Douglas County Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 4102 Woolworth Avenue, Omaha, Nebraska 68105
- CMS Provider Number
- 285019
- Inspections on file
- 20
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Douglas County Health Center during CMS and state inspections, most recent first.
Three residents experienced significant medication errors, including administration of an anticoagulant against physician orders, inappropriate holding of a nerve pain medication, and multiple errors involving sedative, opioid, and cardiac medications. These incidents resulted from miscommunication, incorrect pharmacy labeling, and failures in medication administration and verification processes.
Two residents did not receive pain medications as ordered: one experienced abrupt discontinuation of both gabapentin and Lyrica due to a pharmacy hold, leading to withdrawal symptoms and increased confusion, while another did not have a buprenorphine patch changed as scheduled, resulting in a missed dose. Both incidents were confirmed by staff and documented in medical records.
Dietary staff with facial hair exceeding policy limits were repeatedly observed preparing and serving food without wearing required beard restraints, in violation of both state food code and facility policy. This noncompliance was confirmed by the Dietary Manager and had the potential to impact nearly all residents receiving meals.
A resident with dementia was prescribed Quetiapine Fumarate, but the facility did not identify or monitor target behaviors as required. Physician orders called for daily behavior monitoring, yet neither the MAR nor TAR included prompts or documentation for this, and the care plan lacked identified target behaviors. This was confirmed by staff interview and was not in accordance with the facility's psychotropic medication policy.
A resident admitted with dementia, anxiety disorder, and PTSD did not have PTSD documented in the MDS admission assessment. The assessment only listed dementia and anxiety, omitting PTSD, even though it was an established diagnosis at admission. Staff interviews confirmed the diagnosis should have been included.
A resident with dementia, anxiety disorder, and PTSD was admitted and exhibited confrontational behavior and war-related hallucinations. The MDS assessment failed to include PTSD as a diagnosis, and the care plan did not address the resident's PTSD, despite facility policy requiring all identified needs to be included. Staff confirmed the omission, resulting in the resident's mental health needs not being fully addressed.
A resident with impaired mobility and incontinence developed multiple open wounds that were not consistently evaluated or measured as required by facility policy. Staff failed to document wound measurements during weekly skin assessments, and some wounds were not evaluated at all. Direct observation confirmed the presence of several open lesions, and staff interviews revealed a lack of knowledge regarding wound treatment.
A resident with an existing pressure ulcer and a physician's order for heel offloading was repeatedly observed lying in bed without their heels offloaded. The care plan did not specify interventions for heel protection, and staff confirmed the omission, despite facility policy requiring such measures for pressure injury prevention.
A resident with severe cognitive impairment and total dependence on staff for ADLs was repeatedly observed in a tilt-in-space wheelchair without proper leg or head support, despite physician orders for leg rests and a headrest. Staff did not consistently attach or adjust the leg rests or headrest, and the wheelchair components provided were not suitable for the resident's body size, resulting in inadequate support. The facility did not contact the hospice agency to reevaluate the wheelchair.
A resident with congestive heart failure and obstructive sleep apnea used a BiPAP machine without facility staff obtaining physician orders for its use or settings, and required cleaning protocols for the device were not implemented until several days after admission, contrary to facility policy.
A resident with frequent, severe pain received scheduled Tramadol without assessment of pain levels prior to administration or monitoring of the medication's effectiveness. Documentation and physician orders did not include requirements for pain assessment, and the care plan intervention to evaluate pain relief was not implemented.
A resident with dementia, anxiety disorder, and PTSD, who showed confrontational behavior and war-related hallucinations, did not receive a trauma-informed care assessment or have PTSD addressed in the care plan. Facility policy required identification of trauma triggers and individualized interventions, but these were not implemented.
Staff failed to secure a catheter drainage bag and oxygen tubing for two residents, leaving both items on the floor in violation of infection control protocols. One resident with an indwelling catheter and another receiving oxygen therapy were observed with their medical equipment improperly placed, and staff confirmed these practices did not meet facility policy for maintaining clean, non-sterile items.
A resident with moderate cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to feelings of shock and unsafety. Staff intervened to prevent physical harm, but facility leadership did not report the incident to APS or state authorities as required, citing a belief that the remarks did not constitute reportable abuse. The Administrator later acknowledged the event was reportable, highlighting a lapse in timely reporting procedures.
A resident with cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to a physical confrontation that was stopped by staff. Despite facility policy requiring investigation and reporting of such incidents, nursing leadership did not investigate or report the event, only recognizing its reportable nature after administrative review.
Three residents did not receive a required face-to-face visit by a physician within the first 30 days after admission, as only NPs conducted the initial assessments and there was no facility policy ensuring physician visits. Staff interviews confirmed that the Medical Director relied on NPs for initial care and only became involved if concerns were identified.
A resident in an LTC facility experienced a delay in receiving appropriate care for a shoulder fracture due to the facility's failure to ensure timely follow-up with the physician. Despite the resident's repeated complaints of shoulder pain, the facility did not promptly contact the physician or follow up on x-ray recommendations. This resulted in a 30-day delay between the initial x-ray showing a possible fracture and the follow-up x-ray confirming a healing fracture.
A facility failed to maintain a care-planned intervention for a resident with severe cognitive impairment, leading to repeated altercations with another resident. Despite an active care plan intervention to use a magnetic barrier to prevent room entry, the barrier was removed during remodeling and not reinstalled, resulting in incidents where the resident pushed another resident, causing falls and injuries. Staff interviews revealed inconsistent adherence to the care plan, with no documentation supporting the barrier's removal.
The facility failed to store foods for residents in a sanitary manner, with staff not labeling and dating resident foods, clearing spoiled foods, or maintaining temperature logs for nourishment refrigerators. This affected six neighborhoods and potentially 153 residents.
A resident, who was cognitively intact and expressed a desire to participate, was not invited to their care conferences. Despite facility policy and staff expectations, the resident was excluded from the care planning process, with only their family member participating via phone calls.
A resident's hospice and primary care provider were not informed of an abnormal C&S lab result until a week after it was reported to the facility, delaying necessary antibiotic treatment. The resident had multiple diagnoses and was receiving hospice services. Facility staff failed to follow policy requiring immediate notification of the physician for abnormal lab results.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Both residents, who had mobility issues and were dependent on staff for assistance, were observed with their call lights on the floor and out of reach. Staff confirmed the call lights should have been accessible, and the facility had ordered clips to secure the call lights, but they had not yet been installed.
The facility failed to update PASRRs for two residents after they were diagnosed with new mental illnesses and prescribed psychotropic medications. Despite the facility's policy requiring new PASRRs for significant changes in status, the Admissions Clinical Liaison and Chief Nursing Officer were unaware of the new diagnoses, resulting in non-compliance with state requirements.
A resident in a locked behavioral unit was found with medications left unattended at their bedside. The resident, who was cognitively intact, indicated that it was common for the nurse to leave medications in their room. Staff interviews confirmed that this practice posed risks, and the facility's policy required nurses to observe residents taking their medications.
A facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident with severe cognitive impairment. The RN involved did not use hand sanitizer or wash their hands between resident contacts and touched medications with bare hands, contrary to the facility's hand hygiene policy.
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The survey book was not updated with the latest recertification survey, and no signs were posted to indicate its location.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving three residents. For one resident with a history of traumatic cerebral hemorrhage and severe cognitive impairment, there was a physician order to hold apixaban, an anticoagulant, until cleared by neurosurgery. Despite this, the resident received 21 doses of apixaban due to a miscommunication between the facility, pharmacy, and nursing staff. The medication was dispensed and administered based on an incorrect pharmacy label and a lack of proper verification against the actual physician order, which resulted in the resident receiving the medication prior to neurosurgical clearance. Another resident, who had moderate cognitive impairment and was being treated for nerve pain, experienced a medication error when Lyrica, a prescribed medication, was held for several days without a physician order. This occurred after the pharmacy placed a hold on the medication following a neurology appointment that only called for discontinuation of gabapentin, not Lyrica. Despite attempts by facility staff to clarify the order with the pharmacy, the resident missed nine doses of Lyrica, leading to increased confusion and withdrawal symptoms until the medication was restarted. A third resident, with a diagnosis of congestive heart failure and who was receiving opioid and hypnotic medications, experienced several medication errors. These included administration of a sedative-hypnotic at the wrong time, omission of a scheduled buprenorphine patch change, administration of another resident's medications, and administration of Entresto despite blood pressure readings below the ordered threshold for holding the medication. These errors were confirmed through record review and staff interviews, indicating failures in medication administration, documentation, and adherence to physician orders.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication according to practitioner orders for two residents. For one resident with moderate cognitive impairment and significant assistance needs, gabapentin was discontinued per neurology orders, but Lyrica, which was to be continued, was incorrectly placed on hold by the pharmacy. Despite staff contacting the pharmacy multiple times, the Lyrica was not reinstated, resulting in the resident missing nine doses over several days. The resident subsequently became more confused and stopped eating, and it was noted that the abrupt discontinuation of both medications led to withdrawal symptoms. For another resident with congestive heart failure and extensive care needs, there was a failure to change a prescribed buprenorphine patch for chronic pain management as ordered. The patch, which should have been changed weekly, remained in place for twelve days, resulting in a missed dose. This omission was confirmed by facility staff and documented in the resident's medical records.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Dietary staff members were observed on multiple occasions preparing and plating food in the facility kitchen without wearing required beard restraints, despite having facial hair such as goatees and mustaches exceeding the length specified in facility policy. Specifically, one dietary aide was seen at the service line and another at the short-order grill, both with facial hair and not wearing beard nets, during several morning meal preparations. These observations were made over several days and involved staff directly handling and serving food. A review of the Nebraska Food Code and the facility's own Dress Code Policy confirmed that beard restraints are required for food employees with facial hair longer than half an inch. The Dietary Manager acknowledged that the staff members in question had facial hair that necessitated the use of beard restraints. The failure to comply with these standards had the potential to affect the majority of residents receiving food from the kitchen.
Failure to Identify and Monitor Target Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to identify and monitor target behaviors for the use of an antipsychotic medication for a resident diagnosed with dementia. Record review showed that the resident had physician orders for Quetiapine Fumarate, including instructions to monitor behaviors daily, but the orders did not specify time values. Further review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the relevant month revealed that target behaviors were not identified, and there was no indication or prompt for staff to record behavior monitoring related to the use of Quetiapine Fumarate. Additionally, the resident's care plan did not include any identified target behaviors, and an interview with a registered nurse confirmed that neither target behaviors nor prompts for behavior monitoring were present on the MAR or TAR. The facility's policy on the use of psychotropic medications requires ongoing evaluation of the effects of such medications, including behavior monitoring, but this was not followed in the case of this resident.
Failure to Accurately Document PTSD Diagnosis in MDS Admission Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) comprehensive assessment accurately identified all current diagnoses for a resident upon admission. Specifically, a resident admitted with diagnoses of unspecified dementia, anxiety disorder, and post-traumatic stress disorder (PTSD) did not have PTSD documented in Section I of the MDS admission assessment. The assessment, completed on 03/18/2025, only listed non-Alzheimer's dementia and anxiety as current diagnoses, omitting PTSD despite it being part of the resident's medical history. Interviews with facility staff revealed that the omission occurred because the MDS coordinator did not include PTSD in the assessment, relying instead on the timing of the resident's appointment with a mental health provider, which took place after the MDS was completed. The lead MDS coordinator confirmed that PTSD should have been included in the admission assessment, as the diagnosis was already established at the time of admission.
Failure to Address PTSD in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the mental and psychological needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD). Record reviews showed that the resident was admitted with diagnoses including unspecified dementia, anxiety disorder, and PTSD, and had a moderately impaired cognitive status as indicated by a BIMS score of 10/15. Despite documentation in progress notes of the resident being confrontational and experiencing war-related hallucinations, the admission assessment on the Minimum Data Set (MDS) did not include PTSD as a diagnosis in Section I. The lead MDS Coordinator confirmed that PTSD should have been included in the assessment. Further review of the resident's care plan revealed no evidence that the PTSD diagnosis was addressed. Interviews with facility staff, including the social worker, confirmed that the comprehensive care plan did not include interventions for PTSD. Facility policies required that all identified problems, including those found in the MDS and other assessments, be addressed in the care plan with specific goals and interventions. The failure to include PTSD in both the MDS and the care plan resulted in the resident's mental health needs not being fully addressed as required by facility policy and regulatory standards.
Failure to Evaluate and Monitor Resident Wounds per Policy
Penalty
Summary
Facility staff failed to properly evaluate and monitor open lesions for one resident with significant risk factors for impaired skin integrity, including impaired mobility, incontinence, and anemia. The resident's care plan included interventions such as weekly skin assessments, use of pressure reduction devices, and prompt notification of providers for skin concerns. However, record reviews showed that open wounds on the resident's buttocks and gluteal area were not consistently evaluated or measured as required. Several weekly skin assessments lacked documentation of wound measurements, and in some instances, the wounds were not evaluated at all. Direct observation confirmed the presence of multiple open wounds on the resident's buttocks and upper thigh, with staff interviews revealing a lack of awareness regarding the treatment for these wounds. The facility's own policy required comprehensive weekly skin assessments with detailed documentation, including wound measurements and descriptions, which was not followed. The unit manager confirmed that the wounds had not been measured weekly as required by policy.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to implement ordered interventions to offload the heels of a resident who was at risk for pressure ulcer development and already had a pressure ulcer present. The resident, who was cognitively intact and required extensive to total assistance with mobility and activities of daily living, had a physician's order to offload heels while in bed. However, multiple observations revealed the resident lying in bed with heels resting directly on the mattress, without any offloading devices or supports in place. The resident's care plan addressed pressure ulcer prevention and treatment but did not include specific interventions for heel offloading. The resident reported that while hospitalized, staff offloaded their heels using a pillow, but this was not done at the facility. A registered nurse confirmed during wound care that the heels were not offloaded as required. Facility policy required evidence-based interventions, including heel offloading, for residents at risk or with existing pressure injuries, but these were not implemented for this resident.
Failure to Ensure Proper Wheelchair Positioning and Support
Penalty
Summary
Facility staff failed to ensure proper wheelchair positioning and support for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living and receiving hospice care. Despite physician orders for a tilt-in-space wheelchair with leg rests, repeated observations showed the resident seated without leg rests, resulting in unsupported, dangling legs. The headrest was consistently positioned against the resident's upper shoulders or back, leaving the head unsupported. Even when leg rests were attached, they were too short for the resident's long legs, causing the knees to be elevated and not in contact with the wheelchair seat. The headrest repeatedly failed to stay in position to support the head, and staff did not consistently attempt to reposition it or the resident's legs when they became unsupported. The unit manager confirmed that the facility had not contacted the hospice agency to reevaluate the wheelchair, as it was provided by hospice and selected based on height and weight. Staff interviews and observations indicated a lack of ongoing assessment and adjustment of the wheelchair and its components to ensure proper support and positioning for the resident, despite clear orders and the resident's total dependence on staff for mobility and positioning.
Failure to Obtain Orders and Implement Care for BiPAP Use
Penalty
Summary
Facility staff failed to obtain and implement physician orders for the use of a non-invasive ventilator, specifically a BiPAP machine, for a resident diagnosed with congestive heart failure and obstructive sleep apnea. The resident, who was cognitively intact and required assistance with several activities of daily living, had a BiPAP machine at the bedside, but there were no documented orders specifying its use or settings in the resident's medical record. The care plan included a focus on BiPAP therapy, but interventions were limited to encouraging use, without reference to specific orders or settings. Additionally, the facility did not implement the required daily, weekly, and monthly cleaning protocols for the BiPAP machine until several days after the resident's admission. The Unit Manager confirmed that cleaning procedures were not followed initially because the machine belonged to the resident and not the facility. Facility policy outlined specific cleaning requirements for CPAP/BiPAP equipment, but these were not adhered to until after the deficiency was identified.
Failure to Assess and Monitor Pain Management
Penalty
Summary
The facility failed to assess a resident's pain prior to administering scheduled pain medication and did not monitor the effectiveness of the pain management provided. Record review showed that the resident had a physician's order for scheduled Tramadol HCL 50 mg three times daily for pain, and the resident's Minimum Data Set (MDS) assessment indicated frequent pain rated as 8 out of 10, which limited daily activities. However, the Medication Administration Record for the resident did not include any documentation of pain level assessments at the time of medication administration. Additionally, there was no physician's order in place to assess the resident's pain or to monitor the effectiveness of the scheduled pain medication. The resident's care plan included an intervention to evaluate the effectiveness of pain-relieving interventions, but this was not implemented as required. An interview with a registered nurse confirmed that there was no order or process in place for pain assessments or monitoring the effectiveness of the scheduled pain medication for this resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). The resident, who had moderately impaired cognition as indicated by a BIMS score of 10/15, exhibited confrontational behavior and hallucinations related to war, as documented in progress notes by an LPN. Despite these symptoms and the PTSD diagnosis, there was no evidence in the medical record that a trauma-informed care assessment had been completed for the resident. Further review and interviews revealed that the resident's care plan did not address the PTSD diagnosis, and no assessment had been conducted to identify potential triggers that could cause re-traumatization. The facility's own policy required the use of a multi-pronged approach to identify trauma history and triggers, as well as collaboration with the resident and relevant professionals to develop individualized care plan interventions. These steps were not followed for the resident in question.
Failure to Secure Catheter Bag and Oxygen Tubing Compromises Infection Control
Penalty
Summary
Facility staff failed to properly secure and maintain medical equipment for two residents, resulting in potential infection control deficiencies. For one resident with an indwelling urinary catheter, observations on two separate occasions revealed that the catheter drainage bag was lying on the floor without a cover or barrier. The resident required total assistance with bed mobility, toileting, and bathing, and was unable to complete a mental status interview. A nursing assistant confirmed that the catheter bag was on the floor and acknowledged it should not have been. For another resident receiving oxygen therapy, observations showed that the oxygen tubing and cannula were left lying on the floor in the resident's room while the oxygen concentrator was running. This resident had severe cognitive impairment and required extensive to total assistance with activities of daily living. A nursing assistant confirmed that the oxygen tubing and cannula were on the floor and should not have been. The facility's infection prevention and control policy requires all non-sterile items to be stored and maintained as clean, which was not followed in these instances.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an alleged verbal altercation between two residents to Adult Protective Services and the Department of Health and Human Services within the required timeframe. The incident involved a resident with moderate cognitive impairment, non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. During the altercation, another resident used racial slurs, derogatory language, and made threats, prompting the affected resident to attempt to physically respond before staff intervened. No physical harm occurred, but the resident who was verbally abused reported feeling shocked and unsafe as a result of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, interviews with the Unit Manager, DON, and ADON revealed that they did not consider the verbal remarks or the situation to be reportable and did not initiate an investigation or report the incident. The Administrator, upon review, agreed that the event was reportable, but this determination was made after the fact, indicating a failure to follow established reporting protocols.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an alleged verbal altercation between two residents, one of whom had a history of non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. The incident occurred in the dining room, where one resident used racial slurs, derogatory language, and threatened physical harm toward another resident, who then attempted to physically retaliate. Staff intervened and separated the residents, and no physical harm was reported. Despite the severity of the verbal altercation and the facility's policy requiring investigation and reporting of suspected abuse, the incident was not investigated or reported to the appropriate authorities. Interviews with the Unit Manager, DON, and ADON revealed that they did not consider the incident reportable or requiring further investigation, even though the facility's policy mandates reporting and investigation of all alleged abuse, including resident-to-resident incidents. The Administrator, upon review, agreed that the event was reportable, but no investigation or reporting had been initiated at the time of the survey.
Failure to Ensure Timely Physician Face-to-Face Visits After Admission
Penalty
Summary
The facility failed to ensure that three out of seven reviewed residents received a face-to-face visit by a physician within the required first 30 days after admission. Record reviews showed that these residents were only seen by nurse practitioners (NPs) for their initial admission assessments and subsequent care, with no documentation of a physician visit within the mandated timeframe. Specifically, one resident was admitted and seen by an NP for both the initial assessment and recertification, while two other residents were also only seen by NPs for their admission history and physicals. Interviews with facility staff confirmed that there was no policy in place regarding physician visits, and the Medical Director stated that NPs conducted the initial assessments, with the physician only becoming involved if concerns were raised by the NP.
Failure to Ensure Timely Follow-Up for Resident's Shoulder Fracture
Penalty
Summary
The facility failed to ensure timely follow-up with a physician to obtain x-rays for a resident who complained of shoulder pain. The resident, who was cognitively intact and independent in daily activities, reported pain on multiple occasions starting on May 15, 2024. Despite the resident's repeated requests for an x-ray, the facility staff did not attempt to contact the physician between May 15 and May 17, 2024, to expedite the x-ray process. The x-ray was eventually scheduled for May 21, 2024, but the delay in obtaining the x-ray and the lack of immediate follow-up with the physician contributed to the deficiency. The x-ray results from May 21, 2024, indicated a possible non-displaced fracture of the right shoulder, with a recommendation for follow-up radiographs in 10-14 days. However, the facility did not follow up with the physician regarding these recommendations, and no further x-rays were scheduled until June 21, 2024, after the physician inquired about the follow-up. This resulted in a 30-day gap between the initial x-ray and the follow-up, during which time the resident continued to experience pain. Interviews with facility staff, including the Assistant Director of Nursing, a Registered Nurse, and the Director of Nursing, confirmed that there was a lack of timely communication and follow-up with the physician. The facility's policy required immediate notification of the physician for new or severe pain and suspected fractures, but these protocols were not followed. The resident's fracture was not addressed promptly, leading to a delay in appropriate care and treatment.
Failure to Implement Care-Planned Intervention Leads to Resident Altercations
Penalty
Summary
The facility failed to implement a care-planned intervention for a resident with severe cognitive impairment and a history of physical aggression. The resident, who had been admitted with diagnoses of dementia with agitation and major depressive disorder, had an intervention in place since April 2023 to deter other residents from entering their room using a magnetic barrier. Despite this intervention being active in the care plan, the barrier was removed during a remodeling period, and no documentation was found to support the decision to discontinue its use. Subsequent incidents occurred where another resident entered the room, leading to altercations. On two occasions, the resident pushed the intruding resident out of the room, causing them to fall and sustain injuries. These incidents highlighted the failure to maintain the care-planned intervention, as the magnetic barrier was not reinstalled after the remodeling, and the care plan was not updated to reflect any changes or discontinuation of the intervention. Interviews with facility staff revealed a lack of consistent adherence to the care plan. Staff described the interventions as tools that could be used at their discretion, but there was no documentation to support the removal of the barrier due to the resident's stability. The facility's policy required the interdisciplinary team to update and evaluate care plans as needed, but this was not followed, leading to repeated resident altercations.
Failure to Maintain Sanitary Food Storage
Penalty
Summary
The facility failed to ensure that staff stored foods for residents in a sanitary manner. Specifically, staff did not label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This deficiency was observed across six neighborhoods within the facility, potentially affecting 153 residents. The facility's policy required that all food items brought in by family or visitors be labeled with content and date, and consumed within three days, but this was not adhered to in multiple instances. Observations revealed that nourishment refrigerators in several neighborhoods contained undated and spoiled food items. For example, the Windsong Way neighborhood's refrigerator had undated food containers and an open container of butter spread. Similar issues were found in the Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor neighborhoods, where temperature logs were incomplete, and food items were undated or spoiled. Interviews with staff confirmed that the food items should have been dated and that the dietary department was responsible for maintaining the nourishment refrigerators. The Director of Support Services and the Administrator confirmed that it was the facility's expectation for food items to be labeled and dated, and for refrigerator temperatures to be logged daily. The Assistant Director of Nursing reiterated that the facility's policy required daily checks of the refrigerators to discard any outdated, undated, or spoiled food items. However, these procedures were not consistently followed, leading to the observed deficiencies.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to invite a resident, who was cognitively intact, to attend their care conferences. The resident, diagnosed with chronic atrial fibrillation, unspecified intellectual disabilities, Tourette's disorder, and major depressive disorder, expressed a desire to participate in their care conferences. Despite the facility's policy requiring the involvement of residents in their care planning, there was no documentation indicating that the resident had been invited to any of their care conferences. The resident's family member participated via phone calls, but the resident was not given the opportunity to attend in person. Interviews with facility staff, including the Chief Nursing Officer, Registered Nurse, Social Worker, Assistant Director of Nursing, and the Administrator, revealed a consensus that residents should be invited to their care conferences. However, the Social Worker admitted to not inviting the resident, citing past negative experiences with resident participation. The facility's policy and staff expectations were not followed, resulting in the resident being excluded from their care planning process.
Delayed Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify a resident's hospice service provider of a change in condition. Specifically, Resident #231's hospice and primary care provider were not informed of an abnormal culture and sensitivity (C&S) lab result until a week after it was reported to the facility. This delay resulted in the hospice provider not ordering an antibiotic to treat Resident #231 until a week after the abnormal C&S lab result was reported to the facility. Resident #231 was admitted with diagnoses including neurocognitive disorder with Lewy bodies, dementia, adult failure to thrive, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. The resident had an indwelling catheter and was receiving hospice services. The facility's policy required immediate notification of the physician for laboratory tests revealing a urinary pathogen with symptoms and no treatment. However, the abnormal lab results reported on 11/23/2023 were not communicated to the hospice service provider until 11/30/2023. Interviews with facility staff and the hospice service provider confirmed the delay in notification. The facility's Advanced Practice Registered Nurse (APRN) noted the abnormal results on 11/30/2023, and the hospice service provider received the results the same day. The hospice provider then ordered the necessary antibiotic treatment. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged that the staff should have notified the physician immediately and followed up within 48 to 72 hours if there was no response, or sooner if the situation was urgent.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Resident #487, who had a history of falls and difficulty walking, was observed with their call light out of reach, lying on the floor. Despite being dependent on staff for transfers and having a care plan that directed staff to encourage the use of the call light, the resident was unable to access it without assistance. Nursing Assistant D confirmed the call light should have been within reach and acknowledged that all staff were responsible for ensuring this. The resident expressed difficulty reaching the call light when it fell to the floor and requested a clip to secure it, which was missing at the time of the observation. Licensed Practical Nurse E also confirmed the call light should be within reach and noted the absence of the clip. Similarly, Resident #101, who had muscle weakness and a history of falls, was observed with their call light on the floor multiple times. The resident, who needed substantial assistance from staff for mobility, was unable to reach the call light to request help. Nursing Assistant F and LPN E both confirmed that the call light should be within reach and noted the difficulty in keeping it on the bed due to the lack of securing devices. The resident's care plan also directed staff to encourage the use of the call light for assistance, but the absence of a securing mechanism led to repeated instances where the call light was out of reach. Interviews with the Administrator and Chief Nursing Officer revealed that the facility had evaluated the need for clips to secure call lights and remotes, and clips had been ordered but not yet installed. The deficiency was identified through observations and interviews, highlighting a failure to ensure call lights were accessible to residents, as required by the facility's policy and the residents' care plans.
Failure to Update PASRRs for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure new Level I Preadmission and Resident Reviews (PASRRs) were completed after residents were diagnosed with new mental illness diagnoses and prescribed psychotropic medications for two residents. Resident #12 was admitted in 2008 with no initial mental illness diagnoses. However, in 2022, the resident was diagnosed with traumatic brain injury, unspecified psychosis, bipolar disorder, anxiety disorder, and unspecified moderate dementia with agitation. Despite these new diagnoses and the prescription of multiple psychotropic medications, a new PASRR was not completed. The Admissions Clinical Liaison (ACL) and Chief Nursing Officer (CNO) acknowledged that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Similarly, Resident #74 was admitted in 2021 and readmitted in 2022 with no initial mental illness diagnoses. The resident was later diagnosed with alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and delusional disorders. Despite these new diagnoses and the prescription of psychotropic medications, a new PASRR was not completed. The ACL and CNO both stated that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Interviews with the ACL and CNO revealed that the facility's policy required new PASRRs to be completed when residents had significant changes in status or new mental illness diagnoses. Both staff members acknowledged that the PASRRs for Residents #12 and #74 did not reflect their current psychiatric diagnoses or medications, indicating a failure to comply with the facility's policy and state requirements.
Medications Left Unattended at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside of a resident in a locked behavioral unit. Resident #102, who was cognitively intact with a BIMS score of 15, was observed with a cup of medication at their bedside. The resident had already taken some medications and had placed others on their over-the-bed table. The resident indicated that it was not unusual for the nurse to leave medications in their room, trusting that the resident would take them. This practice was confirmed by the resident and observed by surveyors on 04/22/2024. Interviews with staff, including a Registered Nurse (RN) and the Chief Nursing Officer (CNO), revealed that leaving medications in a resident's room posed several risks, including the possibility of the resident not taking the medications, spilling them, or other wandering residents taking them. The CNO and the Administrator both stated that nurses were expected to observe residents taking their medications and not leave medications unattended in residents' rooms. The deficiency was identified as a failure to provide adequate supervision to prevent accidents and ensure the safety of all residents in the unit.
Failure to Perform Hand Hygiene and Proper Medication Handling
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident. Specifically, a Registered Nurse (RN) was observed preparing medications for a resident without using hand sanitizer or washing their hands after completing a medication pass with another resident. Additionally, the RN touched two medications with their bare hands while placing them into a medication cup. This action was contrary to the facility's hand hygiene policy, which mandates hand hygiene between resident contacts and before handling medications. The resident involved had a medical history that included vascular dementia, type two diabetes mellitus, hypertensive heart disease, unspecified mood disorder, and vitamin D deficiency. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. Interviews with other staff members, including another RN, the Chief Nursing Officer (CNO), and the Staff Development Instructor (SDI), confirmed that the facility's policy prohibits touching medications with bare hands due to infection control concerns. The SDI also confirmed that nurses are trained to avoid such practices during their education sessions.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The facility's policy required that a readable copy of the most recent federal and/or state survey report and plan of correction be maintained in a 3-ring binder in the main lobby and that signs indicating the availability and location of the survey binder be posted throughout the building. However, during the recertification and complaint survey, no signs were observed indicating where the survey results were located, and the survey book did not contain the latest recertification survey from 05/16/2023. The Compliance Officer (CO) confirmed that the survey book was not updated and was located in the lobby at the security desk, but it was the incorrect notebook. Interviews with the facility staff revealed that the CO was responsible for updating the survey notebook and checking it monthly, but this was not done. The Administrator acknowledged that the facility had not put back the signs indicating the location of the survey book after renovations. The Assistant Director of Nursing (ADON) stated that the survey notebook was available in the lobby and the CO's office, but there were no signs on the units to indicate its location. The ADON also mentioned that a handful of residents would ask about the survey results, but none had asked for the recent survey results. The facility's failure to ensure the survey results were readily accessible and properly indicated had the potential to affect all residents in the facility.
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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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