Emerald Nursing & Rehab Columbus
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Nebraska.
- Location
- 2855 40th Avenue, Columbus, Nebraska 68601
- CMS Provider Number
- 285092
- Inspections on file
- 23
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Columbus during CMS and state inspections, most recent first.
A resident with multiple health conditions and stage 3 pressure ulcers did not receive the prescribed dressing change as ordered. An LPN was observed using a different treatment than what was ordered, applying skin prep and Medi-honey instead of the required wound cleanser and Triad paste. The LPN confirmed the mistake during an interview.
The facility failed to use required PPE and proper hand hygiene during care for two residents on Enhanced Barrier Precautions due to pressure ulcers. Staff did not wear gowns during high-contact activities, and a nurse did not change gloves or perform hand hygiene during wound care, as confirmed by the DON.
The facility did not implement its Legionella Water Management Program, failing to take measures to prevent Legionella growth in the water system. Interviews revealed that the maintenance department was not performing required actions, and the Administrator confirmed the absence of documentation for such measures, potentially affecting all 73 residents.
The facility failed to maintain a clean and safe environment, with issues such as missing baseboards, gouges, and holes in drywall, and a loose transition strip in resident rooms and corridors. These deficiencies were confirmed by the Administrator, and the Maintenance Director noted that the areas of concern had not been identified prior to the tour.
The facility failed to employ a Certified Dietary Manager and maintain sufficient staffing, leading to unsanitary conditions in the kitchen. Observations included sticky floors, food debris, and unclean equipment. Interviews revealed that routine cleaning was not completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The Administrator confirmed the unacceptable conditions and lack of routine cleaning evidence.
The facility's kitchen environment and equipment were not maintained to prevent foodborne illness, affecting all residents. Observations revealed sticky floors, food debris, and soiled equipment. The Dietary Manager lacked certification, and routine cleaning was not completed due to staffing issues. The Administrator confirmed the unacceptable conditions.
A resident with cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to consistently implement and revise fall interventions. Despite the facility's policy, interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently applied. Observations and interviews revealed inconsistencies in the use of fall mats and alarms, contributing to the resident's ongoing fall risk.
A resident was prescribed Cefadroxil indefinitely without proper clinical justification, despite the removal of an indwelling Foley catheter and multiple consultations with healthcare providers. The facility's Antibiotic Stewardship Policy was not effectively implemented, leading to the resident receiving unnecessary medication for an extended period.
The facility staff failed to maintain a medication error rate below 5%, with 6 errors observed out of 27 medications administered, resulting in a 22.22% error rate. Three residents received medications without food, contrary to their prescribed orders. The DON confirmed that medications should have been administered with food during breakfast.
The facility failed to serve breakfast room trays at the proper temperature, affecting two residents. Scrambled eggs were prepared at 182°F but were served at significantly lower temperatures of 78°F and 74°F. The trays were prepared and left by the Nurse's Station for 40 minutes before being distributed. A dietary aide confirmed the eggs should have been served at a minimum of 140°F.
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Residents experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Staff interviews revealed that the facility's expectation was for residents to receive baths at least once every seven days, but this was not always happening due to staffing issues. The facility administrator confirmed the deficiency.
The facility failed to provide sufficient nursing staff for bathing, affecting three residents who experienced significant gaps between baths, sometimes extending to 29 days. Staff interviews and records confirmed that residents were supposed to receive weekly baths, but this was not always happening due to staffing issues.
Failure to Follow Dressing Change Orders for Pressure Ulcer
Penalty
Summary
The facility failed to adhere to a practitioner's orders for a dressing change for a resident with pressure ulcers. The resident, who was admitted with multiple health conditions including anemia, high blood pressure, diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease, was assessed to have short- and long-term memory loss, severely impaired decision-making skills, and required total assistance with daily activities. The resident had two unhealed stage 3 pressure ulcers upon admission, and the care plan indicated skin integrity issues due to being bedridden for 28 days prior to admission. On a specific date, an LPN was observed performing wound care on the resident's coccyx pressure ulcer. The LPN did not follow the prescribed order, which required cleansing with a wound cleanser and applying Triad paste twice daily. Instead, the LPN used a skin prep and Medi-honey, which was not in accordance with the practitioner's orders. The LPN later confirmed the error during an interview, acknowledging the incorrect dressing change procedure.
Inadequate PPE Use and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not utilizing the required Personal Protective Equipment (PPE) during direct care activities for two residents on Enhanced Barrier Precautions (EBP). Specifically, staff members did not wear gowns when performing high-contact care activities for Residents 3 and 4, who were on EBP due to pressure ulcers. During an observation, Nurse Aide (NA)-D and Medication Aide (MA)-E did not wear gowns while transferring Resident 3 from a wheelchair to a bed and changing bed linens. Similarly, NA-M did not wear a gown while assisting Resident 4 with dressing, transferring, and toileting. Additionally, the facility did not follow proper hand hygiene and gloving techniques during wound care for Resident 3. Registered Nurse (RN)-F failed to change gloves after removing a dressing and applying barrier cream to Resident 3's pressure ulcer. RN-F also did not perform hand hygiene before assisting with other care activities. These actions were confirmed by the Director of Nursing (DON), who acknowledged that the staff should have adhered to the facility's policies on PPE use and hand hygiene to prevent potential cross-contamination.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement its Legionella Water Management Program, which is crucial for preventing water-borne illnesses such as Legionnaire's disease. The policy, last revised in January 2024, outlined the formation of an interdisciplinary water management team and detailed procedures to identify and mitigate areas in the water system that could foster the growth of Legionella bacteria. However, interviews with the Maintenance Director and the Infection Preventionist revealed that no measures were being taken to prevent the growth of Legionella, and the maintenance department, which was responsible for these measures, was not performing them. The Administrator confirmed that there was no documentation of any actions taken to prevent Legionella growth, indicating a complete lack of implementation of the water management policy. This deficiency had the potential to affect all 73 residents of the facility, as the policy was designed to reduce the risk of Legionnaire's disease by monitoring and controlling the water system effectively. The absence of documentation and action suggests a significant oversight in the facility's infection prevention and control program.
Environmental Deficiencies in Resident Rooms and Corridors
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by the observations made during an environmental tour. The tour revealed several deficiencies in the cleanliness and condition of the facility's walls, floors, and baseboards in five resident rooms and the Northwest corridor. Specific issues included missing baseboards, scrapes, gouges, and holes in the drywall in various rooms, as well as a loose transition stop strip with exposed and discolored flooring. These deficiencies were confirmed by the facility's Administrator during the tour. The Maintenance Director (MD) indicated that a patch panel had been affixed to a wall in one of the rooms due to the wall caving in. However, the MD also reported that the areas of concern had not been identified prior to the environmental tour, despite the existence of a Maintenance Request Log kept at the Nurse's Station. This suggests a lack of proactive maintenance and monitoring of the facility's environment, leading to the observed deficiencies.
Deficiency in Kitchen Cleanliness and Staffing
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) and maintain sufficient staffing to ensure the cleanliness of the kitchen environment, food preparation equipment, and storage equipment, potentially affecting all 73 residents who consumed food prepared by the facility. The job description for the Manager of Dining Services outlined responsibilities including managing the dietary department, ensuring food was prepared and served according to regulations, and maintaining cleanliness and safety standards. However, during an inspection, numerous deficiencies were observed in the kitchen's cleanliness and maintenance. During a tour of the primary kitchen, surveyors noted several unsanitary conditions, including a sticky floor, food debris in grout, and a thick black substance coating various surfaces. The fire suppression system and oven doors were covered in sticky and burnt substances, respectively. Additionally, the food steamer was leaking water, and the walls were coated in a brown sticky substance. Cooking pots were covered in black carbon buildup, and the air return covers had chipping paint and rust. The dry food storage area and walk-in freezer had boxes of food stored directly on the floor, and food service carts were covered in food debris. Interviews with the Dietary Manager and staff revealed that routine cleaning was not being completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The facility Administrator confirmed the unacceptable conditions and acknowledged the lack of evidence for routine cleaning. The Administrator also confirmed that the Dietary Manager had not completed the required training and was frequently involved in cooking, which hindered the maintenance of the kitchen environment and equipment.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen environment, food storage, and preparation equipment in a manner that prevents the potential for foodborne illness, affecting all residents who consumed food prepared by the facility. During an initial tour of the primary kitchen, several deficiencies were observed, including a sticky floor, food debris in grout, and a thick black substance coating the floor beneath various kitchen equipment. The fire suppression system and oven doors were coated with sticky and burnt substances, respectively. Additionally, the food steamer was leaking water into a pan, which was overflowing and cloudy, and the walls adjacent to the oven were covered in a brown sticky substance. Further observations revealed that cooking pots were coated with black carbon buildup, air return covers had chipping paint and rust, and bins of flour and sugar were contaminated by drippings from the food steamer. The reach-in refrigerators and freezers had handprints, smears, and frozen substances, with food boxes stored directly on the floor in both dry and walk-in storage areas. Food service carts and equipment wheels were heavily soiled, and the secondary kitchen exhibited similar issues, including a sticky floor, soiled ice machine, and lime buildup in the dishwashing room. Interviews with the Dietary Manager (DM) and Dietary Staff (DS) revealed that routine cleaning was not being completed due to staffing concerns, and the DM lacked current certification. The facility Administrator confirmed the unacceptable condition of the kitchen and acknowledged that the DM was frequently cooking, which hindered the maintenance of the kitchen environment and equipment. The facility had no evidence of routine cleaning being conducted.
Failure to Implement and Revise Fall Interventions
Penalty
Summary
The facility failed to implement and revise fall interventions for a resident, leading to multiple falls. The resident, who had a history of adult failure to thrive, previous heart attack, and pain, was assessed as having moderately impaired cognition and displayed various behaviors such as verbal and physical aggression, self-harm, and rejection of care. The resident was dependent on assistance for dressing, bed mobility, and transfers, and had experienced a fall without injury since the last assessment. The facility's fall management policy required assessing fall risk at admission, quarterly, or after a fall, and implementing individualized interventions. However, the facility did not consistently follow this policy. The resident experienced several falls, with investigations revealing that interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently implemented. Additionally, there was a lack of documentation and communication regarding the removal of the fall mat and the failure to develop new interventions after subsequent falls. Observations and interviews indicated that the resident's call light was often not within reach, and the use of fall mats and alarms was inconsistent. The Director of Nursing confirmed that new interventions were not developed after certain falls and that the fall mat was removed without proper documentation. This lack of consistent implementation and revision of fall interventions contributed to the ongoing risk of falls for the resident.
Failure to Address Unnecessary Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the long-term use of the antibiotic Cefadroxil. The resident, who had an indwelling Foley catheter, was prescribed Cefadroxil indefinitely by a urologist after cloudy urine was observed. However, there was no urinalysis conducted to support the clinical use of the antibiotic. Despite the removal of the catheter and multiple consultations with both the primary physician and the urologist, the continued use of Cefadroxil was not adequately addressed. The consultant pharmacist repeatedly recommended reviewing the necessity of the antibiotic, but the primary physician deferred the decision to the urologist, who also failed to provide a clear directive. The resident's medical record showed that the Cefadroxil was prescribed without a specified duration, and the facility's Antibiotic Stewardship Policy was not effectively implemented. The policy required tracking antibiotic use, ensuring pharmacy review, and monitoring for adverse reactions, but these measures were not sufficiently followed. The resident continued to receive Cefadroxil without a stop date, and the facility did not receive any information regarding a pending urine culture that could have informed the necessity of the antibiotic. This oversight led to the resident receiving unnecessary medication for an extended period without proper clinical justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate below 5%, as required by their policy. During observations, 27 medications were administered, resulting in 6 errors, which equates to an error rate of 22.22%. These errors involved three residents, who were not given their medications in accordance with the prescriber's orders. Specifically, the medications were not administered with food as required, which is a deviation from the prescribed method of administration. Resident 5 was prescribed Metformin to be taken with food, but the medication was administered without offering food. Similarly, Resident 19 was given Glimepiride, Metformin, Potassium Chloride, and Aspirin without food or a full glass of water, contrary to the orders. Resident 68 was prescribed Meloxicam to be taken with food, but it was administered without food. The Director of Nursing confirmed that these medications should have been administered with food during the breakfast meal, indicating a lapse in following the prescribed medication administration protocol.
Improper Temperature of Breakfast Trays
Penalty
Summary
The facility failed to ensure that room trays were palatable and served at the proper temperature, affecting two residents out of four who received a breakfast room tray. The facility's Beginning Food Cooking Temperatures log indicated that all hot food should be served at a minimum of 140 degrees Fahrenheit. However, on the morning of July 15, 2024, scrambled eggs were prepared with an initial temperature of 182 degrees Fahrenheit but were later served at significantly lower temperatures. Observations revealed that a serving cart with breakfast trays was positioned next to the Nurse's Station at 8:10 AM, and the trays were not distributed until 8:50 AM. When the trays were finally delivered, the scrambled eggs on Resident 34's tray were measured at 78 degrees Fahrenheit, and Resident 66's scrambled eggs were at 74 degrees Fahrenheit. An interview with a dietary aide confirmed that the scrambled eggs should have been served at a minimum of 140 degrees Fahrenheit, and the trays had been prepared between 7:30 AM and 7:45 AM before being placed by the Nurse's Station for distribution.
Failure to Provide Regular Bathing Services
Penalty
Summary
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Resident 1, who had severe cognitive impairment and required total assistance with bathing, experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Resident 4, who was cognitively intact but required moderate assistance with bathing, also had several instances where the time between baths exceeded seven days, with gaps ranging from 14 to 21 days. Resident 5, who had severe cognitive impairment and required assistance with bathing, experienced similar issues, with gaps between baths ranging from 10 to 21 days. These deficiencies were confirmed through record reviews and interviews with staff and residents. Interviews with various staff members, including LPNs, Medication Aides, and Nursing Assistants, revealed that the facility's expectation was for residents to receive baths at least once every seven days. However, this was not always happening due to staffing issues. A confidential resident interview also revealed that the resident had gone three weeks without a bath in February and had requested to have two baths weekly. The facility administrator confirmed that residents were expected to receive weekly baths, and acknowledged that Residents 1, 4, and 5 were not receiving baths as scheduled.
Failure to Provide Sufficient Nursing Staff for Bathing
Penalty
Summary
The facility failed to provide sufficient nursing staff for the provision of bathing for three residents, which had the potential to affect all residents. During a confidential interview, a resident revealed not receiving baths on a regular schedule, going three weeks without a bath in February. The resident had severe cognitive impairment and required total assistance with bathing. The review of the resident's Minimum Data Set (MDS) and care plan confirmed the need for regular bathing assistance, but documentation showed multiple instances where the time between baths exceeded seven days, sometimes extending to 29 days apart. Similar deficiencies were found for two other residents, one with cerebral palsy and another with severe cognitive impairment, both requiring assistance with bathing and experiencing significant gaps between baths, ranging from 10 to 21 days apart. The facility's nursing assignment records from November 1, 2023, to April 30, 2024, revealed numerous dates without a bath aide scheduled and multiple instances where two or more staff members did not report to work. Interviews with various staff members confirmed that residents were supposed to receive baths at least once every seven days, but this was not always happening due to staffing issues. The administrator confirmed that the expectation was for residents to receive weekly baths and acknowledged that the residents in question were not getting their baths completed weekly. The bath aide was often reassigned to other duties when there were staff call-ins, further contributing to the deficiency in providing regular bathing assistance.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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