Emerald Nursing & Rehab Brookside Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 4735 South 54th Street, Lincoln, Nebraska 68516
- CMS Provider Number
- 285049
- Inspections on file
- 38
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Brookside Llc during CMS and state inspections, most recent first.
An LPN did not follow Enhanced Barrier Precautions while providing wound care to a resident with diabetic foot ulcers, failing to don a gown and to perform hand hygiene between glove changes as required by facility policy. The LPN was unaware that EBP applied to wound care, and the DON confirmed that these precautions were expected for residents with chronic wounds.
The facility failed to report and investigate an incident involving two cognitively impaired residents found in a compromising situation, despite both being unable to provide details due to severe cognitive impairment. Staff observed and internally reported the event, but no external report or resident assessment was completed, contrary to facility policy requiring immediate investigation and reporting of suspected abuse.
Staff failed to properly store and handle medications for two residents, resulting in drugs being left unsecured in resident rooms and used inappropriately. In one case, a medication aide used Nystatin powder left on a toilet for a resident with severe cognitive impairment, and in another, a medication cup with cream was left on a bedside table for a resident with moderate cognitive impairment and no self-administration order. The facility lacked a medication storage policy, and staff interviews confirmed these practices.
Staff did not perform hand hygiene before donning gloves or between glove changes during peri-care and catheter care for two residents, including one with severe cognitive impairment and another with a Foley catheter. Staff also failed to wear gowns as required for Enhanced Barrier Precautions and did not dry cleansed areas, with these actions confirmed by the DON as inconsistent with facility policy.
The facility did not accurately code MDS assessments for falls in three residents. One resident's fall with a cervical fracture and other falls with injury were not properly documented on the MDS, while another resident's MDS incorrectly indicated recent falls with injury despite no supporting documentation. A third resident's unwitnessed fall was not recorded on the MDS. These errors were confirmed by the MDS nurse coordinator and identified through record review and staff interviews.
A resident with severe protein calorie malnutrition and GERD was administered Omeprazole only 18 minutes before breakfast, despite a physician's order to give the medication 60 minutes prior to eating. The medication aide and corporate nurse consultant confirmed the timing did not meet the order, resulting in a failure to follow professional standards for medication administration.
A resident's bathroom floor was found to be unsanitary, with cracked tiles, a large brown stain, and cracked caulking with brown stains around the toilet. These conditions were confirmed by the Administrator, indicating a failure to maintain cleanliness.
A resident suffered burns from using a rice cooker in their room, which staff failed to remove despite being aware of it. Another resident, at risk for falls, was improperly assisted off the floor without a full assessment. These deficiencies led to an immediate jeopardy situation, later resolved with corrective actions.
The facility did not ensure residents could access their personal fund money during weekends, holidays, or evening/overnight hours, affecting 65 residents. A resident expressed concerns about limited access, and the Business Office Manager confirmed that funds could only be accessed during business hours. The facility's policy lacked provisions for ongoing access to petty cash for resident requests outside these hours.
The facility failed to maintain proper infection control practices, including a non-functional handwashing sink in the laundry area, inadequate enhanced barrier precautions for a resident with a catheter, improper hand hygiene during peri-care, and incorrect storage of oxygen tubing for multiple residents. Staff interviews revealed a lack of understanding and adherence to infection control protocols, contributing to the risk of cross-contamination.
The facility did not provide the required 12 hours of ongoing training for five direct care staff members, including Medication Aides and Nurse Aides, who had been employed for over a year. This deficiency was confirmed by the Human Resources Director and had the potential to impact all 112 residents in the facility.
A facility failed to follow its standardized recipes during meal preparation, affecting the nutritional needs of 110 residents. An observation revealed that a cook did not measure ingredients as per the meatloaf recipe and admitted to not being trained for the task. The facility's policy requires adherence to written menus and recipes, but this was not followed, as confirmed by the facility administrator.
The facility failed to ensure proper storage and labeling of medications at multiple nursing stations. Temperature logs for medication refrigerators were incomplete, and medication bottles lacked opening dates. Additionally, a resident with moderately impaired cognition had unauthorized access to medication in their room without a self-administration order.
A facility failed to evaluate a resident's ability to self-administer medications and ensure medication security. The resident, diagnosed with COPD and unspecified intellectual disabilities, was cognitively intact but had no care plan for self-administration. Observations showed the resident self-administering inhalers without staff presence, and the DON confirmed no evaluation or physician's order for self-administration.
The facility failed to provide written notices of transfer to three residents when they were transferred to the hospital, as required by policy. A resident with hemiplegia and hemiparesis, another with chronic respiratory failure, and a third resident were all transferred without the necessary documentation. Interviews confirmed the absence of written notices, indicating non-compliance with state requirements.
The facility failed to provide written bed hold notices to three residents or their representatives within 24 hours of hospital transfer, as required by policy. This oversight was confirmed through record reviews and interviews with facility staff, including the DON and CNC.
A resident with severe cognitive impairment suffered a head injury when accidentally hit by a door. Despite facility policy requiring neurological assessments for head trauma, no such assessments were documented. The facility's Corporate Nurse Consultant confirmed the oversight, indicating a failure to follow established protocols.
The facility failed to maintain cleanliness in Stations 1, 3, and 4, compromising residents' right to a safe environment. Observations revealed insulation pieces at Station 1, and Station 3's hallway had debris, food stains, and dead bugs. Station 4's hallway was dirty with debris, and the activity area had torn paper towels and dried food. Interviews confirmed the hallways were scheduled for daily cleaning but were not adequately maintained.
The facility failed to maintain a clean environment in several rooms and hallways, with dirty tray tables, sticky floors, and dirty carpets observed. The Nurse Consultant confirmed these issues and noted the difficulty in hiring weekend housekeeping staff. The facility census was 107.
The facility failed to obtain daily weights for a resident with congestive heart failure and did not complete a Basic Metabolic Panel (BMP) for another resident as ordered by the physician. The Director of Nursing and Nursing Consultant confirmed these deficiencies.
The facility failed to ensure proper hand hygiene and glove changes during and after catheter care for a resident. The Medication Aide did not perform hand hygiene before donning gloves and entering the resident's room, and did not change gloves or perform hand hygiene after handling various items and completing catheter care. The Nurse Consultant confirmed these lapses, which were against the facility's policy on catheter care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with diabetes mellitus type 2 and bilateral toe wounds. The LPN gathered supplies, performed hand hygiene, and donned gloves before entering the resident's room. During the wound care process, the LPN changed gloves but did not don a gown as required by the facility's EBP policy for residents with chronic wounds, such as diabetic foot ulcers. Additionally, the LPN did not perform hand hygiene between glove changes, which is also required by facility policy. The resident involved had a diagnosis of diabetes mellitus type 2, which can lead to poor blood flow and slow-healing wounds, and was under an order for daily wound care with Medi Honey and Band-Aids. The facility's policy specifies that EBP, including gown and glove use, must be followed for residents with chronic wounds. Interviews revealed that the LPN was unaware that EBP applied to wound care and believed it was only necessary for catheter and tube feeding care. The Director of Nursing confirmed that the resident was on EBP and that staff are expected to use gowns and perform hand hygiene as outlined in the policy.
Failure to Report and Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
A deficiency was identified when the facility failed to report an allegation of abuse involving two residents with severe cognitive impairment. Both residents had diagnoses including dementia and Alzheimer's disease, and their care plans indicated significant cognitive and decision-making deficits. On the date of the incident, one resident was found standing next to their bed pulling up their pants, while the other was lying on the same bed with their pants and brief down. Both residents were unable to provide details about the incident due to their mental status and medical history. Despite the circumstances and the residents' inability to consent or recall the event, no assessment was completed for one of the residents following the incident, and the event was not reported to the appropriate authorities as required. Staff interviews confirmed that the incident was observed and reported internally to the charge nurse, but facility leadership determined there was no contact and therefore did not initiate a report or further assessment. Additionally, a subsequent similar incident occurred, and again, the response was limited to internal notification without external reporting or immediate resident protection measures. A review of the facility's Abuse, Neglect, and Exploitation policy indicated that any suspected abuse must be reported and investigated immediately, especially when residents may lack the capacity to consent. However, there was no documentation of a report to authorities or a completed investigation for the incidents involving these two residents. The administrator confirmed that the event was not considered reportable, and no body assessment was performed, contrary to facility policy and regulatory requirements.
Improper Medication Storage and Handling in Resident Rooms
Penalty
Summary
Facility staff failed to properly store medications for two residents, resulting in drugs being left unsecured in resident rooms and used inappropriately. For one resident with severe cognitive impairment and a diagnosis of Alzheimer's disease and unspecified dementia, a medication aide used Nystatin powder that had been left on the toilet in the resident's bathroom, rather than obtaining it directly from the medication cart. The aide admitted to using the powder found in the room and not bringing it in from the cart prior to care. The Director of Nursing confirmed that medications should not be stored in resident rooms or used if not brought in for the specific procedure. In another instance, a resident with moderate cognitive impairment and a history of mental health conditions had a medication cup containing cream left on the bedside table in their room. The resident did not have an order to self-administer medications, nor was there an assessment for self-administration. Staff interviews revealed that the night shift nurse routinely placed Nystatin cream in a cup on the bedside table for use by the next nurse, rather than storing it securely. The nurse who applied the cream discarded the cup left in the room and confirmed that medications should not be stored in resident rooms. Both incidents were observed by surveyors and confirmed through staff interviews. The facility did not have a medication storage policy in place at the time of the survey, contributing to the improper storage and handling of medications for these residents.
Failure to Perform Hand Hygiene and Use PPE During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene before donning gloves and between glove changes during peri-care and catheter care for two residents. In one instance, a medication aide (MA-E) did not wash hands before putting on gloves, nor between glove changes, while providing peri-care to a resident with severe cognitive impairment, Alzheimer's disease, and a history of urinary tract infection. The aide also used Nystatin powder found in the resident's bathroom, which was not brought in from the medication cart, and did not dry the resident's groin area after cleaning. After removing gloves, the aide continued to assist the resident with personal grooming without performing hand hygiene. In another case, two nursing assistants (NA-A and NA-B) provided peri-care and catheter care to a resident with an indwelling Foley catheter and moderate cognitive impairment. Both assistants put on gloves without performing hand hygiene and did not wear gowns as required under Enhanced Barrier Precautions for residents with indwelling devices. During the care, they changed gloves without hand hygiene and did not dry the cleansed areas. After completing care, they performed hand hygiene, but not at the required intervals. Additionally, a registered nurse (RN-C) entered the resident's room already wearing gloves, disposed of a medication cup, applied topical medication, and left the room without performing hand hygiene after glove removal. Interviews with the Director of Nursing confirmed that staff did not follow facility policy, which requires hand hygiene before donning gloves, between glove changes, and after glove removal, as well as the use of gowns for residents under Enhanced Barrier Precautions. The observed failures were consistent with the facility's own infection control policies and procedures, as documented in the report.
Inaccurate MDS Coding for Falls Among Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments related to falls for three out of five sampled residents. For one resident, a fall resulting in a C1 vertebra fracture was not marked as a fall with injury on the Discharge MDS, despite documentation in the progress notes and confirmation by the MDS nurse coordinator. Additionally, this same resident had multiple falls, including incidents resulting in an abrasion and complaints of pain, which were not correctly coded as falls with injury on the Annual MDS. The MDS nurse coordinator confirmed these omissions during interviews. Another resident's MDS was incorrectly marked for falls with major injury, even though there was no documentation of recent falls in the progress notes, care plan, or fall risk assessments, and the last fall occurred over two years prior. For a third resident, an unwitnessed fall was documented in an incident report, but the corresponding Quarterly MDS did not indicate any falls. The MDS nurse coordinator acknowledged that this was an error. These inaccuracies were identified through record reviews and staff interviews, and the facility's policy requires the use of the RAI manual and evidence-based assessment tools to ensure MDS accuracy.
Failure to Follow Physician's Order for Medication Timing
Penalty
Summary
The facility failed to follow a physician's order regarding medication administration for one resident with a primary diagnosis of severe protein calorie malnutrition. The resident, who was cognitively intact, had an order for Omeprazole 20 mg to be administered by mouth every day, specifically 60 minutes before breakfast, for the treatment of GERD. On the day of observation, the medication was given at 7:45 AM, but the resident began eating breakfast at 8:01 AM, only 18 minutes after receiving the Omeprazole, rather than the ordered 60 minutes. The medication aide confirmed during interview that the medication had not been given the full hour prior to breakfast as ordered. The facility's medication administration checklist included a step for correct dose timing, but this was not followed in this instance. The corporate nurse consultant also confirmed, after consulting with the facility pharmacist, that 18 minutes was not sufficient time prior to breakfast for the Omeprazole administration, thus verifying the failure to comply with the physician's order.
Unsanitary Bathroom Conditions for a Resident
Penalty
Summary
The facility failed to maintain a clean and sanitary bathroom floor for one of the sampled residents. During observations on January 21 and January 22, 2025, the bathroom floor of a resident was found to have four cracked tiles in front of the toilet, with one tile having a missing area. Additionally, there was a large brown stained area extending from the base of the toilet, and the caulking around the base of the toilet was cracked and had brown stains around the front. These conditions were confirmed by the Administrator during an interview on January 22, 2025, indicating that the bathroom floor was not maintained in a clean and sanitary manner.
Failure to Prevent Burns and Improper Fall Management
Penalty
Summary
The facility staff failed to implement interventions to prevent hot liquid burns for a resident who was cognitively intact and independent with activities of daily living. The resident was admitted with several diagnoses, including a burn of unspecified body region and muscle weakness. Despite having a history of burns from hot liquids, the resident's care plan did not address skin issues related to burns. The resident used a rice cooker in their room to make hot beverages and food, which led to multiple burn incidents, including a significant burn that required hospitalization. Staff were aware of the rice cooker but did not take action to remove it, assuming it was allowed. Another deficiency involved the facility's failure to evaluate a resident for potential injuries from a fall before moving them. This resident, who was severely cognitively impaired and at risk for falls, was found on the floor by a surveyor. A nursing assistant assisted the resident off the floor without conducting a full body assessment, contrary to the facility's fall management policy. Interviews with the RN and DON confirmed that the nursing assistant should not have moved the resident before an assessment was completed. The facility's failure to address these issues resulted in an immediate jeopardy situation, which was later removed after corrective actions were implemented. However, the initial inaction and lack of adherence to protocols contributed to the deficiencies observed during the survey.
Removal Plan
- Residents wound was assessed, Physician notified and orders received.
- Education provided to resident's Power of Attorney (POA) on what resident can/cannot have in room.
- Items removed from resident room to be returned to son.
- Staff education completed related to items that could potentially cause injury and what to do if items are found.
- Staff education completed on reporting skin issues to Administrator, DON and or Assistant Director of Nursing (ADON) at time wound is found.
- Hot Liquid evaluation for Risk Residents completed on all residents.
- Care plans updated on any resident identified as being at risk for potential injury due to hot liquids.
- All residents have hot liquid evaluation completed on admission and quarterly.
- Nursing staff education related to wound identification who and how to report any potential wounds.
- All new hires will be educated regarding the skin protocol, potential for injury and process of reporting wounds.
- Wounds will be discussed daily as part of morning clinical.
- Residents rooms will be audited weekly for potential hazardous equipment.
- Affected resident room will be audited daily.
- Hot liquid eval's will be completed on admission and quarterly.
- Items that are a potential risk will be identified on admission with personal inventories.
- The plan of correction will be reviewed by the Quality Assurance and Performance Improvement (QAPI) program committee.
- Staff education outlining fall protocol: staff to call for nurse to assess resident prior to moving resident to chair or bed.
- High fall risk residents will be identified.
- Care plan audited to ensure risk for falls or actual falls identified as a focus with resident centered appropriate interventions in place.
- Residents profiles updated indicating fall risk.
- All new admissions fall risk will be identified.
- Resident centered interventions will be put into place on care plans.
- All falls will be reviewed daily in morning clinical.
- Fall packet will be put into place.
- Fall policy and procedure will be gone over with all new nursing hire by DON/ADON.
- All staff education on fall policy and procedure will be ongoing with all staff meetings.
- Post fall huddle will be completed by nursing staff immediately following fall.
- Random gait belt audits will be done on all nursing staff.
- Monitoring will be ongoing.
Restricted Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents could access their personal fund money during weekends, holidays, or evening/overnight hours. This deficiency affected all 65 residents with a personal fund account, out of a total facility census of 112. An interview with a resident revealed concerns about the limited access to their funds, as they could only access their money during business hours when the business office was open or when certain front receptionists were available. The Business Office Manager confirmed that access to personal fund accounts was restricted to Monday through Friday, 8:00 AM to 5:00 PM, at the front desk or the Business Office. A review of the facility's policy showed no evidence of provisions for ongoing access to petty cash to honor resident requests for accessing their personal funds outside of these hours.
Infection Control Deficiencies in Hand Hygiene and Oxygen Tubing Storage
Penalty
Summary
The facility failed to ensure a functioning handwashing sink was available in the laundry area, which had been broken with no running water since December 2023. This was confirmed by both the Environmental Manager and the Regional Administrator Consultant during interviews. The absence of a working handwashing station in the laundry area was a significant oversight in maintaining proper hygiene and infection control practices. The facility also failed to maintain enhanced barrier precautions during the care of Resident 56, who had a supra pubic catheter and was at risk for urinary tract infections. Observations revealed that staff did not wear gowns during high-contact activities such as transferring and providing peri-care, despite the presence of a CDC.gov EBP sign on the resident's door indicating the need for such precautions. Interviews with staff members indicated a lack of understanding and adherence to the enhanced barrier precautions, contributing to the risk of cross-contamination. Additionally, the facility did not ensure proper hand hygiene during peri-care for Resident 56, as staff members did not wash their hands for the recommended 20 seconds and failed to change gloves appropriately during the procedure. Furthermore, the facility did not store oxygen tubing properly for several residents, with tubing found lying on the floor or draped over equipment, contrary to the facility's policy requiring storage in labeled plastic bags. These deficiencies in infection control practices were observed across multiple residents, indicating systemic issues in the facility's infection prevention and control program.
Failure to Provide Required Ongoing Training for Direct Care Staff
Penalty
Summary
The facility failed to provide the required 12 hours of ongoing training for five direct care staff members, including Medication Aides and Nurse Aides, who had been employed for a year or more. This deficiency was identified through interviews and record reviews, which revealed that none of the sampled staff had completed the necessary training. The Human Resources Director confirmed that the training had not been completed for any direct care staff, including the five sampled individuals. This oversight had the potential to affect all 112 residents residing in the facility.
Failure to Follow Standardized Recipes in Meal Preparation
Penalty
Summary
The facility failed to adhere to its established menus and standardized recipes during meal preparation, which had the potential to affect 110 residents who received food from the kitchen. An observation of meal preparation by Cook-A revealed that the cook did not follow the corporate recipe for meatloaf. Specifically, Cook-A was seen preparing meatloaf without measuring the ingredients as specified in the recipe, such as the amount of breadcrumbs added to the mixture. When questioned, Cook-A admitted to not being trained for the task, despite having been employed at the facility for two months. The facility's policy, titled Food Preparation Guidelines, mandates that cooks or their designees prepare menu items according to the facility's written menus and standardized recipes. However, the observation showed a deviation from this policy, as Cook-A did not follow the recipe for meatloaf preparation. The facility administrator confirmed that Cook-A should have adhered to the recipe, indicating a lapse in training and oversight in the kitchen operations. This deficiency in following the prescribed menu and recipe could potentially impact the nutritional needs of the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple nursing stations, as observed during a survey. At stations 1, 2, and 4, the medication storage rooms contained refrigerators with temperature logs that were either incomplete or entirely blank, with no recorded temperatures for several months. Medication Aids and Licensed Practical Nurses interviewed were unsure of who was responsible for recording these temperatures, and no thermometers were found inside the refrigerators. The Corporate Nurse Consultant and Director of Nursing confirmed the lack of a specific policy for monitoring refrigerator temperatures. Additionally, the facility did not properly label medication bottles with opening dates. At station 4, an open bottle of iron and a pump bottle of Cetaphil were found without dates indicating when they were opened. Staff members acknowledged that these bottles should have been marked with the date of opening, but there was no specific policy found for the storage of stock medications. This lack of labeling could lead to potential issues with medication efficacy and safety. Furthermore, the facility failed to adhere to its policy regarding resident self-administration of medications. Resident 42, who has moderately impaired cognition, was found with an opened, undated bottle of ear drops in their room without a self-administration order. The medication should have been stored in a locked medication cart. Interviews with staff confirmed that Resident 42 did not have authorization for self-administration, and the presence of the medication in the room was unauthorized.
Failure to Evaluate Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to evaluate a resident's ability to self-administer medications and ensure the security of those medications. The resident, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and unspecified intellectual disabilities, was found to be cognitively intact according to a recent BIMS assessment. Despite this, there was no evidence in the resident's care plan of any focus, goals, or interventions regarding self-administration of medications. The resident's physician orders included inhaled medications for COPD, but there was no documented evaluation of the resident's ability to self-medicate since an assessment in 2021, which indicated the resident did not wish to self-administer medications. Observations revealed that the resident had an Atrovent inhaler on their bed and was self-administering the medication without facility staff present. Interviews with the resident confirmed that they were self-administering the inhaler in a manner not consistent with the prescribed instructions. The Director of Nursing confirmed that the facility had not completed an evaluation of the resident's ability to safely self-administer medications and that there was no physician's order permitting the resident to do so.
Failure to Provide Written Notices of Hospital Transfer
Penalty
Summary
The facility failed to provide written notices of transfer to three residents, identified as Residents 42, 61, and 84, when they were transferred to the hospital. The facility's policy requires that residents and their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, record reviews and interviews revealed that no such documentation was provided for these residents. Resident 42 was discharged to the hospital on two occasions, and there was no evidence of written notice for either event. Interviews with the Director of Nursing and the Corporate Nurse Consultant confirmed the absence of the required documentation. Resident 61, who had a diagnosis of hemiplegia and hemiparesis following a brain bleed, was on hospital leave, but no written notice of transfer was documented. Similarly, Resident 84, who had chronic respiratory failure with hypoxia, was transferred to the hospital without a written notice of transfer. The Corporate Nurse Consultant confirmed that the facility did not complete the necessary documentation for these hospitalizations, indicating a failure to adhere to the facility's policy and state requirements.
Failure to Provide Bed Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives within 24 hours of being transferred to the hospital. This deficiency was identified for three residents who were hospitalized. The facility's policy, revised in January 2024, mandates that residents or their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, record reviews and interviews revealed that this policy was not followed for the residents in question. Resident 42 was discharged to the hospital on two occasions, but there was no evidence of a bed hold notice being provided. Interviews with the Director of Nursing and the Corporate Nurse Consultant confirmed the absence of documentation. Similarly, Resident 61 was on hospital leave, and no bed hold notice was documented in their electronic health record. The Corporate Nurse Consultant confirmed this oversight. Lastly, Resident 84, who was hospitalized due to respiratory distress, also did not receive a bed hold notice, as confirmed by the Corporate Nurse Consultant.
Failure to Monitor and Document Head Injury
Penalty
Summary
The facility failed to adequately monitor and document a head injury for a resident, identified as Resident 165, who had severe cognitive impairment due to dementia. The incident occurred when a housekeeper accidentally hit the resident in the head with a door, resulting in a bruise on the forehead. Despite the facility's policy requiring neurological assessments following head trauma, no such assessments were documented for this incident. The lack of follow-up documentation and neurological checks was confirmed during an interview with the facility's Corporate Nurse Consultant. The consultant acknowledged that the necessary neurological assessments, referred to as crani checks, were not performed as required by the facility's procedures. This oversight represents a failure to adhere to established protocols for monitoring head injuries, potentially compromising the resident's safety and well-being.
Facility Fails to Maintain Cleanliness in Multiple Stations
Penalty
Summary
The facility failed to maintain cleanliness in several areas, compromising the residents' right to a safe, clean, and comfortable environment. Observations on multiple occasions revealed issues at Stations 1, 3, and 4. At Station 1, there were free-standing pieces of insulation along the window seal. Station 3's hallway floors were littered with clumps of a black substance, debris, food stains, and sticky areas of unknown substances. Additionally, there were colored candy pieces, dead bugs, and a mat covered with dirt, dust, and rubber bands. Cobwebs and dust were also found under a curio cabinet in the hallway. Station 4's hallway was similarly dirty, with brown and black debris and sticky areas. In the activity area, torn paper towels and dried food pieces were found smashed into the floor. Interviews with the Environmental Services Director and the Administrator confirmed the hallways were scheduled for daily cleaning, but acknowledged the areas were not clean and required attention.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean environment in several rooms and hallways, as observed on 4/8/24. Specifically, rooms 113, 211, 212, and 312 had dirty tray tables with dry yellow and brown substances. Room 113 also had a brown sticky substance on the floor, and its bathroom trash can was overflowing with paper towels. Additionally, the floors in rooms 211 and 212 were sticky. The 300 and 400 hallways had dry rings of substances on the laminated floors, while the 100 and 200 hallways had dark rings of substances on the carpets. The kitchenette on the 200 hall had a rug with white and red dry substances and a dirty floor. During an interview and tour of the facility, the Nurse Consultant confirmed the observations, acknowledging that the tray tables, floors, and hallways were dirty and needed cleaning. The Nurse Consultant also mentioned that the facility was unable to hire housekeeping staff for weekends, as no one was willing to work during those times. The facility census was 107 at the time of the observations.
Failure to Obtain Daily Weights and Laboratory Services
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure as ordered by the physician. The resident had specific orders for daily weights to monitor their condition, with instructions to fax recordings weekly to the physician and to call if there was a weight gain of 2-3 pounds for two consecutive days or a weight gain of 5 pounds in one week. However, weights were not documented on multiple dates, and the Director of Nursing confirmed that the daily weights had not been completed as required by the physician's orders and the facility's weight monitoring policy. Additionally, the facility failed to obtain a Basic Metabolic Panel (BMP) for another resident as ordered by the physician following a hospitalization. The BMP was supposed to be completed on a specific date, but there was no record of the BMP being collected or any documentation in the progress notes to notify the physician that the BMP had not been completed. Interviews with the Director of Nursing and the Nursing Consultant confirmed that the BMP was not drawn and should have been, and there were no lab results found for the ordered BMP.
Failure to Ensure Proper Hand Hygiene and Glove Changes During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during and after catheter care for one resident. The Medication Aide (MA) did not perform hand hygiene before donning gloves and entering the resident's room. The MA then proceeded to handle various items in the room, such as removing a trash bag, raising the bed, lowering the blinds, and obtaining supplies, without changing gloves or performing hand hygiene. After completing catheter care, the MA discovered the resident had been incontinent of stool and removed the soiled brief, cleansed the resident with one wipe, and then changed gloves and performed hand hygiene. However, the MA did not change gloves or perform hand hygiene again before placing a new brief on the resident and completing the care process. The Nurse Consultant (NC) confirmed these lapses in hand hygiene and glove changes during the care process. The facility's policy on catheter care, revised in 2014, outlines specific steps for hand hygiene and glove changes, which were not followed by the MA. The policy requires washing and drying hands thoroughly before donning gloves, changing gloves after handling soiled items, and performing hand hygiene after removing gloves. The MA's failure to adhere to these steps resulted in a deficiency in infection prevention and control, as confirmed by both the MA and the NC during interviews.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
