Crest View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chadron, Nebraska.
- Location
- 420 Gordon Avenue, Chadron, Nebraska 69337
- CMS Provider Number
- 285150
- Inspections on file
- 22
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Crest View Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents where root causes were not consistently identified and effective interventions were not implemented or updated in the care plan. Despite repeated falls and injuries, the facility failed to ensure that new or revised fall prevention strategies were put in place, and some interventions were either duplicative or not suitable for the resident's needs.
A resident with severe cognitive impairment and full dependence on staff for ADLs was repeatedly observed in soiled clothing with visible food debris and stains, and staff failed to provide necessary personal hygiene care after meals. The DON confirmed that the resident's hygiene needs were not met as required by the care plan.
A resident with diabetes and heart disease developed Stage 2 pressure ulcers, and the facility failed to consistently complete ordered wound care treatments and weekly skin assessments. Staff often skipped dressing changes and assessments, citing reasons such as clean dressings or missed baths, and did not regularly measure or document wound progress. Facility staff confirmed there was no systematic process for monitoring wound healing, resulting in inadequate management of the resident's pressure ulcers.
The facility's kitchen was found to have unsanitary conditions and expired food items, potentially affecting all residents. Observations included debris on shelving, stovetop, and windowsill, and outdated food items in the refrigerator. The Dietary Manager confirmed the issues and the policy of using or discarding food within five days.
The facility failed to maintain a pest-free kitchen environment, as required by the Nebraska Food Code and facility policies. Observations revealed flying insects landing on food preparation surfaces and resident meal plates. Cook-N confirmed the presence of insects and uncertainty about the regular use of industrial bug spray, potentially affecting all 31 residents consuming food from the kitchen.
The facility did not ensure that five staff members completed their initial orientation as required, potentially affecting all 31 residents. Record reviews and an interview confirmed the absence of evidence for completed orientation for a NA, an LPN, another NA, an RN, and another NA. The facility's assessment indicated that training should be completed at orientation, but personnel records showed no such evidence.
The facility failed to act on pharmacist recommendations for four residents, including dose reductions and lab checks, with no evidence of physician follow-up or rationale for inaction.
The facility failed to implement gradual dose reductions (GDR) for psychotropic medications and did not document the rationale for PRN medication use beyond 14 days for several residents. One resident was on multiple psychotropic medications without GDR attempts, despite a PHQ-9 score indicating no depression. Another resident had a PRN Ativan order without a specified duration, and the facility lacked documentation justifying its continued use. Interviews confirmed the absence of necessary evaluations and documentation.
The facility did not ensure that nurse aides completed the required 12 hours of continuing education, affecting 3 out of 5 sampled employees. NA-K completed 3.85 hours, MA-L completed 11.85 hours, and MA-M completed 9.1 hours, falling short of the mandated training. This deficiency was confirmed by the Administrator and had the potential to impact all 31 residents.
The facility failed to notify physicians of significant weight loss for two residents, as required by policy. One resident lost 12.77% of their weight over six months, and another lost 7.54% in one month. The DON confirmed that these significant weight losses were not communicated to the physicians, and no new interventions were implemented.
The facility inaccurately documented a resident's falls with major injury and another resident's medication use in their MDS assessments. One resident was reported to have multiple falls with major injury, but only had one confirmed incident. Another resident was documented as taking an anticoagulant, but was actually on an antiplatelet medication, aspirin.
A resident with severe cognitive impairment and a history of falls did not receive appropriate interventions after multiple fall incidents, as required by the facility's policy. Despite experiencing falls with varying degrees of injury, the care plan lacked new interventions, and existing interventions were deemed inappropriate. The DON confirmed these deficiencies in the facility's response to the resident's falls.
The facility failed to implement fall prevention measures for a resident with severe cognitive impairment by not ensuring the bed was in the lowest position, as required by the care plan. Additionally, another resident with Alzheimer's disease was transported in a wheelchair without footrests, contrary to safety expectations. These deficiencies were confirmed by staff observations and interviews.
A resident with chronic pain and moderately impaired cognition did not have their pain adequately assessed or documented by the facility staff. Despite physician orders and a care plan for pain management, the facility failed to record progress notes for the resident's reported pain levels of 5 or greater on multiple occasions over several months. An interview confirmed the absence of documentation and assessment of the resident's pain complaints.
A facility failed to assess a resident's dialysis access port site daily, as required by their policy. The resident, diagnosed with end-stage renal disease, had no care plan interventions for monitoring the site, and medical records showed no evidence of such assessments. The DON confirmed the expectation for staff to obtain vital signs and document the resident's condition post-dialysis, but this was not done.
A resident was observed dragging their oxygen nasal cannula on the ground, through food debris and dirt, while ambulating. A nurse aide then placed the nasal cannula back into the resident's nose without disinfecting it first, failing to follow proper infection control practices.
A resident with Alzheimer's and severe cognitive impairment was subjected to a privacy breach when a nurse aide checked their brief for incontinence in a commons area, exposing them in front of other residents. The nurse aide confirmed the action and acknowledged that privacy should have been ensured by conducting the check in the resident's room.
The facility failed to provide necessary toileting assistance for two residents with severe cognitive impairments. One resident, with epilepsy and vascular dementia, was not offered assistance from morning until noon, contrary to their care plan. Another resident with Alzheimer's disease was not assisted for over two hours, and their care plan lacked specific toileting frequency instructions. A nurse aide confirmed limited toileting times, and the DON acknowledged the need for two-hourly assistance.
The facility failed to manage weight loss for two residents, leading to a deficiency in nutrition and hydration. One resident experienced significant weight loss without notification to their medical provider or new interventions. Another resident's dietary needs were not met due to outdated care plans and unawareness of dietary orders, resulting in meals that did not align with their restrictions.
The facility failed to submit investigations of falls with major injuries to the state agency within five working days for three residents. The reports were submitted on an outdated template with an incorrect fax number, and there was no evidence of re-attempts to send the reports after initial failures.
A resident with a history of falls did not receive new interventions after a fall, despite facility policy requiring updates to the care plan. Staff interviews confirmed the lack of new interventions, highlighting a deficiency in fall prevention procedures.
Failure to Identify Root Causes and Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to determine root causes of falls and implement appropriate interventions to prevent recurrence for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with dementia and exhibiting a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, experienced multiple falls during their stay. Despite the facility's policy requiring incident reports, fall scene investigations, and care plan updates after each fall, there were repeated lapses in updating the care plan with new or revised interventions following several of the resident's falls. On multiple occasions, the resident was found on the floor, sometimes with injuries such as lacerations and skin tears. Root causes identified in fall scene reports included impaired memory, gait imbalance, inappropriate footwear, and issues with physical coordination. However, interventions listed in these reports were not consistently added to the resident's care plan, and in some cases, no new interventions were developed at all. Interviews with facility leadership confirmed that interventions identified at the time of the fall were not always implemented long-term, and there was a lack of follow-through in updating the care plan to reflect new risks or strategies. Additionally, some interventions placed on the care plan were duplicative or ineffective, such as encouraging the use of a call light for a resident who was known not to use it due to cognitive impairment. The facility also failed to consistently determine the root cause of each fall, and in some cases, interventions were delayed or not implemented until months after the initial incident. These actions and inactions resulted in a failure to provide adequate supervision and accident hazard prevention as required by facility policy and regulatory standards.
Failure to Maintain Personal Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to provide adequate personal hygiene care for a resident with severe cognitive impairment and full dependence on staff for activities of daily living. The resident, diagnosed with Alzheimer's disease and osteoarthritis, was observed multiple times throughout the day wearing the same soiled clothing, which had visible white flakes, dried fluid stains, and food debris. Additionally, the resident had yellow food debris on the right side of their mouth, and staff were observed only providing cueing during meals rather than direct hygiene assistance. The resident's care plan required staff to provide extensive assistance with personal hygiene due to the resident's self-care deficits. A grievance had previously been filed by the resident's family member regarding the resident's unkempt appearance, and ongoing concerns were expressed about the lack of hygiene care provided. The Director of Nursing confirmed that the resident's clothing and face were dirty and acknowledged that staff should have provided care after meals and changed the resident's clothing when soiled. Despite the resident's documented need for full assistance, observations and interviews indicated that staff did not consistently maintain the resident's personal hygiene.
Failure to Monitor and Treat Pressure Ulcers as Ordered
Penalty
Summary
The facility failed to provide appropriate monitoring and treatment of pressure ulcers for one resident, as required by both facility policy and physician orders. The resident, who had diagnoses of diabetes and heart disease, developed two Stage 2 pressure ulcers after admission. Orders were in place for specific wound care treatments, including scheduled dressing changes, weekly skin assessments, and the use of pressure-reducing devices. However, documentation revealed that these treatments and assessments were not consistently completed as ordered. On multiple occasions, dressing changes and skin assessments were missed, with staff documenting reasons such as the dressing being clean, dry, and intact, or the resident not having a bath that day. Facility policy required comprehensive wound assessments, including measurements and documentation in the medical record, to be completed at least weekly. Review of the resident's records showed that wound measurements and detailed assessments were not consistently performed or documented. Progress notes often lacked information on wound size, stage, and healing progress, and wounds were only measured if the resident was seen by an external wound clinic. The facility did not have a process in place to monitor wound progress internally, relying instead on sporadic documentation tied to bath days. Interviews with facility staff confirmed these practices. The DON acknowledged the absence of a systematic process for monitoring wound progress and stated that wounds were not measured unless the resident was seen by the wound clinic. Another staff member confirmed that skin assessments and dressing changes should occur as ordered, regardless of whether the resident received a bath or if the dressing appeared clean and intact. The lack of consistent monitoring and documentation led to a failure to ensure that the resident's pressure ulcers were properly managed and evaluated for healing.
Sanitation and Food Expiration Issues in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure that food was used or discarded before their expiration dates, potentially affecting all 31 residents who consumed meals from the kitchen. During an initial kitchen tour, surveyors observed several unsanitary conditions, including gray fuzzy matter and brown and black debris on the metal shelving unit where pots and pans were stored, and a large amount of burned food debris on the stovetop. Additionally, the dishwashing sink had a sanitizer dispenser tube resting inside a pot full of yellowish liquid and food debris, and the windowsill above the sink was covered in brown and gray debris. The floor throughout the kitchen was littered with food debris and dried liquid splashes. The surveyors also found several food items that were past their expiration dates or not properly labeled. An unopened bottle of teriyaki sauce had a best-by date from the previous year, and a bag of biscuits was dated over a week prior. In the walk-in refrigerator, several items, including diced onions, soup, turkey breast, chicken breast, marinara, chopped garlic, and parmesan cheese, were all past their labeled dates. The Dietary Manager confirmed that food items should be used or disposed of within five days of opening or preparing and acknowledged the presence of outdated items and unsanitary conditions in the kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as required by the 2017 Nebraska Food Code and the facility's own policies. Observations on September 3, 2024, revealed multiple flying insects in the kitchen, landing on food preparation surfaces, the steamtable, and resident meal plates. These insects were observed at different times throughout the day, indicating a persistent issue. An interview with Cook-N confirmed the presence of flying insects and suggested uncertainty about the regular use of industrial bug spray, which was typically applied at night. This deficiency had the potential to affect all 31 residents who consumed food prepared in the kitchen.
Failure to Complete Initial Staff Orientation
Penalty
Summary
The facility failed to ensure that five out of five sampled employees completed their initial orientation as required by the licensure reference 175 NAC 12-006.04(B)(i). This deficiency was identified through record reviews and an interview, which revealed that the facility did not have evidence of completed initial orientation for a Nurse Aide (NA) - G, a Licensed Practical Nurse (LPN) - H, a Nurse Aide (NA) - I, a Registered Nurse (RN) - B, and a Nurse Aide (NA) - J. The facility's assessment, last updated on 5/19/2024, indicated that training should be completed at orientation, as referenced in the orientation checklist. However, the personnel records provided by the facility showed no evidence of such completion for the aforementioned staff members. An interview with the Administrator confirmed the lack of evidence for the initial orientation completion for these employees. This oversight had the potential to affect all 31 residents residing at the facility.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up on recommendations made by the facility pharmacist during monthly drug regimen reviews for four residents. Resident 6, who was admitted with dementia and anxiety, had several recommendations from the pharmacist, including checking vitamin D and thyroid-stimulating hormone (TSH) levels, and considering gradual dose reductions of olanzapine and sertraline. However, there was no evidence that these recommendations were acted upon or that any rationale was provided for not doing so. Resident 19, admitted with dementia, vitamin D deficiency, hypertension, and urinary incontinence, had a recommendation from the pharmacist to update the diagnosis on their potassium medication order. Despite this, there was no evidence of action taken or rationale provided. Similarly, Resident 27, with a primary diagnosis of Parkinsonism, had a recommendation to discontinue lisinopril due to repeated hypotension, which was not acted upon until an emergency department visit prompted the discontinuation. Resident 14 had multiple recommendations from the pharmacist, including a gradual dose reduction of sertraline and updating lab tests for cholesterol and A1c levels. Again, there was no evidence of physician reviews or actions taken on these recommendations. Interviews with the Director of Nursing and a Nurse Consultant confirmed the lack of follow-up on pharmacist recommendations across these cases.
Failure to Implement GDR and Document PRN Medication Use
Penalty
Summary
The facility staff failed to implement gradual dose reductions (GDR) for psychotropic medications and did not obtain the necessary rationale for the continued use of PRN medications beyond 14 days for certain residents. Specifically, Resident 27 was taking antipsychotic, antianxiety, and antidepressant medications without any attempt at GDR, despite having a PHQ-9 score indicating no depression. The resident's PRN medication orders lacked an end date, and there was no evidence of re-evaluation every 14 days as required. Interviews confirmed the absence of provider attempts at GDR or appropriate documentation for PRN medication continuation. Resident 17 was admitted with diagnoses including delusional disorder and depression and had a PRN Ativan order without a specified duration or stop date. The facility did not have documentation from the physician justifying the extension of the PRN Ativan beyond 14 days. Interviews with facility staff confirmed the lack of evidence for physician documentation regarding the rationale or duration for the PRN medication. Resident 6, who had no current symptoms of depression according to their PHQ-9 score, was also taking multiple psychotropic medications without any attempt at GDR. The resident's medical records did not show any evidence of GDR attempts, and interviews with facility staff confirmed the absence of such attempts. These deficiencies highlight the facility's failure to adhere to policies regarding the management of psychotropic medications, including the necessary evaluations and documentation for GDR and PRN medication use.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of continuing education, as mandated by Licensure Reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and an interview, affecting 3 out of 5 sampled employees. Specifically, Nurse Aide (NA) - K completed only 3.85 training hours, Medication Aide (MA) - L completed 11.85 training hours, and MA-M completed 9.1 training hours. The facility's assessment, last updated on 5/19/2024, indicated that nurse aides should complete at least 12 hours of training per year. The employee records showed that NA-K was hired on 5/22/23, MA-L on 9/9/22, and MA-M on 9/1/22. An interview with the Administrator confirmed that these employees had not met the required training hours, potentially affecting all 31 residents at the facility.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for two residents, as required by their policy. Resident 17 experienced a weight loss of 21 pounds, equating to a 12.77% decrease over six months, which was not communicated to the physician. The Director of Nursing (DON) confirmed that the physician had not been informed of this significant weight loss, despite the facility's policy mandating such notification. Similarly, Resident 21 experienced a 7.54% weight loss in one month, which was also not reported to the physician. The resident's weight loss was documented in the Minimum Data Set (MDS) assessment, but there was no evidence that the primary provider was informed during subsequent visits. The DON acknowledged that the weight loss was significant and should have been verified and communicated to the physician, but no re-weigh was conducted, and no new interventions were implemented.
Inaccurate MDS Documentation for Falls and Medication Use
Penalty
Summary
The facility failed to accurately document falls with major injury for one resident and the use of antiplatelet medication for another resident in their Minimum Data Set (MDS) assessments. For the first resident, the MDS indicated that the resident had experienced two or more falls with major injury since their prior assessment. However, interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the resident had only one fall with major injury on a specific date, and no other falls with major injury had occurred since the resident's admission. For the second resident, the MDS inaccurately documented the resident as taking an anticoagulant, while the resident was actually taking an antiplatelet medication, specifically aspirin, as per the resident's Order Summary. The MDS Coordinator confirmed that the MDS should have reflected the use of an antiplatelet medication instead of an anticoagulant. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate documentation of residents' medical conditions and treatments.
Failure to Implement Post-Fall Interventions for a Resident
Penalty
Summary
The facility failed to develop appropriate interventions after falls for a resident with severe cognitive impairment, identified as Resident 17. The resident, who was admitted with diagnoses of epilepsy and vascular dementia, experienced multiple falls, including two without injury, two with minor injury, and one with a major injury resulting in a right arm fracture. Despite these incidents, the facility did not place new interventions after falls on specific dates, as required by their Fall Prevention and Response Policy. The care plan for Resident 17 acknowledged a history of falls related to unsteady gait and poor balance, yet it lacked evidence of interventions following falls on two occasions. Additionally, the interventions documented for other falls were deemed inappropriate, as they merely stated the resident's right to refuse care and to fall, without implementing measures to prevent further falls. The Director of Nursing confirmed the absence of appropriate interventions for the resident's falls, highlighting a deficiency in the facility's response to fall incidents.
Failure to Implement Fall Prevention and Wheelchair Safety Measures
Penalty
Summary
The facility failed to implement fall prevention interventions for Resident 17, who was admitted with diagnoses of epilepsy and vascular dementia and had severe cognitive impairment. The resident's care plan, last reviewed on 7/19/2024, indicated a history of multiple falls and required the bed to be in the lowest position when the resident was in bed. However, an observation on 8/29/2024 revealed that the bed was not in the lowest position while the resident was resting, which was confirmed by a nurse aide. Additionally, the facility did not ensure the safety of Resident 13 during wheelchair locomotion. Resident 13, admitted with Alzheimer's disease and severe cognitive impairment, required full assistance for wheelchair locomotion. An observation on 8/28/2024 showed that a nurse aide was pushing the resident in a wheelchair without using footrests, which was confirmed by the aide. The Director of Nursing confirmed that the expectation is for staff to use wheelchair footrests to prevent potential injury.
Failure to Document and Address Resident's Pain Management
Penalty
Summary
The facility staff failed to adequately assess and document the pain management for a resident, identified as Resident 19, who had moderately impaired cognition and chronic pain related to osteoarthritis. The facility's policy on pain assessment and management requires a multidisciplinary approach, including documenting the resident's reported level of pain with sufficient detail. Despite this, the facility did not document progress notes for Resident 19's reported pain levels of 5 or greater on multiple occasions across June, July, August, and September 2024. This lack of documentation occurred despite physician orders to monitor for verbal and non-verbal signs of pain every shift and to complete a pain progress note if the pain scale was scored at 5 or more. Resident 19's care plan included scheduled pain medications and non-pharmacological interventions, with specific orders for Tylenol, Voltaren Gel, and Anusol Cream. However, the facility failed to record any progress notes related to the resident's pain on several dates when the resident reported significant pain levels. An interview with a Nurse Consultant confirmed the absence of pain progress notes and the lack of assessment or addressing of Resident 19's complaints of pain during the specified months. This oversight indicates a failure to adhere to the facility's pain management policy and to provide appropriate pain management for the resident.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to assess the dialysis access port site daily for a resident with end-stage renal disease, as required by their policy. The policy, revised in March 2019, mandates daily monitoring of the access site for signs of infection. However, a review of the resident's care plan, which was last reviewed in August 2024, showed no interventions related to assessing the dialysis port site. Additionally, the resident's active physician's orders required a dialysis daily note every Monday, Wednesday, and Friday, but did not specify the details to be documented. A review of the resident's medical records, including Medication Administration Records, Treatment Administration Records, Progress Notes, and practitioners' orders from August to September 2024, revealed no evidence that the facility staff monitored the dialysis access site. An interview with the Director of Nursing confirmed the expectation that the resident's vital signs and weight should be obtained by facility staff, along with a progress note upon the resident's return from dialysis. However, there was no documentation indicating that these assessments were conducted.
Infection Control Lapse in Oxygen Administration
Penalty
Summary
The facility failed to implement proper infection control practices during oxygen administration for a resident. During an observation, a resident was seen ambulating from the dining room to their room while dragging their oxygen nasal cannula on the ground, through food debris and dirt. A nurse aide intervened and placed the nasal cannula back into the resident's nose without disinfecting it first. This action was confirmed in an interview with the nurse aide, who acknowledged the failure to sanitize the nasal cannula before reapplying it.
Resident Privacy Breach During Personal Care
Penalty
Summary
The facility failed to protect the dignity and privacy of a resident during personal care activities. Resident 13, who was admitted with a diagnosis of Alzheimer's disease and had severe cognitive impairment, required moderate assistance for toileting. During an observation, a nurse aide checked Resident 13's brief for incontinence in the commons area by pulling down their pants in the presence of two other residents. This action was confirmed by the nurse aide during an interview, acknowledging that privacy should have been provided by taking the resident back to their room for the check.
Failure to Provide Toileting Assistance for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide necessary assistance with toileting and incontinence care for two residents, both of whom had severe cognitive impairments and required assistance as per their care plans. Resident 17, admitted with diagnoses of epilepsy and vascular dementia, was observed not being offered assistance to the bathroom from 8:58 AM to 12:14 PM, despite their care plan indicating they should be assisted every two hours and before meals. A nurse aide confirmed that Resident 17 had not been offered toileting assistance since before breakfast, which was against the care plan's requirements. Similarly, Resident 13, diagnosed with Alzheimer's disease, was not assisted with toileting from 10:15 AM to 12:21 PM. The care plan for Resident 13 lacked specific instructions on the frequency of toileting assistance, and a nurse aide revealed that residents were only toileted before breakfast, after lunch, and before dinner. The Director of Nursing confirmed that residents should be assisted with toileting every two hours, indicating a failure to adhere to the expected care standards for these residents.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility staff failed to implement interventions to manage weight loss for two residents, leading to a deficiency in providing adequate nutrition and hydration. Resident 21 experienced a significant weight loss of 7.54% in one month, as documented in their Minimum Data Set (MDS) and weight records. Despite this, the resident's primary medical provider was not notified, and no new interventions were put in place to address the weight loss. The care plan for Resident 21 included interventions such as providing liquid protein and monitoring food intake, but these were not effectively implemented or updated in response to the resident's condition. Resident 12, who had diagnoses including Diabetes Mellitus and an open wound, also experienced deficiencies in dietary management. The resident's care plan included a double protein consumption intervention, but there was no corresponding protein supplement order in the physician's records. Additionally, the dietary manager was unaware of the complete dietary orders, leading to inconsistencies in the meals served. Observations revealed that the meals provided did not align with the resident's dietary restrictions, such as low sodium and diabetic diet requirements, as ordered by the wound clinic. Interviews with the Director of Nursing and a Nurse Consultant confirmed that the care plans and dietary orders for both residents were not up to date or reflective of their current needs. The facility's failure to notify medical providers of significant weight changes and to implement appropriate dietary interventions contributed to the deficiency in maintaining the residents' health through adequate nutrition and hydration.
Failure to Report Falls with Major Injuries
Penalty
Summary
The facility failed to submit their investigation of falls with major injuries to the state agency within five working days for three residents. The facility's policy, dated December 2022, mandates that the Administrator, DNS, or Nursing Supervisor ensure that a report is filed, the internal investigation begins immediately, and appropriate reporting takes place. However, the facility did not adhere to this policy. For Resident 1, the facility attempted to fax a 5-page Investigation Report but did not re-attempt after the initial failure. For Resident 2, there was no evidence that the facility attempted to send the report to the state agency. Similarly, for Resident 3, there was no evidence of an attempt to send the report to the state agency. All three reports were submitted on an outdated version of the investigation template containing an incorrect fax number for the state agency. An interview with the Administrator confirmed that the Administrator was responsible for sending investigations to the state agency. The Administrator also confirmed that the fax sheet for Resident 1 was sent to the incorrect fax number listed on the outdated template. This resulted in the failure to report the investigations of falls with major injuries for Residents 1, 2, and 3 to the state agency within the required timeframe.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to reduce falls for a resident with a history of falls. The resident, admitted with diagnoses including epilepsy, vascular dementia, depression, anxiety, and osteoarthritis, was severely impaired in daily decision-making and required moderate assistance with all Activities of Daily Living. Despite having more than two minor injury falls and more than two non-injury falls since admission, no new interventions were placed after the resident's fall on 1/11/2024. The facility's policy required post-fall documentation, including root-cause analysis and updating the care plan with new interventions, but this was not followed. Interviews with facility staff confirmed the lack of new interventions after the fall. The Registered Nurse (RN) and Social Services Director (SSD) both acknowledged that no new interventions were added to the resident's care plan following the fall. The RN indicated a belief that continuing the same interventions was sufficient, while the SSD confirmed the absence of new interventions in the care plan. This failure to update the care plan and implement new interventions after the fall constitutes a deficiency in the facility's fall prevention and response 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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