Christian Homes Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holdrege, Nebraska.
- Location
- 1923 West 4th Avenue, Holdrege, Nebraska 68949
- CMS Provider Number
- 285246
- Inspections on file
- 16
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Christian Homes Health Care Center during CMS and state inspections, most recent first.
An unqualified individual who was not an employee assisted with food preparation in the kitchen due to a staffing shortage. The Dietary Manager confirmed the individual was not qualified to work in the kitchen, and the Administrator was unaware of this occurrence. This had the potential to affect all residents in the facility.
The facility did not notify the State Agency of a change in the DON position within the required timeframe, as confirmed by record review and administrator interview. This delay had the potential to impact all residents in the facility.
A resident reported being hit and restrained by an unidentified individual during the night. The DON investigated the allegation and deemed it unfounded but failed to report it to the State Agency as required by the facility's policy.
The facility failed to identify specific target behaviors for psychotropic medications in several residents, as required by policy. This deficiency was observed in residents prescribed antidepressants, antianxiety, and antipsychotic drugs, with no documentation of targeted behaviors in their care plans. Additionally, PRN orders for psychotropic medications lacked necessary stop dates. Staff interviews confirmed a lack of awareness and documentation, indicating non-compliance with the facility's medication management policy.
The facility did not provide the required SNF ABN and NOMNC to two residents in a timely manner. These notices, which inform residents about costs and appeal rights related to Medicare Part A coverage, were signed after the Last Covered Day for both residents. Interviews confirmed the delay in providing these notices.
A facility failed to report a suspected abuse allegation involving a cognitively intact resident with multiple medical conditions. The resident reported feeling uncomfortable due to a nursing assistant's actions, which was communicated to the ADON by a family member. Despite awareness of the allegation, the facility did not report the incident to the state agency within the required timeframe, as confirmed by a review of reportable incidents.
A resident reported feeling uncomfortable due to a nursing assistant's actions, but the facility failed to investigate or report the alleged abuse. Despite the resident being cognitively intact and the incident being reported to staff and a family member, no investigation was conducted, violating the facility's abuse policy.
The facility failed to accurately code the MDS for a resident with a Level II PASARR evaluation for SMI and ID, marking 'No' instead of 'Yes'. Additionally, another resident's MDS did not reflect the use of an antibiotic, despite it being administered as per the eMAR. These discrepancies were confirmed by the MDS Consultant.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked details on managing antidepressant, antianxiety, and anticoagulant medications, while another resident's care plan did not address an actual fall incident despite being at risk for falls. These deficiencies were confirmed by facility staff.
The facility failed to update the Comprehensive Care Plans for three residents, leading to deficiencies in addressing their current medical needs. A resident with obstructive sleep apnea had a BiPAP order not reflected in their care plan, while another resident's CPAP use was similarly omitted. Additionally, a resident who experienced a fall did not have their care plan updated to address the incident. These oversights were confirmed by the ADON.
The facility failed to implement Enhanced Barrier Precautions for a resident with an MDRO and an indwelling catheter, as staff did not wear gowns or perform proper hand hygiene during care. Additionally, the facility did not ensure daily cleaning of a CPAP device for another resident, as required by physician orders. These deficiencies highlight lapses in infection control practices.
The facility did not designate a licensed RN to work full-time as the Director of Nursing (DON) while the previous DON was on maternity leave. During this period, the ADON, an LPN, and the ADM, who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, and the deficiency had the potential to affect all residents.
Unqualified Individual Assisted in Kitchen Due to Staffing Shortage
Penalty
Summary
The facility failed to ensure that only qualified dietary staff worked in the kitchen, as required by licensure regulations. Record reviews showed that an individual, SR-A, who was not an employee of the facility and did not meet the qualifications outlined in the Dietary Aide job description, was present in the kitchen assisting with food preparation by peeling potatoes. This occurred due to a shortage of staff in the kitchen. The Dietary Manager confirmed that SR-A was not qualified and should not have been working in the kitchen, and the Administrator was unaware of SR-A's involvement until after the fact. This deficiency had the potential to affect all 75 residents residing in the facility.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency of a change in the Director of Nursing (DON) position within the required five-day timeframe. Record review showed that the DON was changed on 11/8/24, but the notification to the State Agency was not received until 1/15/25. During an interview, the Administrator confirmed that the notification was not sent within the required period. This lapse had the potential to affect all 75 residents residing in the facility.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, as required by their Abuse Policy and Procedures. The incident involved a resident who was reported by a Nursing Assistant to have been difficult to arouse during the night. The resident later complained that an unidentified individual was hitting and pounding on their chest, instructing them not to get up until the day shift staff arrived. Despite the resident's inability to provide further details, the incident was documented in the resident's progress notes. The Director of Nursing (DON) was informed of the allegation on the same day it was made. An investigation was conducted by the DON, who concluded that the allegation was unfounded. However, the DON did not report the allegation to the required State Agency, as mandated by the facility's policy. A review of the facility's records confirmed that no reports of staff-to-resident abuse investigations were submitted to the state agency for the month in question.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify specific target behaviors for the use of psychotropic medications in several residents, which is a requirement for monitoring the effectiveness of these medications. This deficiency was observed in five residents who were prescribed various psychotropic medications, including antidepressants, antianxiety, and antipsychotic drugs. The facility's policy requires that target behaviors be documented and monitored, yet this was not done for the residents in question. Interviews with staff, including a Medication Aide and a Registered Nurse, revealed a lack of awareness regarding the behaviors to be monitored, and the Assistant Director of Nursing confirmed the absence of documentation for targeted behaviors in the residents' electronic health records. Resident 35 was prescribed multiple antidepressants and an antianxiety medication, but their Comprehensive Care Plan (CCP) did not include any care plan related to the psychotropic medication uses or identification of targeted behaviors. Similarly, Resident 37 was prescribed an antidepressant without any identification of targeted behaviors in their CCP. Resident 44, who was prescribed both an antidepressant and an antipsychotic, also lacked documentation of targeted behaviors in their care plan. Interviews with staff confirmed the absence of this critical information, which is necessary for assessing the effectiveness of the medications. Additionally, the facility failed to include stop dates for PRN orders of psychotropic medications, as required by their policy. Resident 53 had a PRN order for Ativan without a stop date, and Resident 55 had a PRN order for Buspirone, which should not have been a PRN order and also lacked a stop date. The Assistant Director of Nursing confirmed these oversights, indicating a failure to adhere to the facility's policy on psychotropic medication management.
Failure to Provide Timely SNF ABN and NOMNC Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) to two residents, Resident 3 and Resident 44, or their representatives, in a timely manner. These notices are essential for informing residents about the costs of continuing skilled services and their right to appeal the decision to end Medicare Part A coverage. For Resident 3, the Last Covered Day (LCD) for Medicare Part A services was on 10/05/2024, but the SNF ABN was signed on 10/07/2024. Similarly, for Resident 44, the LCD was on 11/03/2024, but the SNF ABN was signed on 11/07/2024. Interviews with the Social Services Director confirmed that the notices were not signed within the required timeframe prior to the LCD for both residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a suspected allegation of abuse involving a resident to the state agency within the required time frame and did not report the follow-up investigation within the mandated five working days. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 13, and had multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss. The resident reported to a family member that a nursing assistant had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member communicated this allegation to the facility's Assistant Director of Nursing (ADON). Despite being aware of the allegation, the facility staff, including the ADON, did not report the incident to the state agency as required. A review of the facility's reportable incidents confirmed that no report of the alleged abuse had been made in the last six months. The facility's policy and procedures, revised in January 2024, clearly state that allegations of abuse should be investigated and reported to the Department of Health and Human Services, a responsibility designated to the Administrator or the Director of Nursing.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility staff failed to investigate an alleged incident of abuse involving a resident, identified as Resident #53, who was part of a sample of 16 residents in a facility with a census of 61. The facility's abuse policy and procedures, revised in January 2024, require that allegations of abuse be investigated and reported to the state. However, a review of the facility's reportable incidents revealed no report of the alleged abuse involving Resident #53 and a nursing assistant, NA-H, in the last six months. Interviews with facility staff, including a medication aide and a licensed practical nurse, confirmed that the resident had reported feeling uncomfortable due to NA-H's actions, and the matter was brought up in risk management. Despite this, the Assistant Director of Nursing confirmed that no investigation had been conducted. Resident #53, who was admitted with multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss, was cognitively intact with a BIMS score of 13. The resident reported to a family member and a medication aide that NA-H had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member contacted the facility to report the allegation, but the facility failed to follow through with an investigation or report the incident as required by their policy.
Inaccurate MDS Coding for PASARR and Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the Level II PASARR status for a resident with serious mental illness (SMI) and intellectual disability (ID). The resident had a PASARR Level 2 evaluation indicating these conditions, but the MDS was incorrectly marked as 'No' for the presence of SMI and/or ID. This discrepancy was confirmed during an interview with the MDS Consultant, who acknowledged that the MDS should have been marked 'Yes' to reflect the resident's PASARR Level 2 status. Additionally, the facility did not accurately code the use of an antibiotic for another resident. The resident's electronic Medication Administration Record (eMAR) showed a new order for Rifaximin, an antibiotic, which was administered as prescribed. However, the MDS did not indicate that the resident was taking an antibiotic during the 7-day look-back period. This oversight was also confirmed by the MDS Consultant, who stated that the antibiotic should have been checked as taken on the MDS.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, which accurately reflected their care needs. For Resident 35, the admission Minimum Data Set (MDS) indicated the use of antidepressant, antianxiety, and anticoagulant medications. However, the comprehensive care plan did not include any resident-centered plan related to these medications. This omission was confirmed by the MDS Consultant during an interview, highlighting a gap in medication management and mood and behavior considerations as per the facility's policy. For Resident 3, the facility did not address an actual fall in the resident's care plan. Despite being identified as at risk for falls on a Fall Risk Evaluation, the care plan for falls was not initiated until after the resident experienced an unwitnessed fall. The resident, who had a BIMS score indicating cognitive intactness, reported a fall while reaching for food, which resulted in a visit to the emergency room. The Assistant Director of Nursing confirmed that the care plan for falls was delayed, failing to address the resident's actual fall incident.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to revise the Comprehensive Care Plans (CCPs) for three residents, which led to deficiencies in addressing their current medical needs. Resident 14, who was diagnosed with dementia, leukemia, type 2 diabetes, high blood pressure, irregular heartbeat, and obstructive sleep apnea, had an order to use a BiPAP device at night. However, the CCP did not include the use of this device, as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident 62, diagnosed with obstructive sleep apnea among other conditions, had an order for a CPAP device, but this was not reflected in their CCP. Observations confirmed the presence of CPAP equipment, yet the care plan remained unupdated. Additionally, Resident 2, who had diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder, experienced a fall resulting in abrasions to the left temple. Despite this incident, the CCP for Resident 2 was not updated to address the fall. The ADON confirmed the fall occurred, yet the care plan did not reflect this event. These oversights in updating the CCPs for the residents indicate a failure in maintaining accurate and current care plans, which are essential for providing effective and person-centered care.
Inadequate Infection Control Practices for Residents with MDRO and CPAP Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident 3, who had a history of infection with a multi-drug resistant organism (MDRO) and an indwelling catheter. Despite having an order for staff to wear gowns and gloves during catheter care, observations revealed that staff did not wear gowns during these procedures. Additionally, hand hygiene was not performed appropriately, as staff did not wash their hands before donning gloves, between glove changes, or when moving from contaminated to clean body sites. The facility's policy on EBP did not address all high-contact resident care activities, and personal protective equipment (PPE) was not readily available in the resident's room. Resident 3, who was cognitively intact with a BIMS score of 15, reported that staff only wore gloves during catheter and peri care, not gowns. Observations confirmed the absence of EBP signage and gowns in the resident's room. During peri and catheter care, staff failed to perform hand hygiene at critical points, such as before care, between glove changes, and after handling contaminated objects. The Assistant Director of Nursing (ADON) confirmed that the facility's EBP policy was incomplete and that PPE was not easily accessible. The facility also failed to ensure proper cleaning of a CPAP device for Resident 62, who had a diagnosis of obstructive sleep apnea and other medical conditions. Observations showed that the CPAP humidity reservoir was not emptied and cleaned daily as required by the physician's order. The ADON confirmed that the CPAP equipment had not been cleaned according to the facility's policy, which mandates daily cleaning to prevent infection. This oversight in infection control practices highlights deficiencies in the facility's adherence to established protocols.
Failure to Designate RN as Director of Nursing During Leave
Penalty
Summary
The facility failed to designate a licensed Registered Nurse (RN) to work full-time as the Director of Nursing (DON) during a period when the previous DON, RN E, was on maternity leave. The record review of the Archived Time Card Report forms for RN E showed that RN E clocked out in early May and did not return until August, with a Leave of Absence noted during this period. During RN E's absence, the Assistant Director of Nursing (ADON), who was a Licensed Practical Nurse (LPN), and the Administrator (ADM), who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, indicating that this deficiency had the potential to affect all residents. Interviews with the DON, ADM, and ADON confirmed that while RN E was on leave, the ADON, an LPN, was performing the responsibilities of the DON, such as attending meetings and managing staff. The ADM confirmed that the ADON was the designee during this period, and RN E was available by phone if needed. However, the facility did not have an RN designated to perform the duties of the DON while RN E was on leave, which was a requirement according to the licensure reference number 175 NAC 12-006.04(D)(i).
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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