven surfaces. Debris, unidentified powders, and discoloration were present throughout the affected areas. These conditions were directly observed while residents were being assisted with bathing, and the facility was aware of the damage but had no plan in place to repair it. This deficiency affected all six sampled residents, each with complex medical histories such as diabetes mellitus, dementia, respiratory failure, urinary tract infection, depression, anxiety, back pain, hypertension, osteoporosis, chronic kidney disease, heart failure, failure to thrive, broken ribs, and prostate cancer. On the day of the survey, multiple residents received showers in the compromised environment, as confirmed by staff interviews and the facility's bathing schedule. The lack of a safe and sanitary bathing area was evident during direct care activities, impacting the residents' right to a safe and comfortable environment.
Failure to Designate Full-Time DON
Penalty
Summary
The facility failed to designate a full-time Director of Nursing (DON) from 12/24/2024 through 2/10/2025, as required by state regulations. Record review of the Facility Assessment Tool indicated that staffing should include a full-time DON, but staffing documentation showed no evidence of a designated DON during the specified period. Interviews with the Nursing Home Administrator (NHA) and a Registered Nurse (RN-A) revealed that RN-A was assisting with DON duties but was not officially designated as the DON, and there was no clear assignment of the DON role during this time. The facility had a census of 35 residents, all of whom had the potential to be affected by the lack of a designated DON.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Designate Qualified Infection Preventionist Separate from DON
Penalty
Summary
The facility failed to designate the role and duties of the Infection Preventionist to a qualified staff member separate from the Director of Nursing (DON). A review of the DON's job description showed that the DON was responsible for developing, implementing, and maintaining the infection prevention and control program. During an interview, the DON confirmed that they were performing both the DON and Infection Preventionist roles while working forty hours per week as the DON. There was no documented evidence of the number of hours the DON spent specifically on infection preventionist duties. The facility had a census of 35 residents at the time of the survey.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Incorrect MDS Coding for Hypoglycemic Medication Usage
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments regarding hypoglycemic medication usage for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, the hypoglycemic medication box should be checked only if the resident received such medication during the 7-day observation period. Record reviews showed that the resident's MDS assessments on two separate occasions indicated the use of hypoglycemic medication, despite the Medication Administration Records for the corresponding periods showing no evidence that the resident had received any hypoglycemic medications. This discrepancy was confirmed during an interview with a registered nurse, who acknowledged that the MDS assessments were incorrectly coded. The resident in question had not been administered hypoglycemic medication during the lookback periods for either MDS assessment, yet the documentation inaccurately reflected otherwise. The facility census at the time was 35 residents, and this error was identified for one of five sampled residents.
Failure to Identify and Treat Resident's Hand Contracture
Penalty
Summary
A resident with a diagnosis of corticobasal degeneration, cervicalgia, and essential tremor was admitted with a known left-hand contracture, as communicated during the admission report from the discharging facility. The resident exhibited functional limitations in range of motion on both sides of the body, used a wheelchair for ambulation, and required substantial to maximum assistance with activities of daily living. Observations revealed the resident's left hand was contracted, with fingers rigidly straight and the thumb pressed against the fingers, causing pain when manipulated. The resident reported that staff were not working with the hand to address the contracture. A review of the resident's medical record and care plan showed no documentation of the left-hand contracture or any active treatment to prevent its worsening. Interviews with facility staff, including an RN and the DON, confirmed that the contracture was known upon admission but was not identified in the care plan, and no interventions or therapy were in place to address the limited range of motion. The deficiency was identified based on the lack of assessment, documentation, and intervention for the resident's contracture.
Failure to Implement Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to develop and implement appropriate interventions to prevent additional falls for four residents, resulting in two residents sustaining major injuries from subsequent falls. Facility policy required that after a resident fall, appropriate interventions should be recorded in the medical record, and that neglect, defined as failure to provide necessary care to avoid harm, should be reported to the state agency. However, there was no evidence that interventions were added or that serious injuries were reported as required. One resident with dementia, repeated falls, and a broken ankle experienced two unwitnessed falls within a short period, the second resulting in a fractured pelvis and subsequent hip replacement. Despite these incidents, no new interventions were implemented in the care plan following the falls. Another resident with severe cognitive impairment and a history of wandering and falls had multiple unwitnessed falls, including one resulting in a head hematoma. The care plan listed several interventions, but there was no evidence that new interventions were developed or implemented after the falls, and some interventions, such as encouraging use of the call light, were not appropriate for the resident's cognitive status. A third resident with encephalopathy, diabetes, and dementia had multiple falls, including one that resulted in a subdural hematoma and subarachnoid hemorrhage requiring hospitalization. No new fall interventions were added to the care plan after these incidents. A fourth resident with paranoid schizophrenia, heart failure, and dementia had two unwitnessed falls, one resulting in hospital evaluation for possible head injury, but again, no new interventions were added to the care plan. Interviews with the DON confirmed that interventions were not implemented following these falls, despite the expectation that they should have been.
Failure to Monitor and Implement Physician Orders for Post-Surgical Wound Care
Penalty
Summary
The facility failed to provide ongoing monitoring and appropriate care for a resident's post-surgical incision, as well as to follow physician orders and implement necessary interventions to promote healing and prevent infection. The resident, who had a history of dementia, Type 2 Diabetes Mellitus, high blood pressure, and repeated falls, was admitted with additional diagnoses of right hip and pelvic fractures. After undergoing hip replacement and revision surgeries, the resident returned to the facility with specific post-operative instructions for wound care, including keeping the dressing clean, dry, and intact, and later, orders for wound care to other areas. Despite these orders and the facility's own policies requiring wound assessment and documentation, there was a lack of documented assessment and monitoring of the surgical incision for multiple periods. There was no evidence of wound assessment from the time of the resident's return from surgery until several days later, and again for several days after the wound vac was removed. Documentation was also missing regarding the status of the wound, including signs of infection, drainage, and other key indicators. Additionally, the facility did not promptly clarify the frequency of dressing changes with the physician, and there were delays in implementing wound care orders, including the application of zinc oxide and Hibiclens solution. The facility's records further showed that the resident's incision was left uncovered on certain days, contrary to orders, and that wound care interventions were not consistently documented or performed as ordered. Interviews with facility staff confirmed these lapses in monitoring, documentation, and implementation of physician orders. The resident's condition deteriorated, with increased drainage and other concerning symptoms, and the orthopedic surgeon later expressed concern about the wound care and cleanliness at the facility, leading to the resident's hospital admission for further management.
Failure to Address and Act on Negative Trend of Resident Falls in QAPI Program
Penalty
Summary
The facility failed to ensure its Quality Assurance Performance Improvement Program (QAPIP) identified and addressed an ongoing negative trend of resident falls, including some resulting in major injuries, over several months. Record reviews of QAPIP reports from September 2024 through March 2025 consistently showed multiple falls each month, but there was no evidence that these incidents were recognized as a potential concern or that any corrective action plans were developed or implemented. Additionally, there were missing QAPI meeting minutes for December 2024, and subsequent reports did not reflect any discussion or identification of falls as a concern. Interviews with the Nursing Home Administrator confirmed that while the QAPIP team met monthly and reviewed negative trends, including falls, they did not develop or implement a corrective action plan even after identifying falls as a negative trend. The facility's policy outlined a process for tracking, measuring, and addressing quality deficiencies, but this process was not followed in relation to the repeated incidents of falls, affecting the facility's entire resident population.
Failure to Timely Report Major Injury and Submit Investigation
Penalty
Summary
The facility failed to report a fall resulting in a major injury as a potential allegation of abuse or neglect to the State Agency within the required two-hour timeframe and did not submit a complete investigation within five working days. According to the facility's own policy, alleged cases of neglect should be reported within 24 hours, and a completed internal investigation should be submitted within five days. However, the policy did not reflect the regulatory requirement to report serious bodily injury within two hours. Record review showed that a resident with dementia, repeated falls, and a history of a broken ankle experienced two un-witnessed falls, the second of which resulted in a fractured pelvis and subsequent hip replacement surgery. There was no evidence that the facility notified the State Agency within two hours of the serious injury or that a five-day investigative report was submitted. The administrator confirmed that the facility's process was to report within 24 business hours when a fall with potential injury occurs, which does not meet the regulatory requirement for timely reporting of serious injuries. The deficiency was identified for one resident out of a sample of two, with a facility census of 24.
Deficiencies in Food Storage, Temperature Control, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as evidenced by several observations and interviews. During a kitchen tour, it was noted that food items were not stored according to professional standards. Specifically, a package of lime gelatin and a box of tomato juice were improperly labeled and stored, with the latter not being refrigerated after opening as required. Additionally, expired items such as cottage cheese and yogurt were found in the refrigerator, and a box of food was stored on the floor of the walk-in freezer, contrary to facility policy and signage. Dietary Aide E confirmed these discrepancies but was uncertain about the proper disposal timeline for dry storage foods. The facility also failed to maintain safe food temperatures and proper hand hygiene practices. Cook-F was observed serving food at temperatures below the required 135 degrees Fahrenheit, with ground chicken, mashed potatoes, and ground beef all recorded at unsafe temperatures. Cook-F acknowledged the inaccuracies in temperature maintenance. Furthermore, Cook-F and Nurse Aide C were observed failing to perform hand hygiene between glove changes and when assisting multiple residents with eating, which is a violation of the facility's hand hygiene policy. Both staff members confirmed their awareness of the need for hand hygiene but did not adhere to the protocol during the observed instances.
Failure to Maintain Resident Dignity During Meal Services
Penalty
Summary
The facility failed to provide care for residents in a manner that enhanced dignity and respect during meal services. Observations revealed that nurse aides were engaged in personal conversations with each other across the dining room, rather than interacting with the residents they were assisting. This behavior was noted during multiple observations, where nurse aides were either sitting or standing near residents but did not include them in their conversations. The facility's policy on Assistance with Meals, last revised in March 2022, emphasized the importance of feeding residents with attention to safety, comfort, and dignity, which includes minimizing interactions with other staff and preferring staff to sit with residents during meals. The deficiency was further confirmed through interviews with the staff and the Director of Nursing (DON). Nurse Aide (NA)-C admitted to engaging in personal conversations that excluded residents and acknowledged the expectation to be seated while assisting residents with eating. The DON confirmed that the facility's expectations during meal service included staff interacting with residents and being seated while assisting them. The failure to adhere to these expectations affected eight residents, highlighting a lapse in maintaining the dignity and respect of residents during meal times.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, as identified during a survey. Resident 7's care plan did not include their diagnosis of Chronic Obstructive Pulmonary Disease (COPD) or the need for continuous oxygen therapy, despite confirmation from the Director of Nursing (DON) that these were necessary components. Resident 17's care plan inaccurately reflected their weight and Body Mass Index (BMI), which was confirmed by the Dietary Manager (DM) to be incorrect. This discrepancy indicates a failure to accurately assess and document the resident's nutritional needs. Additionally, Resident 27's care plan lacked documentation of the fluctuating assistance required for toileting, which was acknowledged by the DON as an oversight. Resident 12's care plan did not address their severe cognitive impairment or recent weight loss, as confirmed by the DON. These deficiencies highlight a pattern of incomplete and inaccurate care planning, failing to meet the residents' needs and adhere to the facility's policy for comprehensive, person-centered care plans.
Inaccurate Nutritional Assessment on Admission MDS
Penalty
Summary
The facility failed to accurately assess the nutritional status of a resident during their admission Minimum Data Set (MDS) assessment. Specifically, the assessment inaccurately indicated that the resident had experienced a significant weight loss and was on a mechanically altered diet. However, a review of the resident's medical records, including consultation notes and physician's orders, revealed that the resident had not experienced any weight loss in the prior six months and was on a regular diet. The resident's weight was recorded as 116.7 kilograms, equivalent to 257.3 pounds, and there was no evidence of a prescribed weight loss program. The Dietary Manager, who completed Section K of the resident's admission MDS, confirmed that the information recorded was incorrect. The MDS should not have reflected a significant weight loss or a mechanically altered diet for the resident, as these were not accurate representations of the resident's condition. This discrepancy highlights a failure in the facility's process to ensure the accuracy of resident assessments, as required by their policy on certifying the accuracy of resident assessments.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to maintain accurate and updated care plans for two residents, leading to deficiencies in their care. Resident 20's care plan did not accurately reflect the level of assistance needed with Activities of Daily Living (ADLs). Despite the Minimum Data Set (MDS) indicating that the resident required partial to substantial staff assistance with bed mobility, transfers, and toilet use, the care plan inaccurately stated that the resident was independent with set up for all ADLs. This discrepancy was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that the care plan should have been revised in January 2024 to reflect the resident's actual needs. Similarly, Resident 19's care plan was not updated to include a critical nutritional intervention. The resident, diagnosed with Alzheimer's disease and Type 2 Diabetes Mellitus, experienced significant weight loss, prompting a dietary intervention to offer meals in their room if they could not be awakened for meals. However, this intervention was not documented in the resident's care plan. The DON confirmed that the care plan should have been updated to include this intervention, indicating a failure to revise the care plan to reflect the resident's current nutritional needs.
Failure to Administer Hypertension Medication per Prescriber's Orders
Penalty
Summary
The facility failed to administer a hypertension medication, Coreg, in accordance with the prescriber's orders for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses of epilepsy, stroke, and hypertension, had specific parameters set by the prescriber to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. Despite these orders, the medication was administered on multiple occasions when the resident's vital signs were below the prescribed parameters. The record review revealed that the resident received Coreg with a blood pressure of 88/55 and pulses ranging from 48 to 58 on several dates, all of which were below the prescriber's specified limits. The Director of Nursing confirmed these instances of non-compliance with the physician's orders during an interview. This failure to adhere to the prescribed medication administration guidelines represents a deficiency in the facility's care for the resident.
Failure to Ensure Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that an order was in place for a resident's oxygen therapy, resulting in an insufficient oxygen flow rate. The resident, who had moderately impaired cognition and a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was observed using a nasal cannula attached to both a portable oxygen tank and an oxygen concentrator, both set at 1.5 liters per minute (LPM). However, there was no evidence of a physician's order for this oxygen therapy in the resident's current records. Interviews with the Director of Nursing (DON) and the administrator confirmed the absence of an order in the resident's Electronic Health Records (EHR) for the oxygen therapy. It was revealed that the resident should have been on 2 LPM of oxygen continuously, as per a pulmonologist's recent order. The facility's policy on oxygen administration required staff to verify and document physician's orders for oxygen therapy, which was not adhered to in this case.
Failure to Include Stop Dates for Antibiotics
Penalty
Summary
The facility failed to ensure that antibiotics prescribed to residents had a stop date or specified duration of treatment, as required by their own policy on Antibiotic Stewardship. This deficiency was identified during a review of records and interviews with staff. The facility's policy, revised in December 2016, mandates that any antibiotic order must include a stop date or the number of days for therapy. However, this was not adhered to in the cases of two residents. Resident 1, who was admitted with multiple health conditions including Multiple Sclerosis and a Urinary Tract Infection, was prescribed Keflex for prophylaxis without a stop date or treatment duration. Similarly, Resident 19, who had severe cognitive impairment and was diagnosed with Alzheimer's disease, was prescribed Neomycin-Polymyxin-Dexamethasone ophthalmic ointment for pink eye, also without a stop date or treatment duration. Interviews with the Director of Nursing confirmed the absence of these critical details in the antibiotic orders for both residents.
Medication Administration Error: Crushing Extended Release Medication
Penalty
Summary
The facility failed to ensure that a medication that should not be crushed was administered correctly to a resident. Specifically, a medication aide (MA-D) crushed all of Resident 22's medications, including potassium chloride extended release, which is on the 'Do not Crush or Chew List.' The facility's policy on administering medications, last revised in April 2019, did not provide guidance on the crushing of medications. Additionally, Resident 22's order summary for potassium chloride extended release did not include instructions against crushing the medication. An observation on July 10, 2024, at 8:42 AM revealed that MA-D crushed the medication, and an interview with MA-D at 9:20 AM confirmed that they were unaware that potassium chloride extended release should not be crushed. The facility census at the time was 31, and this deficiency was identified for 1 of 4 sampled residents.
Failure to Employ Full-Time Dietician and Certified Food Service Director
Penalty
Summary
The facility failed to employ a full-time dietician or have a certified Food Service Director, which had the potential to affect 29 residents who ate from the kitchen. An interview with the Administrator revealed that the dietician was employed for only six hours a month, and the Food Service Director was currently enrolled in a certification program but was not yet certified. A review of the facility assessment indicated that a Food Service Director was needed for food and nutrition services. Additionally, the job description for the Director of Food Services required graduation from an accredited course in dietetic training and registration as a Food Service Director.
Failure to Ensure Residents are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of a resident with a diagnosis of seizures. The resident was admitted with orders for Keppra, 1,000 mg in the morning and 1,500 mg in the evening. On the morning of the incident, a Medication Aide (MA) prepared and administered a total of 1,500 mg of Keppra instead of the prescribed 1,000 mg. The MA did not have the Electronic Medication Administration Record pulled up on the computer screen to perform the three checks of the five rights of medication administration, leading to the error. The error was confirmed through interviews with the MA and the Administrator, who both acknowledged that the correct morning dose was 1,000 mg. The National Institute of Health's document on Nursing Rights of Administration was reviewed, which emphasizes the importance of the five rights of medication administration: right patient, right drug, right route, right dose, and right time. The failure to adhere to these standards resulted in the administration of an incorrect dose of medication to the resident.
Failure to Perform Proper Hand Hygiene and Use Sanitary Surfaces During Catheter Care
Penalty
Summary
The facility failed to perform proper hand hygiene, change gloves, and utilize a sanitary surface during catheter care for a resident diagnosed with Multiple Sclerosis. The Licensed Practical Nurse (LPN) did not perform hand hygiene at any time while in the resident's room, including when changing the resident's brief and clothing or when leaving the room to obtain supplies for the resident's abdominal skin breakdown. Additionally, the LPN used the resident's roommate's overbed table for catheter irrigation and wound care without sanitizing it prior to use. The facility's policies on hand hygiene and catheter care were not followed. The hand hygiene policy required handwashing before and after resident contact, before performing aseptic tasks, and immediately after glove removal. The catheter care policy required the use of aseptic techniques to prevent healthcare-associated infections. The LPN's actions were confirmed during an interview, where they acknowledged not performing hand hygiene and using an unsanitized surface for the procedures.
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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