Emerald Nursing & Rehab Lancaster Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 1001 South Street, Lincoln, Nebraska 68502
- CMS Provider Number
- 285275
- Inspections on file
- 44
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Lancaster Llc during CMS and state inspections, most recent first.
Surveyors found that all four dining room steam tables contained brown water with floating particles, corrosion, and dried food, and that a toaster in one serving station was heavily soiled with crumbs, black stains, and dried food on its surfaces and surrounding counter. Facility policies required daily draining, cleaning, and sanitizing of steam tables and adherence to Food Code standards for clean food-contact and non-food-contact surfaces. A cook and the Food Service Manager acknowledged that the steam tables were not being cleaned and the water was not being changed daily, and could not identify when this was last done. The Administrator confirmed that dietary sanitation was deficient and that no process improvement plan was in place, affecting meal service for about 170 residents using the dining area.
A resident with a history of substance use and cognitive impairment was found to have an unsecured bottle of alcohol in their room, despite provider orders limiting alcohol consumption to special occasions. Multiple staff members were aware of the alcohol but did not secure it, and there was no documentation of a self-administration assessment or notification to the POA or provider. The resident became intoxicated, and the POA was only informed after the incident.
The facility did not maintain adequate nursing staff on all shifts, with staffing records showing nurse and NA coverage below required ratios. Residents reported long waits for call light responses, and staff described frequent call-ins and being left to care for large numbers of residents, especially at night and on weekends. Grievances about delayed care further confirmed the staffing deficiencies.
A facility failed to change soiled bed linens for a resident with bladder incontinence, despite the resident's care plan requiring routine checks and changes. During an observation, NAs A and B were seen providing care to the resident, and it was noted that the draw sheet and fitted sheet had yellow stains. Although a new draw sheet was obtained, the fitted sheet was not changed because the resident was scheduled for a bath later. The DON confirmed that the soiled linens should have been changed immediately.
A nursing assistant failed to follow proper infection control practices by not performing hand hygiene at required intervals and improperly using gloves while providing care to multiple residents. The assistant did not change gloves or wash hands between resident interactions, leading to potential cross-contamination. The Director of Nursing confirmed the breach of protocol despite previous staff education on hand hygiene.
The facility failed to have an RN on duty for at least 8 consecutive hours on a weekend, as required. Staffing schedules showed no RN was scheduled, and interviews confirmed the absence. The staffing coordinator was unaware of RN identities due to missing titles on schedules, and the DON admitted that procedures to cover RN absences were not followed.
The facility failed to provide the required 12 hours of ongoing training for five direct care staff members, including four NAs and one UD. Record reviews and interviews revealed that none of the sampled staff completed the mandated continuing education hours, with attendance ranging from 5 to 10 hours during 2024. The absence of documentation for ongoing education was confirmed by the COO and Administrator, highlighting a potential impact on all 174 residents.
The facility failed to maintain proper food safety and hygiene standards, with undated and outdated food items found in storage, a dirty ice machine, and inadequate hand hygiene practices by staff. Observations revealed that kitchen staff did not consistently wear hair restraints or wash hands for the required duration, as confirmed by interviews with the Director of Food Service.
The facility failed to prevent cross-contamination in laundry handling and did not adhere to infection control practices for CPAP/BiPAP cleaning and oxygen tubing replacement. A resident's BiPAP machine was observed with layers of dust, and two residents had outdated oxygen tubing. Staff interviews confirmed the lapses in following the facility's infection control policies.
The facility failed to ensure a clean environment, with observations revealing lint and debris on fans, a pivot stand, and a vent cover. The facility's cleaning policies did not include these items, and the last deep cleaning dates were outdated. The Administrator confirmed the need for cleaning.
The facility lacked a qualified Activity Professional, affecting all residents involved in activities. The AD had no activity training, and the MOO, who oversaw activities, lacked experience in recreational programs. The RA confirmed no staff had formal training in activities, and 20-25 residents routinely refused activities.
The facility failed to provide written notices of transfer to residents or their representatives prior to hospitalization, as required by policy. Four residents were transferred without receiving notices that included the reason for transfer, location, and appeal rights. Interviews confirmed the facility's non-compliance with providing the necessary information for emergency transfers.
A facility failed to accurately document a resident's unstageable pressure ulcer in the MDS. The resident had an unstageable pressure ulcer on the right hand, covered with eschar, but the MDS incorrectly recorded zero unhealed pressure ulcers. The DON confirmed the error and acknowledged that the MDS should have indicated one unhealed pressure ulcer, as per the RAI manual guidelines.
The facility failed to provide scheduled activities for residents in the Alzheimer's Unit, affecting three residents with cognitive impairments. Observations showed no activities on Station 5, despite scheduled events on the activity calendar. Interviews confirmed the absence of an activities person for two months, and no activities were documented for the affected residents in the last 30 days. The facility's policy required staff education on resident rights, but no activities were scheduled due to a norovirus outbreak.
A facility failed to obtain a complete, valid prescription for a CPAP machine for a resident. The resident confirmed using the CPAP nightly, and the Order Summary Report included instructions for its use with oxygen. However, the DON confirmed the absence of a valid prescription with current settings.
The facility did not have a qualified Infection Preventionist (IP) since mid-October, affecting infection control duties for all 178 residents. The Infection Prevention and Control Program Policy outlined the IP's responsibilities, but no documentation was available for November. Interviews with the DON and Administrator confirmed the absence of an IP and the lack of infection control activities.
A resident with a UTI experienced delays in urine sample collection and antibiotic administration due to communication breakdowns among staff. Despite the resident's guardian expressing concerns, the facility did not collect a urine sample until several days after it was ordered, and there were delays in starting a new antibiotic after receiving culture results.
A facility failed to follow its infection control policies during wound care for a resident. An RN did not wear an isolation gown as required by the Enhanced Barrier Precautions policy and washed hands for less than the mandated 20 seconds at various stages of the procedure. Interviews confirmed the facility's expectations for PPE use and hand hygiene.
A resident with a Stage 2 pressure ulcer on the coccyx did not receive appropriate wound care as per medical orders, leading to the ulcer worsening to Stage 3. Despite a care plan indicating risk for skin breakdown, no wound care treatments were documented or administered. Interviews with staff confirmed the absence of treatment orders and care, resulting in a deficiency.
The facility failed to honor the religious preferences of a Muslim resident, who was unable to pray and fast as desired, and did not include these preferences in their care plan. Additionally, several residents experienced significant gaps between scheduled baths, contrary to their stated preferences. Staff interviews revealed a lack of awareness and action regarding these preferences, with systemic issues in documentation and implementation of resident rights and self-determination policies.
Two residents left the facility unsupervised due to staff's failure to follow procedures for monitoring residents with wanderguards and Community Access Passes. One resident, who was cognitively impaired and at risk for elopement, wore a wanderguard that did not trigger the alarm. The other resident, who was cognitively aware, had a pass to sit out front only but was able to leave with the first resident. Staff were unaware of the residents' departure, and the receptionist mistakenly allowed them to leave, thinking one was a visitor.
Two residents left the facility unaccompanied, despite one wearing a wandering device. The receptionist cleared the alarm, mistaking one resident for a visitor. The facility did not conduct a formal investigation or report the incident to the State Agency, as management deemed it not an elopement.
A resident with multiple health issues, including dementia and a history of UTIs, showed increased confusion and hallucinations. Despite a family member's request for a urinalysis, the facility failed to notify the physician of the change in condition. This delay led to the resident being hospitalized for a UTI.
A resident with severe cognitive impairment and communication challenges was sent to a CT scan appointment without an escort, contrary to the facility's practice for residents with low BIMS scores. The DON confirmed that staff should have accompanied the resident to provide necessary support.
A resident with a history of falls and cognitive impairment experienced multiple falls from a recliner due to impulsiveness and confusion. Despite previous incidents, the LTC facility did not assess the resident's ability to use the recliner safely, resulting in a severe fall causing a subdural hematoma. The facility lacked a policy for assessing the use of mechanical lift chairs.
A resident with multiple diagnoses, including ataxia and chronic heart failure, exited the facility undetected due to a malfunctioning Wander Guard system. The resident, who required assistance with all activities of daily living and had moderate cognitive impairment, was not initially identified as an elopement risk. Increased confusion and agitation led to the placement of a Wander Guard bracelet, but no subsequent elopement assessment was documented. The Wander Guard system failed to alarm, and the resident was found outside after tipping over in a wheelchair. Staff awareness of elopement risks and Wander Guard functionality varied, and the facility lacked specific policies and procedures for managing wandering and elopement risks. Quarterly nursing assessments, including elopement risk, were not conducted as required.
A facility failed to ensure that a bed alarm was properly connected for a resident with severe cognitive impairment and a history of falls. Despite staff education, the bed alarm cord was found unplugged, rendering it ineffective and increasing the resident's risk of falls.
A resident's preference for two baths per week was not honored, as documented in their care plan and confirmed by the resident and the Director of Nursing. The resident received baths on only a few occasions over several months, despite being present in the facility and having no documented refusals.
Failure to Maintain Sanitary Steam Tables and Toaster in Dining Areas
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation and equipment maintenance when observing all four dining room steam tables and a toaster in one dining area. Policy review showed the facility’s Resident Rights policy guarantees residents a safe, clean, comfortable environment, and the facility’s steam table cleaning policy requires daily draining of water, cleaning, and sanitizing of the units. The 2022 Food Code requires food-contact surfaces to be free of encrusted grease and soil, and non-food-contact surfaces to be free of dust, dirt, food residue, and other debris. During the tour, steam tables at stations one, two, and three were observed with brown liquid containing floating particles in the compartments, brown corrosion on the sides, and dried food present. The steam table at station four contained dark brown liquid with floating particles in all compartments, and the toaster at station four was covered with food crumbs, stained black, and had dried food on the top, sides, and counter below. Further observation with the Food Service Manager confirmed that the water in all steam table compartments at all four stations was brown with floating particles. In interviews, the cook stated the steam tables were supposed to be cleaned daily, including changing the water, but acknowledged this was not occurring and could not state when the water was last changed. The Food Service Manager confirmed that all unit steam tables had brown water with floating particles, that they should be cleaned and sanitized daily, and that they were unaware of when the water was last changed. The Food Service Manager also confirmed the toaster at station four was soiled and needed replacement. The Administrator acknowledged that dietary sanitation needed improvement and that there was no process improvement plan in place. These actions and inactions affected the sanitation of food service equipment used by approximately 170 residents who utilized the dining area for meals.
Failure to Prevent Accident Hazard Due to Unsecured Alcohol
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to prevent potential accidents for a resident with a history of substance use and multiple medical conditions. The resident, who was moderately cognitively impaired and used a manual wheelchair, had an invoked Power of Attorney (POA) for healthcare decisions. The resident's care plan and provider orders allowed for alcohol consumption only on holidays or special events, yet the resident was found to have an unsecured bottle of alcohol in their room for an extended period, accessible at any time. Staff interviews and record reviews revealed that several staff members, including nursing assistants and social services, were aware of the bottle of alcohol in the resident's room but did not take action to secure or remove it, believing the resident had an order for alcohol. However, the order was limited to specific occasions, not for unsupervised possession. There was no documentation of a self-administration assessment to determine if the resident could safely manage alcohol, nor was there evidence of provider or POA notification regarding the unsecured alcohol. Additionally, after the resident was found intoxicated, there was no record of an alcohol toxicology test being completed as part of the emergency room visit, despite a provider order for a toxicology screen. The resident's POA was not informed about the presence of alcohol in the room until after the intoxication incident. The facility's social services staff had previously consulted with the Ombudsman regarding confiscation of alcohol, who advised that alcohol could not be taken from a resident without their consent. Despite this, the facility did not ensure that the resident's access to alcohol was consistent with the provider's order or that appropriate safety measures were in place, resulting in a failure to prevent a potential accident hazard.
Failure to Maintain Sufficient Nursing Staff on All Shifts
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on all shifts, as required by its own policies and state regulations. Record reviews showed that the facility's staffing levels frequently did not meet the ratios outlined in its Facility Assessment, with nurse and nursing assistant (NA) coverage falling short on multiple days and shifts. For example, there were instances where the nurse-to-resident ratio was as high as 1 nurse for every 91 residents, and NA-to-resident ratios were also higher than the facility's stated standards. The facility's own Director of Nursing confirmed that staffing was insufficient on certain shifts during the reviewed period. Residents and staff interviews corroborated the staffing shortages. Multiple residents reported having to wait long periods for their call lights to be answered, sometimes over an hour, and attributed these delays to short staffing and high staff turnover. Staff members also described frequent call-ins and being left to care for large numbers of residents, particularly during the night shift and on weekends. Nursing assistants reported being responsible for entire wings by themselves and having to wait for assistance with residents requiring more complex care, such as Hoyer lift transfers. A review of grievances filed in 2025 revealed 18 complaints related to long call light response times, further supporting the finding of inadequate staffing. The combination of documented staffing levels, resident and staff interviews, and grievance records demonstrated that the facility did not consistently provide enough nursing staff to meet the needs of all residents, as required by policy and regulation.
Failure to Change Soiled Linens for Resident
Penalty
Summary
The facility failed to ensure that soiled bed linens were changed for a resident, identified as Resident 2, who was part of a sample size of five residents in a facility with a census of 183. Resident 2 was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. The resident's care plan highlighted bladder incontinence related to impaired mobility, with a goal to keep the resident clean and dry through routine checks and changes at standard intervals. However, during an observation, Nursing Assistants (NAs) A and B were seen providing peri care to Resident 2, and it was noted that the draw sheet and fitted sheet had yellow stains. Although NA-B acknowledged the need for a new draw sheet and obtained one, the fitted sheet was not changed because NA-A mentioned that Resident 2 was scheduled for a bath later that morning. The Director of Nursing (DON) confirmed that the expectation for nursing assistants is to change any soiled linens immediately, regardless of whether it is a bath day. Both NA-A and NA-B admitted that the stained fitted sheet should have been changed. This oversight in changing the soiled fitted sheet was acknowledged by the DON, who confirmed that the actions of the nursing assistants did not meet the facility's standards for maintaining cleanliness and hygiene for residents, particularly those with incontinence issues.
Infection Control Breach Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by the actions of Nursing Assistant (NA)-A. During observations, NA-A was seen walking down the hallway with gloves on and entering Resident 2's room without removing the gloves or performing hand hygiene. NA-A then performed peri care on Resident 2, gathered dirty linens and trash, and proceeded to the trash room without changing gloves or performing hand hygiene. This pattern continued as NA-A entered Resident 1's room, again failing to perform hand hygiene before and after care, and similarly with Resident 3. NA-A did not perform hand hygiene after removing gloves or handling trash, which is a violation of the facility's infection control standards. The Director of Nursing (DON) confirmed that the facility had conducted audits and provided education on proper handwashing practices, yet the observed actions of NA-A did not align with these standards. The DON acknowledged that gloves should not have been worn down the hallway and that hand hygiene should have been performed before and after resident care. The failure to follow these protocols raises concerns about the potential for cross-contamination between residents, as NA-A did not adhere to the infection control practices outlined in the facility's guidelines.
RN Staffing Deficiency on Weekend
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least 8 consecutive hours on the weekend of January 4th and 5th, 2025. This deficiency was identified through a review of nursing staffing schedules, which revealed no RN was scheduled to work on these dates. Interviews with the Nursing Assistant working as the staffing coordinator and the Director of Nursing (DON) confirmed the absence of an RN on these days. The staffing coordinator was unaware of which staff members were RNs due to the lack of staff titles on the schedules. The DON acknowledged that if an RN calls in sick, other RNs should be contacted to cover the shift, and incentives should be offered, but this procedure was not followed, resulting in no RN being present in the facility on the specified dates.
Deficiency in 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 four Nursing Assistants (NAs) and one Unit Director (UD). This deficiency was identified through a record review and interviews, revealing that none of the sampled staff completed the mandated continuing education hours. Specifically, NA-N, NA-O, NA-P, UD-Q, and NA-R did not meet the 12-hour requirement, with their attendance ranging from 5 to 10 hours of in-service training during 2024. The facility's policy mandates that the Staff Development Coordinator maintain a training schedule and documentation system, and failure to complete the required training should result in termination. Interviews with the Chief Operating Officer and the Administrator confirmed the absence of documentation for the ongoing education of the NAs over the past 12 months. The Administrator also noted that the review of continuing education hours is conducted annually based on the calendar year rather than the hire date. This lack of compliance with training requirements had the potential to affect all 174 residents in the facility, as the ongoing education is crucial for maintaining employment status and ensuring quality care.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards, as observed during a survey. In the kitchen, various food items were found to be improperly stored, with some being undated, opened, or outdated. This included chicken breaded powder, macaroni, cakes, turkey patties, grilled chicken breast fillets, and precooked pork breaded patties. Additionally, lemonade and coleslaw were found to be out of date. Interviews with the cook and the Director of Food Service confirmed these lapses in food safety practices. Furthermore, an ice machine was found to be dirty, with gray-blackish debris on the ice chute, and the last recorded cleaning was several months prior. The facility's ice policy was not followed, as evidenced by a nurse assistant placing an ice scoop back into a cooler without performing hand hygiene. The facility also failed to ensure that kitchen staff adhered to hygiene protocols, such as wearing hair restraints and performing adequate hand hygiene. Observations revealed that a dietary aide scooped ice without a hairnet and performed hand hygiene for only 15 seconds, contrary to the facility's policy of 20 seconds. Similarly, a cook was observed washing hands for less than the required time during food preparation. These actions were confirmed by interviews with the Director of Food Service, who acknowledged the need for staff to follow proper hygiene procedures to prevent foodborne illness.
Infection Control Deficiencies in Laundry Handling and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices in several areas. During an observation, a laundry aide was seen handling clean linens improperly by holding them against their uniform and placing a towel that had fallen on the floor back into a clean linen cart. Interviews with the laundry aide and the Director of Environmental Services confirmed that linens should not be held against the body and any linens that fall to the floor should be placed in the dirty laundry bin. The facility's laundry policy emphasizes that soiled laundry should be handled and transported according to best practices for infection prevention and control. Resident 101, who was diagnosed with obstructive sleep apnea and used a BiPAP machine, had their equipment observed to be unclean over several days. The BiPAP machine was noted to have layers of white and gray fuzzy substances on its surface, indicating a lack of cleaning. The facility's infection control policy required that CPAP and BiPAP machines have their external surfaces wiped twice a week, but there was no order for cleaning the machine itself in Resident 101's records. The Director of Nursing confirmed the machine's unclean state during an observation. Additionally, the facility failed to ensure the timely replacement of oxygen tubing for Residents 60 and 66. Observations revealed that there was no indication of when Resident 60's oxygen tubing was last changed, and Resident 66's tubing had a date of 11/9, which was not within the weekly replacement guideline. Interviews with a registered nurse and the unit coordinator confirmed that oxygen tubing should be changed weekly and dated accordingly. The facility's policy on cleaning respiratory equipment required masks and cannulas to be replaced within seven days or as needed when contaminated.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the presence of lint and debris on wall-mounted oscillating fans, a pivot stand, and a vent cover. Observations revealed that the shrouds and blades of fans in several resident rooms contained a moderate amount of gray fuzzy substance. Additionally, a pivot stand located in the hallway outside a resident room was found to have a large amount of brown fuzzy and grainy substance on its base, along with gray scum on the handles and bars. The vent cover above the whirlpool tub in the Station 2 bathhouse also contained a large amount of brown and gray fuzzy substance. The facility's Cleaning and Disinfection - Environmental Infection Control policy indicated that environmental surfaces should be disinfected regularly and when visibly soiled. However, the facility's Survey Readiness Environmental Checklist and Environmental Service Associate checklist did not include cleaning of the bathhouses, pivot stand, or room fans. The Deep Cleaning Calendar showed that the rooms had not been deep cleaned recently, with the last deep cleaning dates ranging from October 2024 to January 2025. Interviews with the facility's Administrator confirmed the observations and acknowledged that the items should have been cleaned.
Lack of Qualified Activity Professional
Penalty
Summary
The facility failed to have a qualified Activity Professional, which had the potential to affect all residents participating in activities. The Activity Director (AD) confirmed during an interview that they had not received any activity training, and a review of their credentials supported this lack of training. The Facility Assessment, which should document the facility's needs to care for residents, was undated, and the facility policy emphasized the need for staff education on resident rights and responsibilities. The Manager of Operations (MOO), who was the activities supervisor, did not engage with the activities program and lacked experience in recreational or therapeutic activity programs. The Regional Administrator confirmed that no staff, including the MOO, had formal training or full-time experience in an activity program. Additionally, the AD noted that 20-25 residents routinely refused activities.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to residents or their representatives prior to hospitalization for four sampled residents. The facility's policy on Transfer and Discharge from the Facility, dated January 2024, requires that notices include the reason and effective date of the discharge/transfer, the location where the resident was transferred, a statement of the resident's appeal rights, and contact information for the agency that receives discharge appeal requests and the State Long Term Care Ombudsman's office. However, the facility did not adhere to this policy. Resident 16, who had diagnoses including toxic encephalopathy and dementia, was transferred to the hospital on November 21, 2024, without receiving a notice containing the required information. Similarly, Resident 85, with Alzheimer's disease and a history of cerebrovascular infarction, was transferred on October 5, 2024, without the necessary notice. Both residents' Bed Hold/Therapeutic Leave Policy forms lacked the location or reason for transfer and appeals information. Resident 99, with conditions such as deep vein thrombosis and high blood pressure, was transferred twice, on December 7, 2024, and January 1, 2025, without proper notice. Resident 115, diagnosed with deep vein thrombosis, type 2 diabetes mellitus, and COPD, was also transferred twice, on December 5, 2024, and January 16, 2025, without the required notice. Interviews with the Clinical Consultant and Regional Administrator confirmed that the facility had not been providing written notices of transfer that included the required information for emergency transfers.
Inaccurate MDS Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the current number of unhealed pressure ulcers for a resident. A review of the resident's tissue analytics revealed an unstageable pressure ulcer on the right hand, fully covered with eschar. However, the MDS inaccurately recorded the number of unhealed pressure ulcers as zero for all stages, including unstageable-slough and/or eschar. During an interview, the Director of Nursing confirmed the presence of the unstageable pressure ulcer and acknowledged the error in the MDS documentation, which should have indicated one unhealed pressure ulcer. The facility follows the Resident Assessment Instrument (RAI) manual to complete the MDS, which requires accurate coding of pressure ulcers within a 7-day look-back period.
Failure to Provide Scheduled Activities in Alzheimer's Unit
Penalty
Summary
The facility failed to provide activities to meet the needs of residents in the Alzheimer's Unit, specifically affecting three residents. Observations on multiple occasions revealed that no activities were taking place on Station 5, despite the activity calendar indicating scheduled events such as cafe cart, Catholic Mass, Pampered Nails, Baby Sitting, Crafts, and Active Games. Interviews with staff, including a Nursing Assistant and the Activity Director, confirmed the absence of an activities person on Station 5 for about two months, and no evening or weekend activities were offered during this period. Resident 109, diagnosed with Non-Alzheimer's Dementia and having a BIMS score of 0, was observed sitting alone without participating in any activities. The resident's Comprehensive Care Plan indicated a goal of attending 3-5 activities weekly, with preferred activities including arts and crafts, bingo, and musical movement. However, no activities were documented for this resident in the last 30 days. Similarly, Resident 133, also with a BIMS score of 0, was observed alone, with no activities available. The resident's care plan required participation in activities 3-5 times weekly, but no activities were documented in the last 30 days. Resident 168, with a diagnosis of Alzheimer's Disease and a BIMS score of 15, was also affected by the lack of activities. The resident's care plan included participation in activities 1-2 times weekly, with preferences for bingo and live music, yet no activities were documented in the last 30 days. The facility's policy required staff education on resident rights and responsibilities, but interviews revealed that no activities were scheduled due to a norovirus outbreak, which led to the closure of all units from mid-December 2024 to mid-January 2025. The Clinical Coordinator confirmed the absence of a facility Activity Policy.
Incomplete CPAP Prescription for Resident
Penalty
Summary
The facility failed to ensure a complete, valid prescription was obtained for a CPAP machine for Resident 60. An observation revealed a CPAP machine on Resident 60's bedside stand, and an interview with the resident confirmed that they use the CPAP every night. A review of the resident's Order Summary Report indicated instructions for using the CPAP with oxygen, including connecting O2 tubing to the mask and filling the chamber with distilled water. However, the Director of Nursing confirmed that there was no complete, valid prescription with the current settings for the CPAP machine.
Failure to Employ Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) to oversee the infection prevention and control program, which had the potential to affect all 178 residents. A review of the facility's Infection Prevention and Control Program Policy, dated May 20, 2017, indicated that the designated IP is responsible for consulting staff on infectious diseases, resident room placement, implementing isolation precautions, and conducting surveillance and epidemiological investigations. However, the Antibiotic Stewardship and Infection Control Surveillance Record showed no documentation for November 2024. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility had been without an IP since mid-October 2024. The DON confirmed that infection control duties had not been performed since that time. The Administrator acknowledged the absence of an IP and mentioned that a new hire for the position would start the following week.
Failure to Timely Address UTI Symptoms
Penalty
Summary
The facility failed to adequately assess and monitor a resident for potential signs and symptoms of a urinary tract infection (UTI). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was prescribed antibiotics for a UTI on multiple occasions. However, there was a delay in collecting a urine sample for urinalysis and culture, which was ordered on 11/15/24 but not collected until 11/20/24. This delay occurred despite the resident's guardian expressing concerns about the resident's symptoms and behaviors indicative of a UTI. Interviews revealed communication breakdowns among staff members. The Social Services (SS) staff reported the guardian's concerns to an LPN, but the symptoms were not communicated on the physician's board. The LPN assumed that SS had informed the floor nurse, which did not happen, leading to a delay in addressing the resident's condition. The facility received UA results on 10/31/24 and started an antibiotic, but there was further delay in starting a new antibiotic after receiving culture and sensitivity results, which were faxed to the doctor multiple times before an order was received.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during the wound care of a resident. Specifically, a registered nurse (RN) did not follow the Enhanced Barrier Precautions policy by neglecting to wear an isolation gown while performing wound care on a resident's left heel. The resident was admitted to the facility with a wound vac on the left heel, requiring dressing changes every night shift on specified days. During the observation, the RN brought supplies into the room, performed hand hygiene with sanitizing gel, and donned gloves but did not wear the required isolation gown. Additionally, the RN did not comply with the facility's hand hygiene policy, which mandates washing hands for at least 20 seconds. The RN washed hands for only 11 to 12 seconds at various stages of the wound care process, including after removing edema wear and old dressing, cleaning the wound, opening dressings, and applying skin prep. Interviews with the RN and the Director of Nursing confirmed the expectation to wear PPE during wound care and to wash hands for the required duration.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to follow the medical practitioner's orders regarding wound care for a resident, leading to a deficiency in pressure ulcer management. The resident, who was admitted with Chronic Obstructive Pulmonary Disease and Type 2 Diabetes, had a Stage 2 pressure ulcer on the coccyx that was documented to have worsened over time. Despite the presence of a comprehensive care plan indicating the resident was at risk for skin breakdown, there were no documented orders for wound care treatments on the Treatment Administration Record (TAR) from August through early October. The resident's condition deteriorated to a Stage 3 pressure ulcer, with no evidence of wound care being administered as per the practitioner's orders. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of documented treatment orders and the lack of wound care provided to the resident. The LPN acknowledged the presence of a wound but could not confirm the treatment details or completion. The Director of Nursing also confirmed the absence of wound treatment orders on the TAR and acknowledged the wound's progression. This lack of adherence to the facility's Skin and Wound Management Policy and the practitioner's orders resulted in the deficiency noted by the surveyors.
Failure to Honor Resident Preferences in Religious Practices and Bathing
Penalty
Summary
The facility failed to honor the religious preferences of Resident 2, who is Muslim and expressed a desire to pray and fast according to their religious practices. Despite having an intact cognitive status, as indicated by a BIMS score of 14, Resident 2's care plan did not include their religious preferences or requirements. The resident expressed distress over their inability to pray and fast, and although the facility contacted the Islamic Foundation for support, there was no follow-up documentation of visits or services provided. Interviews with staff revealed a lack of awareness and action regarding Resident 2's religious needs. Additionally, the facility did not respect the bathing preferences of several residents, including Residents 1, 4, 5, 6, and 7. These residents experienced significant gaps between scheduled baths, contrary to their stated preferences and the facility's policy. For instance, Resident 1 preferred two baths per week but went up to 13 days without a bath. Similarly, Resident 4, who was dependent on staff for bathing, experienced intervals of up to 10 days without a bath. The facility's documentation did not reflect refusals or alternative arrangements, indicating a systemic issue in honoring resident preferences. Interviews with staff, including the DON and nurse aides, confirmed that residents' bathing preferences were not consistently asked about or documented during care plan meetings. Staff shortages and reassignments further contributed to the failure to provide baths as scheduled. The facility's policies on resident rights and self-determination were not effectively implemented, leading to unmet needs and dissatisfaction among residents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement interventions to prevent elopement for two residents, leading to an immediate jeopardy situation. Resident 1, who was moderately cognitively impaired and assessed as an elopement risk, was wearing a wanderguard safety device. Despite this, Resident 1 was able to leave the facility without staff or family, as the wanderguard did not trigger the alarm system. The resident was observed to have increased confusion and was exit-seeking, yet the staff did not effectively monitor or prevent the resident from leaving the premises. Resident 2, who was cognitively aware and had a Community Access Pass allowing them to sit out front only, was able to leave the facility with Resident 1. The staff did not realize the residents were gone, and the receptionist mistakenly allowed them to leave, thinking Resident 1 was a visitor. The facility's procedures for monitoring residents with wanderguards and Community Access Passes were not followed, and staff were not adequately informed about which residents were at risk for elopement. Interviews with staff revealed a lack of awareness and communication regarding residents' permissions and restrictions. The wanderguard system was not effectively managed, and staff did not consistently check or refer to the lists of residents with wanderguards or Community Access Passes. This oversight allowed the residents to leave the facility unsupervised, leading to the immediate jeopardy situation.
Removal Plan
- Resident resides on a locked unit.
- Resident is hospitalized. Community Pass has been revoked.
- Staff member who shut the Wanderguard system off has been suspended pending investigation related to supporting documentation that had been educated on facility procedures.
- Immediate Education to Receptionist with Competency.
- Community Pass Policy revised as a Best Practice of the facility and not a physician's order.
- Current Community Pass residents will be evaluated for prior restrictions to ensure following revised policy.
- Receptionist staff will be re-educated with Competency by the Administrator or designee on resident safety with community passes and wanderguards prior to next immediate shift.
- All staff will be re-educated by the Administrator or designee on resident safety with community passes and wanderguards immediately.
- Competency will be placed in Orientation for all new hires and agency staff.
- Audits to be completed to ensure receptionist are knowledgeable about resident safety with community passes and wanderguards.
- The Plan of correction will be reviewed by QAPI committee.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to ensure a formal investigation was completed and the State Agency was notified regarding the elopement of two residents. The facility's Missing Resident/Elopement Procedure required all nursing staff to be aware of residents' whereabouts and to activate the elopement procedure if a resident could not be located. However, the facility did not document any elopement incidents for the two residents involved, nor did they notify the State Agency as required. Resident 1, who had impaired cognitive function and was at risk for elopement, was wearing a wandering device. Despite this, Resident 1 was able to leave the facility unaccompanied, pushing Resident 2 in a wheelchair. The facility's security video showed that the receptionist cleared the wanderguard alarm, allowing the residents to exit the building. The receptionist mistook Resident 1 for a visitor and did not realize the resident was wearing a wanderguard. The residents were later found at a nearby location and returned to the facility. The facility's management group determined that the incident was not an elopement, and thus, no formal investigation was conducted, and no report was submitted to the State Agency. The Director of Nursing confirmed that the only action taken was viewing the security video, and the Clinical Consultant acknowledged that the receptionist should not have turned off the alarm. This lack of action and failure to follow protocol led to the deficiency noted in the report.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which is a violation of the regulatory requirement to immediately inform the resident's doctor of any significant changes. The resident, who was admitted with multiple diagnoses including urinary tract infections, Type 2 diabetes, and unspecified dementia, exhibited increased confusion and hallucinations. A family member visiting the resident reported these symptoms and suspected a urinary tract infection, requesting a urinalysis. Despite this request being communicated to the facility staff, there was no documentation of the physician being informed of the resident's change in condition from May 2 to May 8. The situation escalated when the resident was found yelling in the hall and displaying confusion, prompting a delayed order for a urinalysis. The family member was not updated on the physician's order until May 10, and the resident was eventually sent to the hospital on May 12 due to altered mental status and other symptoms. Interviews with the family member, a registered nurse, and the Director of Nursing confirmed the failure to update the physician and the delay in addressing the family's concerns, which ultimately led to the resident's hospitalization for a urinary tract infection.
Failure to Provide Escort for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an escort for a resident with significant cognitive and communication impairments during a scheduled CT scan appointment. The resident, who was admitted with diagnoses including aphasias following cerebral infarction, epilepsy, and major depressive disorder, was dependent on staff for assistance with daily activities and had severe cognitive impairment as indicated by prior BIMS assessments. The care plan noted the resident's communication challenges and dependency on staff for mobility and other activities. On the day of the CT scan, the resident was sent to the hospital without an escort, despite the facility's typical practice of sending staff or family members with residents who have a BIMS score under 10. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that staff should have accompanied the resident to the appointment to provide necessary support.
Failure to Assess Resident's Ability to Use Recliner Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to safely use a recliner/lift chair, leading to a fall with major injury. The resident, who had a history of falls and was moderately cognitively impaired, was found on multiple occasions to have fallen or slid out of the recliner due to impulsiveness and confusion. Despite these incidents, the facility did not have a policy in place to assess the resident's ability to use the recliner safely. The resident had a complex medical history, including dementia, anxiety, depression, and cerebrovascular disease, which contributed to their impulsiveness and confusion. The facility's records showed multiple falls from the recliner, with interventions such as encouraging the resident to call for help and placing signage in the room. However, these measures were insufficient, as the resident continued to experience falls, culminating in a severe incident where the resident fell and sustained a subdural hematoma and other injuries. Interviews with staff and the resident's power of attorney revealed that the facility did not assess the resident's ability to use the recliner safely and did not have a policy for mechanical lift chairs. The facility's failure to assess the resident's ability to use the recliner and to implement effective interventions to prevent falls resulted in a significant injury to the resident.
Elopement Risk Management and Wander Guard System Failure
Penalty
Summary
The facility failed to ensure elopement door alarms were functioning, leading to a resident (Resident 3) leaving the facility without staff knowledge. Resident 3, who had diagnoses including ataxia, cerebral infarction, attention deficit, and chronic heart failure, was moderately cognitively impaired and required assistance with all activities of daily living. Despite not being identified as an elopement risk initially, Resident 3 exhibited increased confusion and agitation on 3/22/2024, prompting the placement of a Wander Guard bracelet. However, there was no documentation of an elopement assessment after the bracelet was placed. The Wander Guard system on the front door failed to alarm when Resident 3 exited the facility on 3/27/2024, resulting in Resident 3 being returned after tipping over in a wheelchair outside. The maintenance log indicated that the Wander Guard system was tested on 2/29/2024, with the next scheduled check on 3/31/2024. Interviews with staff revealed varying levels of awareness regarding residents at risk for elopement and the functioning of Wander Guard bracelets. The facility lacked a policy and procedure for wandering/behavior or elopement for at-risk residents, and nursing assessments, including elopement risk, were not being done quarterly as required. The deficiency was further highlighted by the lack of an elopement assessment for Resident 3 on 3/22/2024, as confirmed by the Director of Nursing and Clinical Consultant.
Failure to Ensure Bed Alarm Functionality for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that interventions were in place as care planned for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including late-onset dementia and restlessness, was dependent on staff for all activities of daily living and transfers. The comprehensive care plan included the use of bed and chair alarms to prevent falls. However, during an incident, the bed alarm was found to be non-functional because it was not connected to the alarm box, despite staff education on the importance of ensuring alarms were properly set up. Observation revealed that the bed alarm cord was not plugged into the alarm box, rendering it ineffective. Interviews with staff confirmed that the bed alarm was an essential intervention for the resident and should have been connected. The Assistant Director of Nursing also confirmed that the bed alarm was a necessary intervention that was not properly implemented at the time of the observation. This failure to ensure the bed alarm was functional directly contributed to the resident's risk of falls and injury.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor Resident 4's bathing preferences, as documented in their undated Admission Record and confirmed by the resident's Minimum Data Set (MDS) and Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness. Despite Resident 4's stated preference for two baths per week, the facility's records show that the resident received baths on only a few occasions over a span of several months. Specifically, baths were documented on 12/5/23 and 12/29/23 in December, 1/3/23, 1/8/23, and 1/27/24 in January, and 2/5/24 in February, with significant gaps in between. The resident was hospitalized for short periods in December but was otherwise present in the facility without documented refusals or reasons for missed baths. The undated Preference Sheet printed on 2/1/24 confirmed the resident's preference for two baths a week, which was not met according to the records reviewed. The Comprehensive Care Plan (CCP) for Resident 4, revised on 10/27/23, included an intervention for showers/baths per schedule, which was not adhered to. The Director of Nursing (DON) confirmed in an interview that Resident 4 went 18 days in January and 9 days in February without a bath. The facility's policy dated December 2016, titled Care Plans, mandates that the Comprehensive Person-Centered Care Plan should include the resident's stated preferences, which was not followed in this case. This failure to provide the resident's preferred bathing schedule constitutes a deficiency in honoring resident self-determination and choice.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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