Emerald Nursing & Rehab Legacy Pointe Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 3110 Scott Circle, Omaha, Nebraska 68112
- CMS Provider Number
- 285239
- Inspections on file
- 31
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Legacy Pointe Llc during CMS and state inspections, most recent first.
Staff did not follow hand hygiene protocols during peri-care for two residents who required extensive assistance due to significant medical conditions. Nurse assistants changed gloves without using hand sanitizer or washing their hands and failed to perform hand hygiene before leaving the rooms. Both staff and the DON confirmed these lapses, and the facility lacked a specific peri-care policy.
A resident with significant communication and functional impairments exhibited respiratory symptoms and was ordered a STAT chest x-ray, which revealed possible pneumonia. The results were not promptly communicated to the healthcare practitioner, resulting in a delay in antibiotic treatment. The DON confirmed the delay in notification and subsequent care.
Surveyors found that the facility did not document or implement required Legionella water management practices and failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact care for two residents with multidrug-resistant organisms and indwelling devices. Staff provided care such as showers and catheter care without wearing gowns, contrary to facility policy and posted EBP signage.
Kitchen staff did not follow prescribed menu portion sizes for residents on regular textured diets, serving inconsistent amounts of meatballs and failing to use dietary cards, which led to 48 residents receiving incorrect meal portions as outlined in the facility's menu and diet spreadsheet.
Kitchen staff did not maintain required food temperatures, resulting in multiple resident complaints about cold and unappetizing meals. Observations confirmed that hot foods were served below the required temperature, and cold foods were not kept sufficiently cool. Staff interviews supported these findings, and the Dietary Service Manager confirmed the facility's obligation to follow food safety codes.
Facility staff did not notify practitioners when insulin doses were omitted for three residents with ESRD and diabetes who were out of the facility for hemodialysis. MARs showed multiple missed doses marked as 'Out of Facility,' and staff interviews confirmed a lack of awareness and failure to communicate these omissions, despite facility policy requiring such notifications.
Two residents with complex medical conditions were transferred to the hospital without receiving written notice of transfer, including the reason for transfer, as required. In both cases, the Bed Hold/Therapeutic Leave Forms were incomplete, and the Director of Nursing confirmed that neither the residents nor their representatives were provided with the necessary written documentation.
A resident with dementia, hypertension, and major depressive disorder, who was dependent on staff for toileting, did not have a bowel movement for six consecutive days. Despite physician orders for daily and PRN laxatives, staff did not assess bowel function, administer the PRN medication, or document interventions. The care plan lacked constipation interventions, and interviews confirmed no assessment or policy was in place.
Facility staff did not administer scheduled insulin doses to several residents with ESRD and diabetes while they were out of the facility for dialysis, repeatedly marking the doses as missed on the MAR and failing to notify practitioners or adjust medication regimens as required by facility policy.
A resident with multiple chronic conditions received daily polyethylene glycol for constipation without a documented stop date or evidence of ongoing prescriber evaluation, contrary to facility policy and medication guidelines. The medication was administered consistently, and staff confirmed there was no documentation of reassessment for continued use.
Two residents with significant dental needs did not receive required dental services, including follow-up with a dentist or oral surgeon after referrals were made. Despite documented oral health problems and care plans noting poor dentition, the facility did not ensure that dental appointments were scheduled or completed as needed.
A resident with multiple chronic conditions and a stated religious preference for avoiding pork was offered meals containing pork. The facility did not document the resident's religious dietary restrictions on the tray card or care plan, despite conducting an admission food preferences interview and having information about the resident's religious beliefs in other records.
A resident with quadriplegia and severe cognitive impairment, fully dependent on staff for ADLs, was observed to have long, untrimmed fingernails over multiple days. Despite being scheduled for bathing and nail care, staff confirmed that nail trimming was not performed, and the resident verbally requested their nails be cut.
A resident with ESRD and diabetes, who required partial assistance and attended hemodialysis three times weekly, did not receive an individualized activity program that accommodated their schedule and preferences. The facility did not offer activities in the evenings or on weekends, and there was no documentation of activity participation for the resident after readmission, despite their expressed interests and care plan directives.
A resident with multiple chronic conditions and limited mobility did not receive interventions to prevent further decline in range of motion, despite facility policy and therapy recommendations. The resident's records showed no restorative nursing program or documented interventions, and both the resident and DON confirmed the absence of such measures.
Staff failed to maintain a medication error rate below 5%, with errors including a CMA not instructing a resident to rinse their mouth after using an Advair Diskus inhaler, and an LPN priming insulin pens with 1 unit instead of the 2 units required by manufacturer instructions for two residents. These actions resulted in a medication error rate of 10.71%.
A resident at risk for pressure ulcers was observed with heels not elevated off the mattress, contrary to care plan and guidelines. Despite having a low loss air mattress and a treatment order for an existing wound, staff failed to follow the facility's policy and national guidelines for heel elevation, leading to a deficiency in care practices.
A resident with multiple health issues, including a wound and feeding tube, did not have Enhanced Barrier Precaution (EBP) implemented as required. Observations showed no EBP indications in the resident's room, and an LPN performed treatments without a gown. The DON confirmed the resident should have been on EBP, but the LPN was unaware of the protocol.
The facility failed to secure the east medication room, leaving keys in the lock, which could have been accessed by 22 self-mobile residents and two unauthorized staff. Observations showed the keys were left unattended, and interviews confirmed this was against policy. A resident with severe cognitive impairment was nearby, and the Director of Nursing acknowledged the breach.
The facility failed to maintain a safe and clean environment, affecting 55 residents. Observations included damaged walls, dusty ventilation covers, a broken wheelchair armrest, and poor water pressure in bathrooms. Rusty tiles were noted in shower rooms. The Maintenance Director confirmed the issues, with no work orders in place.
A facility failed to address PTSD triggers for a resident, as their care plan lacked interventions for managing PTSD despite the resident's cognitive intactness and expressed needs. Interviews revealed that the resident experienced nighttime difficulties and preferred specific conditions to avoid being startled. The facility's policy emphasized individualized care, but no assessment or interventions were documented for the resident's PTSD.
A resident alleged that a family member stole their Net Spend card, but the facility failed to investigate and submit a written report to the state agency within the required 5 working days. The Director of Nursing confirmed that the investigation and results were not completed or sent, despite the facility's policy requiring timely reporting to authorities.
Failure to Follow Hand Hygiene Procedures During Peri-Care
Penalty
Summary
Staff failed to follow established hand hygiene procedures during the provision of peri-care for two residents. Facility policy and infection control standards require staff to perform hand hygiene before and after direct contact with residents, after contact with blood or body fluids, and before and after wearing gloves. Observations revealed that nurse assistants changed gloves without using hand sanitizer or washing their hands and did not perform hand hygiene prior to exiting the residents' rooms after providing peri-care. One resident involved was chairfast, required maximum to total assistance for mobility and hygiene, and had multiple chronic conditions including venous stasis ulcers and chronic respiratory failure. During peri-care, two nurse assistants donned appropriate PPE but failed to use hand sanitizer or wash their hands when changing gloves and before leaving the room. Both confirmed in interviews that they did not follow proper hand hygiene protocols. Another resident, admitted for skilled nursing care following a cerebral infarction and with moderate cognitive impairment, also required substantial assistance with personal hygiene and was always incontinent of bowel and frequently incontinent of urine. During peri-care, two nurse assistants used hand sanitizer before entering the room and donned gloves, but did not change gloves or perform hand hygiene during care or before exiting. Both acknowledged in interviews that they should have performed hand hygiene as required by facility policy. The Director of Nursing confirmed the expectation for glove changes and hand hygiene during peri-care and noted the absence of a specific peri-care policy.
Delay in Notification of Chest X-ray Results Leading to Treatment Delay
Penalty
Summary
Facility staff failed to promptly notify the resident's healthcare practitioner of chest x-ray results that indicated new left midlung and right lower lobe opacities, which may represent pneumonia. The resident, who was rarely able to make themselves understood and required total assistance with all activities of daily living, exhibited symptoms including audible moist wheezes, green nasal drainage, and glassy eyes. A STAT portable chest x-ray was ordered and obtained, but the results were not communicated to the healthcare practitioner until two days later, resulting in a delay in ordering antibiotics for pneumonia. The Director of Nursing confirmed the delay in notification and subsequent treatment.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and document an effective infection prevention and control program, specifically regarding the mitigation of Legionella growth and the use of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During an interview, the Maintenance Director confirmed there was no documentation of flushing holding tanks or other areas prone to stagnant water, despite the facility's policy requiring surveillance and control measures for Legionella. The policy outlined the need to identify and monitor areas at risk for Legionella growth, such as storage tanks and water heaters, and to document control measures, but these actions were not carried out or recorded. For two residents with MDROs, staff did not follow the facility's EBP policy during high-contact care activities. One resident, who required total assistance with toileting and bathing and had an active MDRO in the urine, was observed receiving a shower from a nursing assistant who did not wear a gown as required by EBP protocols. The nursing assistant and another staff member confirmed that a gown should have been worn during this activity. Another resident with ESBL resistance and an indwelling urinary catheter was also not provided care in accordance with EBP. During catheter care, the nursing assistant performed hand hygiene and wore gloves but did not don a gown, despite EBP signage and policy requirements. The nursing assistant acknowledged that a gown should have been worn during the procedure. The facility's policy specified that EBP, including gown and glove use, must be followed during high-contact care for residents with wounds or indwelling medical devices.
Failure to Follow Prescribed Menu Portion Sizes for Regular Diet Residents
Penalty
Summary
Kitchen staff failed to follow the prescribed menu serving sizes for 48 residents on regular textured diets. Observations revealed that dietary assistants did not use dietary cards, which provide essential information on diet type, portion sizes, food consistency, preferences, and allergies. Instead, staff served inconsistent and incorrect portions of meatballs, with one dietary assistant serving 5 meatballs and another serving between 5 and 12 meatballs per resident, contrary to the menu's specified portion of 3 one-ounce meatballs. The Food Service Director later confirmed that the correct serving size should have been 6 half-ounce meatballs, and acknowledged that the menu portion sizes were not followed. Record reviews showed that the menu and diet spreadsheet clearly outlined the required portion sizes for each food item, but these were not adhered to during meal service. Staff interviews indicated a lack of knowledge regarding the correct serving sizes, and the absence of dietary card usage contributed to the inconsistency. The deficiency affected a significant portion of the facility's census, as 48 out of 63 residents on regular textured diets did not receive meals in accordance with the established menu and portion guidelines.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
Facility kitchen staff failed to ensure that food served to residents was maintained at appetizing and palatable temperatures, as required by the Nebraska Food Code. Observations and interviews revealed that hot foods were not held at the required temperature of 135 degrees Fahrenheit or above, and cold foods were not consistently kept at 41 degrees or below. Multiple entries in the facility grievance log documented resident complaints about cold food, unappetizing meal presentation, and dissatisfaction with food temperature and quality. Specific grievances included reports of cold breakfast items, cold food delivered to rooms, and mismatched temperatures of meal components such as hot cucumbers and cold zucchini. Direct observation of meal service showed that food items on a test tray, including meatballs, potatoes, green beans, and hot dog alternates, were served below the required hot holding temperatures, with some items as low as 96.0 degrees Fahrenheit. Pudding, intended to be served cold, was found to be too warm. Staff interviews confirmed that the food was not at appropriate temperatures and did not taste good. The Dietary Service Manager acknowledged that the facility is expected to follow the Nebraska Food Code for food holding temperatures.
Failure to Notify Practitioners of Omitted Insulin Doses During Dialysis Absences
Penalty
Summary
Facility staff failed to notify residents' practitioners when scheduled insulin doses were omitted for three residents who were out of the facility receiving hemodialysis. Each of these residents had orders for insulin administration and required dialysis on specific days of the week. The Medication Administration Records (MARs) for these residents showed that insulin doses were marked as 'Out of Facility' (OF) on multiple occasions corresponding to their dialysis appointments, indicating the medication was not administered. Interviews with nursing staff, including agency nurses, LPNs, and the unit manager, revealed a lack of awareness regarding responsibility for insulin administration when residents were out for dialysis. Staff confirmed that practitioners should be notified when insulin is not given, but this notification did not occur for any of the affected residents. The facility's own policy required immediate notification to the resident, their representative, and the attending physician or delegate when there was a change in condition or treatment, including omitted medications. The residents involved had significant medical histories, including End Stage Renal Disease (ESRD), Diabetes Mellitus, and dependence on hemodialysis. Their cognitive status ranged from intact to moderately impaired, and they required varying levels of assistance with activities of daily living. Despite these complexities, the facility did not communicate missed insulin doses to practitioners, as confirmed by record review and staff interviews.
Failure to Provide Written Notice of Transfer to Residents or Representatives
Penalty
Summary
The facility failed to provide written notice of transfer, including the reason for transfer, to two residents or their representatives as required by regulations. For one resident with a history of COPD, diabetes mellitus type 2, heart failure, and major depressive disorder, the facility transferred the resident to the emergency department due to chronic diarrhea and abdominal pain. Although the resident opted for a bed hold, the Bed Hold/Therapeutic Leave Form did not include the reason for transfer, and no written notice of transfer was found in the resident's electronic health record or progress notes. The Director of Nursing confirmed that the required written notice was not provided. Similarly, another resident with diagnoses including hemiplegia, hemiparesis, systemic inflammatory response syndrome, and COPD was transferred to the hospital and was expected to return. The Bed Hold/Therapeutic Leave Form for this resident also lacked the reason for transfer, and no written notice of transfer was present in the electronic health record or progress notes. The Director of Nursing confirmed that the facility did not provide the resident or their representative with the required written notice of transfer.
Failure to Evaluate and Manage Bowel Function for a Resident
Penalty
Summary
Facility staff failed to evaluate and manage bowel function for a resident with dementia, hypertension, and major depressive disorder, who was dependent on staff for toileting. The resident had physician's orders for daily polyethylene glycol and PRN Senexon-S for constipation. Despite documentation showing no bowel movement for six consecutive days, there was no record of an assessment being performed or the PRN laxative being administered during this period. The resident's comprehensive care plan did not include interventions for constipation. Review of the electronic medical record and medication administration record confirmed the absence of both PRN medication administration and evaluation of bowel function. Interviews with the Unit Manager and DON confirmed the lack of assessment, intervention, and a facility policy on bowel and bladder elimination. The DON stated that staff should utilize PRN laxatives, perform evaluations, or notify the provider when a resident has not had a bowel movement for six days, but this was not done in this case.
Failure to Manage Insulin Administration for Dialysis Residents
Penalty
Summary
Facility staff failed to identify and implement a plan to manage medications, specifically insulin, for residents receiving dialysis services. Facility policy required that care and treatment, including medication management, be consistent with professional standards, physician orders, and care plans, and that communication with outside providers be maintained to ensure safe, continuous care. However, for three residents with End Stage Renal Disease and diabetes who were receiving hemodialysis and insulin injections, staff documented that insulin doses scheduled during dialysis times were not administered, marking them as 'Out of Facility' (OF) on the Medication Administration Record (MAR). For each of these residents, the MARs showed repeated instances where scheduled insulin doses were omitted on dialysis days, with no evidence that the residents' practitioners were notified of the missed doses. Interviews with nursing staff and unit managers confirmed that staff were unaware of who was responsible for administering insulin while residents were at dialysis and that practitioners were not notified when insulin was not given. There was also no indication that the insulin regimens were modified to account for the dialysis schedule or missed doses. The residents involved had significant medical histories, including End Stage Renal Disease, diabetes, and other chronic conditions, and required varying levels of assistance with activities of daily living. Despite these needs and the facility's own policy requirements, the lack of communication with practitioners and failure to adjust medication administration for dialysis schedules resulted in a deficiency in providing safe and appropriate dialysis care and services.
Failure to Evaluate Ongoing Use of Laxative Medication
Penalty
Summary
The facility failed to evaluate the ongoing use of a laxative medication, polyethylene glycol, for a resident diagnosed with dementia with behavioral disturbance, hypertension, and major depressive disorder. The resident had a physician's order for daily administration of polyethylene glycol for constipation, with no stop date indicated. Review of the resident's electronic medication administration record showed the medication was administered daily, except for one refusal, and there was no documentation that the prescriber had reassessed the need for continued use of the medication. Facility policy requires the attending physician to regularly review each resident's medication regimen, including dose, duration, indication, monitoring, and adverse consequences. However, there was no evidence in the resident's health record that the continued use of polyethylene glycol had been evaluated by the prescriber, despite drug manufacturer guidance that it should not be used for more than seven days without reassessment. The unit manager confirmed the lack of documentation regarding evaluation of the medication's ongoing use.
Failure to Provide or Obtain Required Dental Services
Penalty
Summary
The facility failed to ensure that dental services were provided or obtained for two residents, as required by policy and regulation. One resident, who was cognitively intact and required partial assistance with activities of daily living, had been assessed as having obvious or likely cavities and broken natural teeth. This resident had been referred for oral surgery due to the need for multiple extractions and removal of residual root tips, but had not seen a dentist since the initial referral and had no dental services currently scheduled. Observation confirmed the presence of broken, discolored teeth, and interviews with staff verified the lack of follow-up dental care. Another resident was observed to be missing multiple teeth and to have several broken teeth, with documentation indicating no dental visit since the previous year. Although the care plan acknowledged poor dentition and included interventions to monitor and report oral health issues, records showed that the resident had not been seen by a dentist or oral surgeon as recommended. Staff interviews and record reviews confirmed that necessary dental referrals had not resulted in completed or scheduled dental services for this resident.
Failure to Document and Honor Resident Religious Dietary Preferences
Penalty
Summary
Facility staff failed to evaluate and document a resident's food preferences related to religious beliefs, specifically for a resident who identified as Seventh Day Adventist and reported not eating pork. During an interview, the resident stated that meals containing pork were offered despite their religious dietary restrictions. The Food Services Director confirmed that while a food preferences interview was conducted at admission and results are typically recorded on the resident's tray card, this resident's religious dietary preferences were not included on the tray card. Record reviews showed that the resident's admission record, social services data, and comprehensive care plan did not include interventions or documentation regarding religious dietary preferences. The resident's tray card only listed a controlled carbohydrates diet with regular texture, omitting any mention of religious dietary restrictions. The resident's medical history included chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, and major depressive disorder. The annual MDS indicated that religious services or practices were somewhat important to the resident, but no cognitive assessment was documented.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary nail care for a resident with quadriplegia who was completely dependent on staff for all activities of daily living, including personal hygiene. The resident was assessed as having severe cognitive impairment and required total assistance with eating, hygiene, dressing, toileting, bathing, transfers, and bed mobility. The resident's care plan documented a functional deficit with ADLs and indicated dependence on staff for personal hygiene. Multiple observations over two days revealed the resident's fingernails were approximately 1 centimeter in length and remained untrimmed despite being scheduled for a bath and receiving a shower. Nursing assistants confirmed the resident's nails were long and had not been trimmed during bathing or showering, even though nail care was expected to be provided at those times. The resident verbally requested that their nails be cut, but this care was not provided as required.
Failure to Provide Individualized Activity Program for Resident Receiving Dialysis
Penalty
Summary
The facility failed to implement an individualized activity program for a resident who was assessed as cognitively intact and had a diagnosis of End Stage Renal Disease (ESRD) and Diabetes Mellitus. The resident required partial assistance with activities of daily living and was receiving hemodialysis three days a week, returning to the facility in the late afternoon. The resident expressed that there were no activities offered in the evening or on weekends, which was confirmed by a review of the facility's activity calendar for the month. Documentation showed that the resident had not participated in any activities since readmission following a hospital stay, despite previously documented interests in activities such as animals/pets, arts/crafts, bingo, family/friend visits, movies, music, and special events, and a preference for activities two to five times per week. The resident's care plan indicated a dependence on staff for activity participation and a need to provide materials for individual activities as desired. However, there was no evidence that the facility provided or facilitated access to activities that matched the resident's preferences or schedule, particularly considering the resident's dialysis treatments and late return to the facility. Interviews and record reviews confirmed the lack of scheduled activities during evenings and weekends, and the absence of documented activity participation for the resident after readmission.
Failure to Implement Interventions to Prevent Decline in Range of Motion
Penalty
Summary
Facility staff failed to implement interventions to prevent further decrease in range of motion (ROM) for a resident with multiple medical diagnoses, including pain, type 2 diabetes mellitus, heart failure, and major depressive disorder. The resident was admitted with these conditions and was identified as having limited mobility. Despite the facility's policy to provide maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome, there was no evidence in the resident's records of any restorative nursing program or interventions aimed at maintaining or improving ROM. Therapy screenings indicated that the resident would benefit from skilled services due to lack of mobility, but the resident refused out-of-bed activity and was only monitored and screened as needed. Observations revealed decreased ROM and nodules in the resident's left hand, and both the resident and the DON confirmed that no interventions were in place to prevent further decline in ROM. The comprehensive care plan and electronic health record lacked documentation of any such interventions.
Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by regulation, with observations revealing a rate of 10.71% based on 3 errors out of 28 medication administrations. The errors involved three residents. For one resident, a Certified Medication Assistant (CMA) administered an Advair Diskus inhaler but did not instruct the resident to rinse their mouth after use as ordered, instead providing water to drink. The CMA confirmed during interview that the resident was not cued to rinse their mouth. For two other residents, a Licensed Practical Nurse (LPN) administered insulin using insulin pens but primed the pens with only 1 unit instead of the 2 units specified in the manufacturers' instructions. The LPN confirmed during interviews that the pens were primed with 1 unit for both residents. Manufacturer instructions for both Lispro and Lantus insulin pens require priming with 2 units to ensure proper dosing. These actions resulted in medication administration errors as observed and documented by surveyors.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility staff failed to implement necessary interventions to prevent the development of pressure ulcers for a resident identified as being at risk. The resident, who was admitted with diagnoses including pain, hypertension, hemiplegia, and hemiparesis related to a cerebral infarction, was assessed to have moderately impaired cognition and was dependent on staff for various activities of daily living. The resident's care plan included the use of a low loss air mattress to prevent pressure ulcers, and a treatment was ordered for an existing wound on the buttock/coccyx area. Despite these measures, observations revealed that the resident's heels were consistently not elevated off the mattress, contrary to the facility's pressure ulcer prevention policy and national guidelines. Multiple observations over two days showed the resident's heels were in contact with the mattress, and interviews with staff confirmed that the heels should have been elevated, such as on a pillow, to prevent pressure ulcers. The facility's policy and national guidelines emphasize the importance of heel elevation to prevent pressure ulcers, particularly as the heel is a common site for such injuries. The failure to elevate the resident's heels as required by the care plan and guidelines represents a deficiency in the facility's care practices.
Failure to Implement Enhanced Barrier Precaution
Penalty
Summary
The facility staff failed to implement Enhanced Barrier Precaution (EBP) for a resident, identified as Resident 7, who was admitted with diagnoses including pain, hypertension, hemiplegia, and hemiparesis related to a cerebral infarction. The resident was dependent on assistance for eating, toilet use, dressing, personal hygiene, and rolling, and was at risk for pressure ulcer development. The resident also received tube feedings and had a treatment order for a wound on the buttock/coccyx to be completed three times a day. Despite these conditions, observations revealed that there were no indications in the resident's room or at the entrance that EBP was being implemented. Further observations showed that an LPN performed treatments on the resident without wearing a gown, and during an interview, the LPN admitted to not knowing what EBP was. The Director of Nursing confirmed that the resident should have been on EBP. The facility's infection control policy for EBP, revised earlier in the year, required staff to use gowns and gloves during the care of residents with wounds or indwelling medical devices, such as feeding tubes, which was not adhered to in this case.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure the security of the east medication room, which had the potential to affect 22 of 64 residents who were self-mobile and resided in the facility, as well as two unauthorized staff members. On the morning of May 23, 2024, observations revealed that the keys were left in the lock of the medication storage room door on the east side of the building, beside the nurses' station. This door was visible to anyone passing by in the hallway, and there were no staff present at the nurses' station at that time. Registered Nurse (RN)-A was observed at the end of the east hall, and a resident with severe cognitive impairment was in a wheelchair beside the nurses' station. Further observations showed that RN-A entered the medication room and removed the keys from the door at 4:40 AM. Interviews with RN-A and the Director of Nursing (DON) confirmed that the keys, which also included the key for the medication fridge padlock, should not have been left in the lock. The DON confirmed that the medication storage rooms are to be locked at all times and acknowledged that the east medication room was unsecured when the keys were left in the lock. The facility's policy requires that compartments containing drugs and biologicals be locked when not in use, and that access to controlled medications be separate from non-controlled medications.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and functional environment for its residents, as observed during a survey. Specific deficiencies were noted in seven resident rooms and two shower rooms, affecting 55 out of 64 residents. Observations included multiple scrapes on walls, irregular holes around air conditioner power intake covers, and dust-covered ventilation covers in several rooms. Additionally, a resident's wheelchair had a broken armrest with a sharp edge, and bathroom doors and baseboards showed significant wear and dust accumulation. The bathroom faucet in one room had poor water pressure, and there were gouges in the drywall around soap dispensers. Further observations revealed rusty and discolored ceramic tiles in the east and west shower rooms. Interviews with the Maintenance Director and the Director of Nursing confirmed these issues, with the Maintenance Director acknowledging the absence of work orders for the identified concerns. The Director of Nursing confirmed that 55 residents used the affected shower rooms, highlighting the widespread impact of these deficiencies on the facility's residents.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to evaluate and implement interventions to manage triggers for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident, who was admitted on September 20, 2023, was found to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. Despite this, the resident's Comprehensive Care Plan (CCP) did not include any mention of PTSD or interventions to mitigate triggers associated with the condition. Interviews with the resident revealed that they experienced difficulties at night and preferred having the TV on and a soft voice to wake them up, as sudden movements by staff could be frightening. Further interviews with the Director of Nursing (DON) and the Social Worker (SW) confirmed that there were no documented triggers or interventions for the resident's PTSD in their medical record. The SW admitted that no interview, assessment, or interventions had been completed for the resident's PTSD. The facility's Mood and Behavior Policy and Procedure, dated January 2024, emphasized a resident-centered approach to care, requiring individualized plans based on comprehensive assessments. However, this policy was not adhered to in the case of the resident with PTSD, leading to the deficiency.
Failure to Investigate and Report Alleged Misappropriation
Penalty
Summary
The facility staff failed to investigate and submit a written investigation of an alleged misappropriation to the state agency within the required 5 working days. This deficiency involved a resident who reported that a family member had stolen their Net Spend card, which is similar to a debit card. The facility had a census of 64 residents at the time of the incident. The Adult Protective Services (APS) report dated January 2, 2024, indicated that APS was notified of the alleged theft on the same day at 11:57 AM. During an interview conducted on May 22, 2024, the Director of Nursing (DON) confirmed that the investigation and the results had not been completed or sent to the required state agency. The facility's policy on abuse protection, dated January 2024, outlines the procedures for reporting and responding to incidents of abuse, neglect, or misappropriation. It specifies that reports must be made to the Department of Health and Human Services (DHHS) and local law enforcement within 24 hours after forming a reasonable suspicion, or within two hours if the events could result in serious bodily injury. However, the facility did not adhere to these procedures in this case.
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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