Emerald Nursing & Rehab Omaha
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 5505 Grover Street, Omaha, Nebraska 68106
- CMS Provider Number
- 285097
- Inspections on file
- 37
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Omaha during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and frequent urinary incontinence, but intact cognition, was the subject of a grievance from a family member alleging the resident remained wet for over four hours and that requests for assistance were ignored until other staff were found. The resident reported waiting up to about 45 minutes after activating the call light, sometimes resulting in incontinence, and another family member described a call light going unanswered for up to four hours. Although the DON recognized this grievance as an allegation of potential neglect and stated an investigation was conducted, it was not documented, and the event was not entered on the reportable incident log or reported to the State Agency. The ADM stated the allegation was not reported because they believed that, without a resident outcome, it did not require reporting, contrary to facility policy and regulatory requirements for timely reporting of alleged neglect.
A resident with metabolic encephalopathy, repeated falls, muscle weakness, moderate cognitive impairment, and documented needs for partial/moderate assistance with transfers, toileting, and ambulation did not receive ADL care and voiding pattern assessment as care planned. The care plan called for 1-person assist with ambulation using a walker, bed mobility, transfers, toileting hygiene, supervision with toilet transfers, and establishing voiding patterns while using disposable briefs, but no voiding pattern assessment was completed. Over a two-day period the resident experienced multiple falls, some unwitnessed, and on an observed morning staff did not check or change the resident for several hours, with an NA only delivering a meal tray and an LPN allowing the resident to ambulate to and from the bathroom and transfer on and off the toilet without assistance or supervision. The resident’s spouse was observed changing the bed and cleaning the room, reporting that staff did not perform these tasks, and both an NA and the DON confirmed residents were to be checked every 2 hours and that the resident should have been assisted and supervised with transfers and toileting per the MDS and care plan.
Two residents with vascular disease and surgical/venous wounds did not receive wound care as ordered. For one resident with a venous ankle ulcer, an LPN performed dressing care without the ordered ABD pad and instead used the technique ordered for the toes. For another resident with diabetes, peripheral vascular disease, and a left 3rd toe amputation, wound vac orders for dressing changes every 3 days and constant suction, as well as backup wet-to-dry and other wound treatments to the left foot and leg, were frequently not completed or not documented as completed. Progress notes described periods when the wound vac was not running due to a dead battery and missing charger, with no documentation of how long it was off or what interim care was provided. A provider later documented a macerated amputation site with slough and new skin breakdown, and the resident reported that wound vac dressings were changed only weekly and that there were multiple six-day stretches without dressing changes. Staff interviews revealed lack of formal wound vac competency training and absence of a wound vac policy, and the DON acknowledged that wound care orders were not followed.
The facility failed to follow its falls management policy for several residents by not consistently identifying causal factors for falls, not updating or documenting fall-prevention interventions, and not completing required post-fall and neuro assessments. One resident with cognitive impairment and mobility deficits had multiple falls without documented causal analysis or new interventions, and neuro checks were only initiated after one of several unwitnessed falls. Staff did not perform required two-hour checks and allowed this resident to transfer and toilet independently despite care plan requirements for one-person assist and supervision. Another resident with a right femur fracture from a fall remained on an air mattress even though the internal fall investigation identified the air mattress as the root cause and no additional interventions beyond therapy were documented. A third resident with hemiplegia and hemiparesis had a witnessed bathroom fall, but there was no evidence of the required 72-hour post-fall monitoring and documentation, despite staff acknowledging that such monitoring and documentation should occur.
A resident with hemiplegia and hemiparesis following a stroke, who was cognitively intact and frequently incontinent of bladder, did not have voiding patterns established despite the care plan directing this intervention. Admission documentation indicated functional urinary status with a treatment program of routine check and change and prompted voiding, but record review showed no bladder diary or documented voiding patterns. Observations found the resident’s brief and bed pad wet with urine, and the resident reported needing to use the call light and wait for toileting assistance and wanting a toileting program that had not been offered. A NA confirmed the resident was only toileted when calling for help, and the DON acknowledged that voiding patterns had not been completed.
Staff failed to follow infection control policies during wound care for a resident with ESBL resistance and a history of MRSA. One LPN performed a dressing change using gloves stored in personal pockets and did not perform hand hygiene between glove changes, contrary to the facility’s handwashing and glove-use policy. Another LPN provided wound care to the same resident, who was on Enhanced Barrier Precautions, without wearing a gown, brought a treatment cart into the room, placed wound care supplies on an uncleaned bedside table without a barrier, and used scissors from the table to cut xeroform gauze without disinfecting them. The DON confirmed that staff are expected to follow the EBP signage process for residents on EBP, including those identified by door magnets.
Surveyors found that the facility did not maintain several occupied rooms in a safe, clean, and well-functioning condition. During an environmental tour with the Maintenance Supervisor and Administrator, they observed missing bathroom call strings, very low sink water pressure in multiple rooms, cobwebs on walls and ceilings, and ventilation covers coated with dust-like buildup. They also noted a non-functioning bathroom light, stained bathroom ceilings, light covers and floors, a deeply gouged bathroom door, and cracked or broken call light and phone outlet covers. The Maintenance Supervisor confirmed these problems, stated they required cleaning or repair, and reported there were no active work orders for them and that staff were inconsistent in submitting work orders.
The facility failed to report two separate serious incidents to the State Survey Agency as required by its own abuse and incident reporting policy. One resident with a history of TBI, mood disorder, falls, behavioral symptoms, and wandering left the building twice without notifying staff; during the second elopement, staff were unaware of the resident’s whereabouts, the wheelchair was later found outside, and the resident returned with abrasions, shoulder pain, and required hospital evaluation. The resident’s care plan noted impulsivity and a preference for walking outside but lacked interventions for wandering. In a separate event, another resident sustained a ground-level fall resulting in a facial laceration that required suturing in the hospital. A clinical consultant and the Administrator confirmed that neither the elopement with injury nor the fall with significant injury was reported to the State Agency.
A resident was transferred to the hospital on multiple occasions, but the facility did not provide the required written bed-hold information or written reasons for transfer at the time of each hospitalization. Facility policy requires that residents and their representatives receive written information on State bed-hold duration and payment amounts before hospital transfer or therapeutic leave, and that this information be provided at admission and prior to each transfer. Record review showed no bed-hold notices or transfer-reason documentation for any of the resident’s hospital leaves, and the Social Service Director confirmed that no such forms were completed, despite the policy and staff education requirements.
A resident admitted for surgical aftercare following circulatory system surgery did not receive ordered wound care to a left fourth toe because nursing staff did not enter the hospital AVS wound treatment orders into the TAR at admission. As a result, the prescribed twice-daily regimen of cleansing, Betadine application, gauze placement between toes and in the fifth toe crease, and use of a Rooke boot was not documented or performed for several days, which was confirmed by review of the MAR/TAR and by interviews with the IDON and DON.
A resident with quadriplegia, amputations, a Stage III sacral pressure ulcer, multiple venous ulcers, and a surgical wound was care planned for a low air loss mattress, but there was no corresponding physician order or usage parameters. The mattress alarm beeped for weeks, indicating malfunction, yet staff, including an LPN and the IDON, did not know how to correct or calibrate it and key personnel were not notified of the problem. Observations showed the mattress set at the highest weight setting despite the resident’s much lower recorded weight, and the mattress was calibrated based on comfort rather than manufacturer-recommended weight-based settings, contrary to the device instructions.
A resident with TBI, mood disorder, history of falls, inattention, disorganized thinking, depression, and documented wandering behaviors was not provided with appropriate elopement or fall prevention interventions. The care plan noted impulsivity, poor redirectability, and a preference for walking outside, yet contained no elopement or wandering interventions, and the resident’s Wanderguard was removed after being assessed as low risk. The resident left the facility multiple times without signing out, and on one occasion staff only realized the resident was gone after finding the resident’s wheelchair outside, leading to a search by staff and law enforcement before the resident was returned with abrasions and complaints of pain. Despite multiple documented falls, the care plan lacked updated fall interventions, and observations showed environmental hazards in the resident’s room, including scattered paper towels, multiple beverage cases and boxes on the floor, and a urinal out of reach, with no fall prevention measures in place.
After an allegation of potential abuse by a nursing assistant, a resident was not protected as required because the accused staff member continued to be scheduled and had access to residents for several shifts before being suspended, contrary to facility policy.
A resident with cognitive and psychiatric conditions reported to nursing staff that a CNA caused a large hematoma on her leg during incontinence care. Multiple staff observed the injury and were aware of the resident's allegation, but the administrator did not notify the State Survey Agency of the abuse allegation within the required two-hour timeframe, as mandated by facility policy.
A resident with multiple serious medical conditions was not informed of a scheduled cardiology appointment, resulting in a missed visit. The resident, who was cognitively intact, reported not being notified and was eating breakfast when transportation arrived. Staff interviews revealed confusion and lack of clarity about who was responsible for notifying residents of appointments, and the facility had no policy or procedure in place for appointment notifications.
Facility staff did not measure or document the size of a resident's MASD wounds over several weeks and failed to re-evaluate or update the treatment plan despite ongoing symptoms. The only intervention provided was continued application of barrier cream, with no further assessment or specialist consultation.
A resident who was always incontinent of bladder and frequently incontinent of bowel was not evaluated for a toileting program, despite being cognitively intact and dependent on staff for toileting. Observations showed the resident repeatedly remained wet with a urine odor present, and the resident expressed wanting more assistance to stay dry. Staff interviews confirmed the lack of a toileting program and frequent episodes of incontinence.
Staff did not follow infection control protocols, including hand hygiene, glove changes, and use of gowns, while providing care to a resident with MRSA and multiple areas of MASD. Both a nursing assistant and an LPN failed to perform hand hygiene and change gloves between tasks, and did not use gowns as required by facility policy.
The facility failed to follow practitioner's orders for wound and skin care for two residents. One resident with quadriplegia did not receive prescribed PREVENT Silicone Cream for a pressure ulcer due to unavailability and insurance issues. Another resident with moderate cognitive impairment did not have palm guards applied as ordered for contractures, as they were unavailable. Staff confirmed the orders were not followed, and the physician was not contacted for alternative treatments.
A resident with a history of end-stage renal disease and a past heart transplant experienced significant medication errors in the administration of Warfarin. Despite orders to hold the medication, staff administered incorrect doses on multiple occasions. The errors were confirmed by the Unit Director and the DON.
A resident with a history of diabetes and other conditions developed Moisture Associated Skin Damage (MASD), but the facility failed to provide timely treatment. Despite identifying the issue and notifying the physician, there was no follow-up until a Nurse Practitioner provided treatment orders, which were delayed in implementation. Observations revealed significant skin issues, and interviews confirmed the delays in care.
The facility did not follow its standardized recipe for Shepherd's Pie, affecting the taste and nutritional value of the dish served to residents. The cook substituted specified ingredients with green beans and added unmeasured amounts of other ingredients without consulting the recipe. This deviation was confirmed by the Dietary Manager and the Director of Nursing, who acknowledged the potential impact on all residents consuming the meal.
The facility failed to maintain proper hand hygiene and equipment cleanliness in the kitchen, risking foodborne illness for all 68 residents. Staff did not wash hands for the required duration or change gloves between tasks, and kitchen equipment was found to be unclean, with dust, grease, and rust present. The Dietary Manager confirmed these issues, which were not documented in maintenance records.
The facility was found to have multiple environmental deficiencies in 16 resident rooms, including stained toilets and floors, broken bed footboards, and strong urine odors. Interviews confirmed these issues, and the Maintenance Director noted no work orders had been filed for the problems, indicating a failure to follow facility policies on maintenance and work orders.
A facility failed to investigate and report an alleged staff-to-resident abuse incident involving a resident with impaired cognition. The resident reported being mishandled by a staff member, but no written investigation was completed or submitted to DHHS as required. The DON confirmed the lack of investigation and reporting, contrary to facility policies.
A facility failed to create a comprehensive baseline care plan for a resident with complex medical conditions, including heart disease, renal disease, and a diabetic foot infection. The care plan did not address critical needs such as dialysis status, wound care, and medication management. Interviews revealed the resident had not received a copy of the care plan, and an LPN confirmed its inadequacy in informing staff of the resident's needs.
A resident with a history of CVA and moderate cognitive impairment was admitted without proper orders for feeding tube care. The feeding tube was found unsecured and contained a dark substance, potentially leading to infection. Facility staff failed to follow protocols for feeding tube management, as confirmed by the DON and NP.
A resident with multiple medical conditions, including End Stage Renal Disease, did not receive proper evaluation of their dialysis access site. Nursing staff failed to complete required pre and post dialysis observations, and were unaware of the resident's access site locations. The facility's policies for monitoring medical conditions and dialysis access sites were not followed, leading to this deficiency.
A resident with orthostatic hypotension was administered Midodrine despite having a systolic blood pressure above the prescribed threshold, contrary to physician orders. The facility's policy on Medication Regimen Review was not followed, resulting in unnecessary medication use. The Director of Nursing confirmed the medication was given when it should have been held.
The facility failed to implement proper infection control measures, including inadequate hand hygiene during skin care for a resident with ESBL and MRSA, improper storage of oxygen tubing for two residents, and failure to use PPE during wound care for a resident on Enhanced Barrier Precautions. The DON confirmed these deficiencies.
The facility failed to notify the medical provider of abnormal blood sugar levels for a resident with hyperglycemia. Despite multiple instances of blood sugar readings outside the specified parameters, the provider was only notified on two occasions. Additionally, insulin doses were held based on nursing judgment without proper documentation or provider notification.
Failure to Timely Report Allegation of Potential Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of potential neglect to the State Agency within required timeframes. Facility policy on Abuse, Neglect and Exploitation, revised 1/2024, requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not, to the administrator and appropriate officials including the State Survey Agency. The policy also requires that results of all investigations be reported to the administrator and State Survey Agency within 5 working days. The Grievance Policy similarly directs that upon receipt of a grievance, the Grievance Official determine if it is reportable and, consistent with the Abuse Prevention Policy, immediately report all alleged violations involving neglect or abuse to the administrator and as required by state law. Resident 1 was admitted with hemiplegia and hemiparesis following a stroke and was frequently incontinent of bladder, with intact cognition as evidenced by a BIMS score of 13. A grievance form dated 02/27/2026 documented that a family member reported the resident had stayed wet for over four hours and that when assistance was requested, the request was ignored, requiring the family member to find different staff to assist. This grievance was heard by the facility social worker. Review of the facility’s Reportable Incident Log for the relevant period showed no reportable incident involving this resident, indicating that the allegation was not entered as a reportable event. During interviews, the resident reported having to wait for assistance after activating the call light, sometimes resulting in incontinence in the brief, with the longest wait being approximately 45 minutes. Another family member reported an instance of waiting up to four hours for a call light to be answered, though the date was unknown. The DON stated that an investigation into the grievance was conducted but not documented and confirmed that the grievance related to the resident was an allegation of potential neglect that should have been reported to the State Agency within required timeframes. The administrator acknowledged that the allegation of potential neglect was not reported, explaining that they believed a report was not required if there was no resident outcome. This sequence of events led to the failure to report the allegation of potential neglect as required by facility policy and licensure regulations.
Failure to Provide ADL Assistance and Voiding Pattern Assessment per Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) assistance and to assess and follow voiding patterns as outlined in the resident’s care plan. Resident 3, admitted in early February and readmitted from the hospital later that month, had diagnoses including metabolic encephalopathy, repeated falls, and muscle weakness, and a BIMS score of 9 indicating moderate cognitive impairment. The resident’s MDS documented a need for setup/clean-up assistance with eating and upper body dressing, supervision with oral hygiene, and partial/moderate assistance with bathing, lower body dressing, footwear, toileting, bed mobility, and transfers. The care plan specified one-person partial assistance with ambulation using a walker, bed mobility, transfers, toileting hygiene, and supervision with toilet transfers. The resident was occasionally incontinent of bladder, frequently incontinent of bowel, on a diuretic, and care plan interventions included establishing voiding patterns and using disposable briefs changed as needed. Despite these documented needs, the facility did not complete a voiding patterns assessment for the resident, and staff did not follow the planned assistance and monitoring. Progress notes showed multiple falls over two days, including unwitnessed falls where the resident was found on the floor next to the bed and a witnessed fall where staff saw the resident sliding out of bed. On the morning of the survey observation, staff did not enter the resident’s room to check or change the resident between 4:30 a.m. and 8:55 a.m., except when a nursing assistant briefly delivered a breakfast tray without assessing needs. Later, an LPN observed the resident independently getting out of bed, ambulating with a walker to the bathroom, and transferring on and off the toilet without offering assistance or supervision, despite the care plan and MDS indicating the need for partial/moderate assistance and supervised toilet transfers. The resident’s spouse was observed changing the bed and picking up the room, stating that staff “don’t do anything” and noting dried blood on the bedding. The NA and DON both confirmed residents were supposed to be checked every two hours, that this had not occurred, that no voiding pattern assessment had been completed, and that staff should have assisted and supervised the resident with transfers and toileting as care planned.
Failure to Follow Wound Care Orders and Manage Wound Vac for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound care and to provide ordered treatments consistently for two residents with significant vascular disease and surgical wounds. For one resident with chronic venous hypertension, venous insufficiency, and peripheral vascular disease, the admission record and skin assessment documented a venous ulcer on the right ankle with an order on the Treatment Administration Record to cleanse the right lateral ankle, apply Xeroform to the wound bed, cover with an ABD pad, and secure with kerlix, changing the dressing daily and as needed. During an observed wound care episode, an LPN cleansed the wound and applied Xeroform and kerlix secured with tape but did not apply the ordered ABD pad. The LPN confirmed that the ABD pad should have been used and that the dressing technique performed matched the order for the resident’s right toes rather than the right ankle. For a second resident with Type 2 diabetes, peripheral vascular disease, and a recent surgical amputation of the left 3rd toe, multiple wound care orders were in place over time, including wound vac dressing changes to the left 3rd toe every three days and as needed, wound vac suction at 100 mmHg with constant suction, backup wet-to-dry dressings if the wound vac could not be used, and various betadine and gauze treatments to the left foot, toes, leg, thigh, and calf. Progress notes documented that the wound vac was not running due to a dead battery and missing charger, with no documentation of how long the wound vac had been off or what was done for the wound during that time. Later notes indicated the resident returned from dialysis with the wound vac machine off and no charge, the facility could not find the cord, and the wound vac was removed and replaced with a wet-to-dry dressing. Subsequent notes showed the wound vac was removed at an appointment and not reapplied, and that the resident at one point refused a wound vac dressing change, preferring a nurse who had previously performed it successfully. Review of the MAR/TAR for this resident showed multiple wound-related orders were not completed or not documented as completed as ordered. The wound vac dressing order for one date was not completed, and a subsequent order for wound vac dressing changes every three days was entered as Monday/Wednesday/Friday instead of every three days and was marked refused on one date. The order to maintain wound vac suction at 100 mmHg with constant suction was not marked as completed on several specified shifts and was marked "no" on 23 of 45 shifts. The order to apply wet-to-dry dressings if the wound vac could not be used was not marked as completed, and orders for left leg and left thigh/calf wound care were not documented as completed on multiple ordered days. A provider note later documented that the left 3rd toe amputation site was macerated with a large amount of slough and that the resident reported the wound vac had only been changed weekly instead of three times per week, with new skin breakdown on the bottom of the foot attributed to that. The provider discontinued the wound vac and ordered daily betadine-moistened gauze dressings. The resident confirmed by telephone that only a few staff knew how to manage the wound vac or amputated toe dressing and reported multiple six-day stretches without dressing changes. An agency LPN reported no formal wound vac competency training, and the DON confirmed there was no wound vac policy or competencies and that the resident’s wound care orders were not completed as ordered.
Failure to Analyze Falls, Implement Interventions, and Complete Post-Fall/Neuro Assessments
Penalty
Summary
The deficiency involves the facility’s failure to follow its own falls management policy by not completing causal factor analyses, not implementing or documenting fall-prevention interventions, and not performing required post-fall and neurological assessments for multiple residents. For one resident with metabolic encephalopathy, repeated falls, muscle weakness, moderate cognitive impairment, and identified need for partial/moderate assistance with mobility and transfers, the record showed several falls over a short period. Progress notes for these falls documented basic assessments and vital signs but did not include causal factors for the falls or new interventions to prevent recurrence, except for resident education to use the call light and a transfer to the emergency department after the final fall. Neuro checks were only initiated after one of several unwitnessed falls, despite the facility’s policy requiring neuro checks after any unwitnessed fall or fall with possible head injury. The same resident’s care plan identified risk factors such as weakness, limited mobility, new environment, medications with potential adverse reactions, confusion, and poor safety insight, and called for one-person assist with ambulation, transfers, and toileting, as well as routine visual rounding. However, observations showed staff did not enter the resident’s room for several hours overnight to check or change the resident, despite a requirement to check residents every two hours. Later, an LPN observed the resident independently getting out of bed, ambulating with a walker to the bathroom, and transferring on and off the toilet without assistance or supervision, contrary to the resident’s MDS and care plan requirements. The DON confirmed staff should have checked the resident every two hours, assisted with transfers, and supervised toilet transfers, and also confirmed that the care plan did not include interventions related to the resident’s multiple falls and that neuro checks were not started after the first unwitnessed fall as required. Another resident with a right femur fracture from a fall had a fall data collection form identifying the air mattress as the root cause of the fall, with an initial intervention to change to a regular mattress. The care plan documented a new fall with right femur fracture and surgical aftercare, with an intervention of working with therapy post-surgery. Observations on two separate days showed this resident still lying on an air mattress. The DON confirmed that the internal fall investigation identified the air mattress as the reason for the fall, that the mattress had been changed to a regular mattress and then changed back to an air mattress at the resident’s request, and that there was no additional evidence of other interventions beyond therapy. A third resident, admitted with hemiplegia and hemiparesis following a stroke and cognitively intact per MDS, experienced a witnessed non-injury fall during a self-transfer in the bathroom. The fall data collection documented the fall event, and progress notes included an entry at the time of the fall and a follow-up note the next day. However, review of the electronic health record, including progress notes, skilled services documentation, and scanned documents, revealed no further evidence of post-fall injury monitoring or documentation for the 72 hours following the fall. Nursing staff and the DON confirmed that residents should be monitored for 72 hours after a fall, with progress notes and vital signs every shift, and the DON confirmed there was no additional evidence that such assessments were completed for this resident. Across these residents, the facility did not ensure completion of causal factor analyses, implementation and documentation of fall-prevention interventions, or consistent post-fall and neurological assessments as required by policy.
Failure to Establish Voiding Patterns and Toileting Program for Continent/Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to establish voiding patterns and develop an effective toileting program for a resident who was frequently incontinent of bladder. The resident was admitted with hemiplegia and hemiparesis following a stroke and had an admission MDS showing intact cognition with a BIMS score of 13. The MDS documented that the resident was frequently incontinent and not on a toileting program. The Comprehensive Care Plan included interventions stating the resident required assistance with toilet transfers and toileting hygiene, and specifically listed “establish voiding patterns” and “incontinent: routine check and change on rounds and as required for incontinence” as interventions. The Nursing Admission Data Collection indicated the resident had functional urinary status and that the treatment program included routine check and change and prompted voiding. Record review of the electronic health record, including scanned documents, progress notes, and forms, revealed no evidence that voiding patterns or a bladder diary had been established for this resident. During observation, staff assisted the resident out of bed and to the toilet, and the resident’s bed pad and brief were noted to be wet with urine. In interviews, the resident reported being aware of the urge to use the restroom, needing to turn on the call light and wait for assistance, and expressed a desire to be on a toileting program to restore continence, which had not been offered. A nurse aide confirmed the resident was not on a toileting program and was toileted only when calling for help. The DON confirmed there was no bladder diary or established voiding patterns in place and acknowledged that the established voiding patterns should have been completed.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow established infection prevention and control policies, including hand hygiene and appropriate glove use, during wound care for one resident. The facility’s handwashing and glove-use policy, revised 1/2024, requires hand hygiene before and after direct resident contact, between contaminated and clean body sites, after contact with intact skin, blood or body fluids, contaminated equipment, and after removing gloves, as well as proper glove application and removal. During an observed wound dressing change for Resident 4, an LPN performed initial hand hygiene, then donned gloves from a box and removed the wound dressing. The LPN then removed the gloves, took additional gloves from the pocket of the scrub top, and continued wound cleansing and dressing steps, repeating this process of using pocketed gloves without performing hand hygiene between glove changes. The LPN later acknowledged that hand hygiene should have been completed between glove changes and that gloves should not have been taken from personal pockets but from a clean glove box. The facility’s MDRO PPE-Enhanced Barrier Precautions policy, revised 1/2024, requires gown and glove use for high-contact care activities, including wound care, for residents with wounds or MDROs, and specifies that everyone must clean their hands before entering and when leaving the room. Resident 4’s record showed diagnoses of ESBL resistance and a personal history of MRSA infection, and an EBP magnet was present on the room door frame. During another observed wound care episode for this resident, an LPN entered the room with a treatment cart, did not don a gown, and placed wound care supplies on an uncleaned bedside table without disinfecting the surface or using a protective barrier. Scissors already on the bedside table were used to cut xeroform gauze without prior disinfection. The LPN confirmed that the treatment cart should not have entered the room, that EBP (gown and gloves) should have been used for the dressing change, that the table should have been disinfected before placing supplies, and that the scissors should have been disinfected before use. The DON confirmed that the EBP signage process is the expectation for all staff providing high-contact care to residents on EBP, including those with EBP magnets on their door frames.
Environmental Maintenance and Call System Deficiencies in Multiple Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment in 11 of 42 occupied rooms during an environmental tour conducted with the Maintenance Supervisor and Administrator. Observations included missing call strings in at least one resident bathroom, very low water pressure in multiple room sinks, cobwebs along the walls and ceiling in one room, and multiple ventilation covers coated with a gray, fuzzy dust-like substance in several rooms (301, 304, 305, 306, 316, 502, 505, 511, 512, 514). Additional issues included a non-functioning bathroom light in one room, reddish-brown stains on the bathroom ceiling and light cover and dark stains on the bathroom floor in another room, scratches and a deep gouge in a bathroom door, a cracked and broken call light outlet on a wall, and a broken phone outlet cover on a wall. In an interview, the Maintenance Supervisor confirmed all of these issues, acknowledged they needed cleaning and/or repair, and stated there were no active work orders for the identified concerns and that staff were inconsistent in submitting work orders. No specific resident medical histories or clinical conditions were described in relation to these environmental deficiencies.
Failure to Report Elopement and Fall With Major Injury to State Agency
Penalty
Summary
The facility failed to timely report to the State Survey Agency an elopement and a fall with major injury involving two residents, as required by its Abuse, Neglect, and Exploitation policy. The policy required all allegations of abuse, neglect, exploitation, and injuries of unknown source to be reported within 2 hours for serious bodily injury and within 24 hours if no injury, with investigation results submitted within 5 working days. One resident, with a history of traumatic brain injury, mood disorder, history of falling, inattention, disorganized thinking, depression, verbal behaviors that interfered with care and put others at risk, and documented wandering behaviors, left the facility twice on the same day without signing out or notifying staff. Progress notes showed that the resident’s care plan included preferences for walking outside and described the resident as very impulsive and not easily redirectable, but did not include interventions addressing wandering behaviors. On the second elopement, staff did not know where the resident was going, the resident’s wheelchair was later found near the drive-up area, and the resident ultimately returned with abrasions, complaints of shoulder pain, and required hospital evaluation for hypothermia and injuries from a fall. The Administrator confirmed this elopement incident was not reported to the State Agency. A second resident experienced a ground-level fall resulting in a right facial laceration that required transport to the hospital. The hospital discharge summary documented a right upper eyelid laceration with sutures, indicating a significant injury. Interview with a clinical consultant confirmed that this fall with significant injury was not reported to the State Agency, despite the facility’s policy requiring reporting of such events. These two unreported incidents, an elopement with injury and a fall with major injury, occurred among a sample of four residents in a facility with a census of 62 and constituted the basis for the cited deficiency under the licensure requirement to timely report suspected abuse, neglect, or theft and the results of investigations to proper authorities.
Failure to Provide Bed-Hold Information and Written Transfer Reasons for Hospital Transfers
Penalty
Summary
The facility failed to provide required bed-hold information and written reasons for transfer for a resident on multiple occasions. The facility’s “Bed Hold and Return to Facility Policy and Procedure,” created in May 2017 and revised in January 2024, states that residents who are transferred to the hospital or go on therapeutic leave are to be provided written information about the State’s bed-hold duration and payment amount before the transfer. The policy also states that residents and their representatives will be provided with bed-hold and return information at admission and before a hospital transfer or therapeutic leave, and that nursing and social work staff are educated on these requirements. Record review showed that one resident, admitted on an unspecified date, was listed on hospital leave on five separate occasions: 11/30/25, 12/01/25, 12/09/25, 12/18/25, and 01/02/26. Progress notes from 11/30/25 at 2:12 AM documented that the doctor’s office was notified and the resident was sent to the emergency room. However, review of the resident’s medical record, including progress notes and miscellaneous documents, revealed no bed-hold information or written reason for transfer for any of the five hospital transfers. In an interview on 1/20/26 at 9:50 AM, the Social Service Director confirmed that the facility had no completed bed-hold forms or reason-for-transfer forms for this resident and acknowledged that one should have been completed with each transfer to the hospital.
Failure to Initiate and Provide Ordered Surgical Wound Care
Penalty
Summary
Facility staff failed to provide ordered surgical wound care for one resident following admission. The facility’s new/re-admission process required a licensed nurse to review admission orders and input wound treatment orders into the system. The resident was admitted with a diagnosis of encounter for surgical aftercare following surgery on the circulatory system. The hospital after visit summary (AVS) included detailed wound care orders for the left fourth toe, specifying cleansing with soap and water, application of povidone (Betadine), placement of gauze between each toe space and in the crease of the fifth toe, and use of a Rooke boot, to be performed twice daily. Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the wound care order from the AVS was not activated on the TAR until several days after admission, and no wound care was charted during that period. Interviews with the Interim Director of Nursing and the Director of Nursing confirmed that staff should have used the wound care orders from the AVS and that the wound care was not initiated or completed during the identified dates.
Failure to Ensure Proper Functioning and Calibration of Low Air Loss Mattress for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper functioning and calibration of a low air loss mattress for a resident with significant skin integrity issues. The resident had spastic hemiplegia, quadriplegia, amputations of the left foot and right leg above the knee, a history of wounds, and at the time had a Stage III sacral pressure ulcer, multiple venous ulcers on the left leg and stump, and a surgical wound on the right stump. The resident’s care plan included an intervention for a low air loss mattress, but there was no corresponding physician order or parameters for its use in the order summary. The manufacturer’s instructions for the Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress specified that the mattress should be kept in alternating pressure mode when the patient is lying down and that pressure should be set according to the patient’s weight using the weight setting buttons. Multiple observations showed the resident’s mattress alarm beeping on more than one occasion, indicating a malfunction, and later showed the mattress set at the highest weight setting despite the resident’s last recorded weight of 190.4 lbs. An LPN acknowledged the alarm indicated the mattress was not working correctly, admitted not knowing how to correct or calibrate it, and could not provide evidence of having contacted the equipment company as claimed. The resident and a medication aide both reported that the mattress had been beeping for weeks, and the interim DON and maintenance director stated they had not been informed of the issue until the survey date. The interim DON and maintenance director also reported not knowing how to calibrate the air mattress according to manufacturer instructions, and the mattress was instead adjusted based on the resident’s comfort rather than the resident’s weight, despite the presence of active wounds and the manufacturer’s specified weight-based settings.
Failure to Implement Elopement and Fall Prevention Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and care plan a resident’s elopement risk and fall risk, and to implement interventions to prevent accidents. The facility had an Elopement/Exit Seeking policy stating it would provide a safe and secure environment and be proactive in preventing elopement. The resident involved had a history of traumatic brain injury, unspecified mood disorder, history of falling, inattention, disorganized thinking, depression, and exhibited wandering behaviors that significantly interfered with care and put others at risk for physical injury. The resident’s care plan documented impulsivity, poor redirectability, irritability with safety reminders, and a preference for walking outside, but did not include interventions related to wandering or elopement despite these behaviors and diagnoses. The resident’s MDS showed a BIMS score of 13, indicating cognitive awareness, and documented that the resident required supervision or touching assistance with all mobility and assistance with several ADLs. The resident had a wander/elopement alarm noted on the MDS, but the facility’s Audit of Wanderguards did not list the resident as having a Wanderguard. Progress notes showed that an elopement risk assessment was completed and the resident was deemed to have no active elopement attempts, and the Wanderguard safety device was documented as no longer applicable. Later, the resident left the facility multiple times without signing out or notifying staff, including two exits on the same day without using the sign-out book, and continued to exit seek after being educated on sign-out procedures. On one occasion, staff became aware the resident was missing only after finding the resident’s wheelchair outside near the drive-up area, and documentation showed that staff and law enforcement had to search the surrounding area before the resident was returned by police and the Administrator. The facility also failed to implement and update fall interventions for this resident despite multiple falls. Progress notes and fall data collection forms documented falls on several dates, including in-facility falls and an out-of-facility fall, but the resident’s care plan did not show fall interventions to prevent recurrence of the falls on those dates. Root cause documentation for some falls noted factors such as spilled pop on the floor and nighttime medications causing drowsiness, but there were no documented interventions to prevent similar events in the future or after the resident returned from the hospital. Observations of the resident’s room showed paper towels scattered on the floor, multiple boxes and cases of soda and other items on the floor near the bedside table and between the bed and restroom, and the resident’s urinal hanging on a trash can by the door and not within reach. No fall interventions were observed in the room. Facility staff, including the Clinical Consultant, confirmed that interventions were not put in place following the resident’s falls and that no interventions were implemented to protect the resident from eloping because the resident was considered cognitively aware and able to make their own decisions.
Failure to Remove Accused Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from potential abuse after an allegation was made against a nursing assistant (NA). According to the facility's abuse policy, staff accused of abuse should be immediately removed from resident care areas and suspended pending investigation. However, after an allegation of potential abuse involving a nursing assistant and a resident was documented, the accused NA continued to be scheduled and had the opportunity to care for residents on multiple shifts following the incident. The nursing schedule confirmed that the NA worked several overnight shifts after the allegation was identified, and the administrator acknowledged that the NA was not suspended as part of the abuse investigation until several days later. This lapse in following the facility's abuse policy resulted in the resident not being protected from potential further abuse during the investigation period. The administrator confirmed that the accused NA was only sent home for unrelated reasons on one of the scheduled days and was otherwise present and able to provide care to residents, including the resident involved in the allegation. The failure to immediately remove the accused staff member from resident care areas constituted a breach of the facility's own procedures for protecting residents after an abuse allegation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Agency within the required timeframe for one resident. According to the facility's policy, any suspected abuse, neglect, or exploitation must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, a resident with a history of bipolar disorder, cognitive impairment following a stroke, osteoarthritis, and generalized anxiety disorder reported to nursing staff that a CNA applied excessive pressure to her left leg during incontinence care, resulting in a large hematoma. Documentation showed that the resident informed a registered nurse about the injury, and the nurse made a late entry in the progress notes regarding the resident's report. Multiple staff members, including a CNA and a certified medication assistant, observed the bruise and were aware of the resident's allegation that staff caused the injury. The CNA involved reported the incident to the facility administrator, and other staff members documented their observations and interactions with the resident regarding the injury. Despite these reports and observations, the facility administrator did not notify the State Survey Agency of the abuse allegation until the administrator was made aware of the situation, which was not within the required two-hour window. The administrator confirmed that the progress note entered by the registered nurse constituted an allegation of abuse and acknowledged that it should have been reported within two hours, but was not.
Failure to Notify Resident of Scheduled Medical Appointment Due to Lack of Process
Penalty
Summary
The facility failed to ensure that a process was in place to notify residents of scheduled medical appointments, resulting in a resident missing a critical cardiology appointment. Record review showed that the resident, who was cognitively intact and had significant medical diagnoses including carcinoma in situ of the cervix, anemia due to chemotherapy, and thrombocytopenia, was not informed of a scheduled cardiology appointment. The appointment was documented on the facility's appointment calendar and later marked as canceled after the resident did not attend. Progress notes indicated that the resident was unaware of the appointment and was eating breakfast when transportation arrived, leading to the missed appointment. The resident's hematology and oncology provider's office contacted the facility to stress the importance of the appointment due to an upcoming procedure. Interviews with facility staff revealed inconsistent understanding and communication regarding responsibility for notifying residents of appointments. The Director of Nursing stated that nurses document and communicate appointments to transportation, while the Medical Records Clerk and other staff provided differing accounts of who is responsible for notifying residents. The facility Administrator confirmed that there was no policy or procedure in place regarding appointment notifications. This lack of a clear process led to the resident not being informed and missing the scheduled medical appointment.
Failure to Assess and Re-Evaluate MASD Treatment
Penalty
Summary
Facility staff failed to properly assess and document the wound sizes and did not re-evaluate treatment interventions for a resident with Moisture Associated Skin Damage (MASD). The resident had an order for barrier cream to be applied to the buttocks and perineal areas three times daily due to MASD. Weekly skin and wound observation sheets consistently noted redness and scattered scratch marks on both buttocks, but did not include measurements of the affected areas. This lack of measurement persisted over several weeks, as documented in the resident's records. Additionally, there were no changes or re-evaluations of the treatment plan despite the ongoing presence of MASD and no improvement in the resident's condition. The medical record review showed that the only intervention since the initial order was the continued application of barrier cream, with no documented reassessment or consultation with a wound care specialist. The unit manager confirmed that the area of redness was not measured and that an evaluation of the treatment's effectiveness had not been completed.
Failure to Evaluate and Implement Toileting Program for Incontinent Resident
Penalty
Summary
Facility staff failed to evaluate and implement a toileting program for a resident who was always incontinent of bladder and frequently incontinent of bowel, despite being cognitively intact and dependent on staff for toileting. The resident's Minimum Data Set indicated no toileting program was in place, and the Comprehensive Care Plan noted a history of excoriation due to incontinence and refusal of care, but there was no documentation of refusal during the review period. Observations on two consecutive days revealed the resident was seated in a wheelchair with wet pants and a strong urine odor present in the room. During interviews, the resident expressed a desire for more assistance with toileting and staying dry, and an LPN confirmed the resident was often found wet during shifts. The Director of Nursing acknowledged that the resident had not been evaluated for a toileting program.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
Facility staff failed to follow proper infection prevention and control protocols, specifically regarding hand hygiene, glove use, and the implementation of Enhanced Barrier Precautions (EBP) during care for a resident colonized with Methicillin Resistant Staphylococcus Aureus (MRSA). The resident had Moisture Associated Skin Damage (MASD) in multiple areas, and the care plan directed staff to wear gowns and gloves when changing contaminated linens. However, observations revealed that a nursing assistant did not perform hand hygiene or don a gown before applying a gait belt and cleansing the resident after toileting. The assistant also failed to change soiled gloves or perform hand hygiene between cleaning different body areas and after glove removal. Additionally, a licensed practical nurse was observed providing wound care to the same resident without donning a gown or performing hand hygiene before gloving. The nurse applied treatment ointment and then, without changing gloves or sanitizing hands, touched clean briefs, the resident's arm, shirt, and gait belt. Both staff members later confirmed in interviews that they did not follow required hand hygiene, glove changing, or gown use protocols as outlined in facility policy.
Failure to Follow Wound and Skin Care Orders
Penalty
Summary
The facility failed to ensure that practitioner's orders for wound and skin care were followed for two residents. Resident 1, who was cognitively intact and required total assistance with daily activities due to quadriplegia, had three pressure ulcers. Upon readmission from the hospital, there was an order for PREVENT Silicone Cream to be applied twice daily to a wound on the resident's right posterior thigh. However, the cream was not available from 12-02-2024 to 12-05-2024, and the wound was left open to air. The pharmacy had received the order but was waiting for facility approval due to insurance coverage issues, and the LPN confirmed that the treatment was not administered as ordered. Resident 4, who had moderate cognitive impairment and required total assistance with daily activities, had an order to apply palm guards to both hands every morning and remove them at bedtime for contractures. Observations revealed that the palm guards were not applied on two separate occasions. An LPN confirmed that the order was not being followed because the palm guards were not available, and the DON confirmed that the physician had not been contacted to obtain an alternative treatment.
Significant Medication Errors in Anticoagulant Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, had a medical history that included end-stage renal disease, a past heart transplant, and a recent blood clot in the left upper extremity. The resident required moderate assistance with daily activities and was on anticoagulant medication. According to the resident's progress notes, a PT/INR test was scheduled for 09-26-2024, and the facility received orders to adjust the Warfarin dosage accordingly. However, the Medication Administration Record (MAR) revealed that the staff administered incorrect doses of Warfarin on multiple occasions. Specifically, the resident received 0.5 mg of Warfarin on 09-27-2024, 09-28-2024, and 09-29-2024, despite orders to hold the medication. Additionally, on 10-02-2024, the resident was given 3 mg of Warfarin, contrary to the order to hold the medication until after a rescheduled procedure. Interviews with the Unit Director and the Director of Nursing confirmed these errors, identifying them as significant medication errors.
Failure to Provide Timely Treatment for Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate treatment for a resident with skin breakdown, specifically Moisture Associated Skin Damage (MASD). The resident, who had a history of Diabetes Mellitus Type 2, Severe Protein Calorie Malnutrition, Cirrhosis of the liver, and Clostridium Difficile Enterocolitis, was identified with MASD on 09-09-2024. Despite notifying the physician, there was no follow-up or treatment administered until 09-18-2024, when a Nurse Practitioner provided treatment orders. However, these orders were not implemented until 09-21-2024, leaving the resident without necessary care for an extended period. The resident required extensive assistance with daily activities and was always incontinent of bowel and bladder, which contributed to the skin issues. On 09-15-2024, the resident's condition worsened, with increased redness and a new open area on the right buttock. Despite this, the resident was not seen by a physician or Nurse Practitioner until 09-18-2024, and the treatment was delayed further. Observations on 09-23-2024 revealed significant skin issues, including a dark red and swollen penis and scrotum, and an open area on the right buttock. Interviews with facility staff confirmed the delays in treatment and lack of timely physician assessment. The Director of Nursing acknowledged that the resident was not seen on the scheduled date and that treatment was not implemented promptly. The facility's Skin and Wound Management policy outlined specific care for skin integrity issues, but these were not followed, resulting in the deficiency.
Failure to Follow Standardized Recipe for Shepherd's Pie
Penalty
Summary
The facility failed to adhere to its standardized recipe for Shepherd's Pie, which is a requirement to ensure the taste and nutritional value of the food served to residents. During an observation, it was noted that the cook, identified as [NAME] D, did not follow the written recipe while preparing the dish. Instead of using the specified ingredients, [NAME] D substituted peas, carrots, and tomatoes with green beans, believing they tasted better. Additionally, the cook added unmeasured amounts of mashed potatoes, cheese, parsley, and paprika without consulting the standardized recipe. This deviation from the recipe was confirmed during an interview with [NAME] D, who acknowledged not following the recipe. The Dietary Manager and the Director of Nursing both confirmed that the standardized recipe should have been followed to maintain the intended taste and nutritional value of the Shepherd's Pie. The Dietary Manager acknowledged that substituting vegetables could potentially affect the nutritional content of the dish. The Director of Nursing confirmed that all residents in the facility consumed food prepared in the facility kitchen, indicating that the failure to follow the recipe could have impacted all residents. The facility census at the time was 68, suggesting a significant number of residents could have been affected by this oversight.
Deficiencies in Hand Hygiene and Equipment Maintenance in Kitchen
Penalty
Summary
The facility failed to adhere to proper hand hygiene and gloving protocols during food preparation, as observed in multiple instances involving dietary staff. On several occasions, staff members did not wash their hands for the required 20 seconds before returning to food preparation areas after handling soiled equipment or leaving the kitchen. Additionally, gloves were not changed between tasks, and hand hygiene was not performed when switching between handling raw and ready-to-eat foods. These lapses in hygiene practices were contrary to the facility's policy on preventing foodborne illness, which mandates hand washing and glove changes to prevent contamination. The facility also failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to foodborne illness. Observations revealed that a circulation fan inside the walk-in cooler was coated with dust, and the ventilation hood and lights above the stove were covered in grease. Furthermore, an air conditioning unit was observed to be rusted and dripping condensation into the food preparation area, which could contaminate food being prepared. These conditions were confirmed by the Dietary Manager, who acknowledged the need for cleaning and maintenance but could not provide documentation of any work orders for these issues. The Director of Nursing confirmed that all residents in the facility consumed food prepared in the kitchen, indicating that the deficiencies in hygiene and equipment maintenance had the potential to affect the entire resident population. The facility census at the time was 68 residents, all of whom were at risk due to the observed deficiencies in food safety practices.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during an environmental tour. The tour, conducted with the facility's Assistant Administrator, Housekeeping Director, and Maintenance Director, revealed numerous issues across 16 of the 50 occupied resident rooms. These issues included stained toilets and floors, broken bed footboards, stained walls, missing baseboards, gouged drywall, unclean surfaces due to tape, non-functional window blinds, strong urine odors, bugs in light fixtures, exposed insulation due to missing air conditioner covers, and missing doorknobs. These observations indicate a lack of proper maintenance and cleanliness in the facility. Interviews with the Assistant Administrator and Housekeeping Director confirmed the presence of these issues, and the Maintenance Director acknowledged that no work orders had been filed for the identified problems. The facility's policies on maintenance and work orders, dated from 2009 and 2010, respectively, outline the responsibilities of the Maintenance Department to maintain the facility in a safe and operational manner and the process for submitting work orders. However, the lack of work orders suggests a failure to adhere to these policies, contributing to the observed deficiencies.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough written investigation and report an allegation of staff-to-resident abuse within the required timeframe to the Department of Health and Human Services (DHHS). The incident involved a resident with moderately impaired cognition, who required maximum assistance with daily activities. The resident reported that a staff member had grabbed them by the shirt and thrown them into bed. Although the facility staff called Adult Protective Services (APS) to report the allegation, no written investigation report was completed or submitted to DHHS as required by facility policy. The Director of Nursing (DON) confirmed that no investigation had been conducted, and therefore, no report was made to DHHS. The facility's policies require that all allegations of abuse be reported immediately and investigated thoroughly, with findings submitted to the state survey agency within five working days. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and investigation into the reported incident involving the resident.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident, identified as Resident 177, within 48 hours of admission, as required by regulations. The resident's electronic health record and pre-admission information indicated multiple complex medical conditions, including atherosclerotic heart disease, heart failure, end-stage renal disease, and a history of heart transplant, among others. The resident also had a diabetic foot infection, a deep vein thrombus in the left upper arm, and a wound on the right upper arm requiring a wound vac. Despite this, the baseline care plan did not address critical aspects of the resident's care needs, such as dialysis status, skin issues, wound care, central line management, or medication requirements. Interviews conducted with the resident and an LPN revealed that the resident had not received a copy of the baseline care plan, and the LPN confirmed that the existing care plan was insufficient to inform nursing staff of the resident's specific needs. This oversight in developing a comprehensive baseline care plan could potentially impact the quality of care provided to the resident, as essential information regarding the resident's medical conditions and care requirements was not adequately communicated to the care team.
Failure to Maintain Proper Feeding Tube Care
Penalty
Summary
The facility failed to maintain proper care for a gastric feeding tube for Resident 65, who was admitted with a diagnosis of CVA, hemiplegia, dysphagia, hypertension, and anxiety. The resident had a moderate cognitive impairment with a BIMS score of 12 and required assistance with various activities of daily living. Upon admission, there were no orders for the use, site care, flushes, or securement of the feeding tube. During an interview and observation, it was noted that the feeding tube was unsecured and contained a dark brown, black substance, which was confirmed by the LPN and the Nurse Practitioner to potentially cause an infection. The facility's policy on the care and treatment of feeding tubes, dated January 2024, outlines the necessity for licensed nurses to monitor and verify the placement of feeding tubes, ensure securement, and check the insertion site for potential complications. However, the facility staff failed to adhere to these protocols, as evidenced by the lack of securement and the presence of a potentially infectious substance in the feeding tube. The Director of Nursing confirmed that the staff should have contacted the resident's practitioner for care and treatment orders, highlighting a significant oversight in the management of the resident's feeding tube care.
Failure to Evaluate Dialysis Access Site
Penalty
Summary
The facility staff failed to evaluate a dialysis access site for a resident who required dialysis services. The resident, identified as Resident 177, had multiple medical conditions including End Stage Renal Disease, dependence on renal dialysis, and a history of heart transplant with long-term use of immunosuppressive biologics. The resident's medical orders required a dialysis pre-observation and post-observation to be completed on specific days, but these were not documented in the resident's electronic health record for the dates in question. Observations and interviews revealed that the nursing staff, including LPNs A, B, and C, were unaware of the exact location and condition of the resident's dialysis access sites. LPN C confirmed that they had not assessed the resident's femoral access device correctly and had not noticed it had three lumens. Additionally, LPNs A and B did not know where the dialysis access site was located on the resident. This lack of awareness and assessment led to the failure to complete the required pre and post dialysis observation forms. The Director of Nursing confirmed that it was expected for floor nurses to perform complete assessments of residents, including identifying unused dialysis catheters. The facility's special needs policy and dialysis transportation policy required that medical conditions be monitored and managed to prevent complications, and that fistula/shunt sites be checked every shift for signs of issues. However, these policies were not followed, resulting in the deficiency noted in the report.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that the medication regimen for a resident was free from unnecessary drugs, specifically related to the administration of Midodrine, a medication used to treat orthostatic hypotension. The resident, who had a diagnosis of orthostatic hypotension, diabetes, bipolar disorder, and a left below-the-knee amputation, was prescribed Midodrine with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 120. However, the medication was administered multiple times despite the resident's SBP being above the prescribed threshold, indicating a failure to follow the physician's orders. The Director of Nursing confirmed that the medication was given when it should have been held, resulting in unnecessary medication use. The facility's policy on Medication Regimen Review (MRR) emphasizes the importance of preventing, identifying, and resolving medication-related problems, including ensuring that each resident's drug regimen is free of unnecessary drugs. Despite this policy, the facility did not adhere to the prescribed parameters for administering Midodrine, leading to the deficiency identified in the survey.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to perform hand hygiene adequately to prevent cross-contamination during skin care for a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) resistance and a history of Methicillin Resistant Staphylococcus Aureus Infection (MRSA). The resident, who was cognitively intact, did not have Enhanced Barrier Precautions (EBP) signage outside their door, and the nursing aide did not perform hand hygiene between cleaning different areas of the resident's abdominal fold. Additionally, the facility did not secure oxygen tubing properly to prevent potential cross-contamination for two residents. Observations revealed that the oxygen tubing for these residents was either wrapped around the concentrator or left on the floor, without being placed in a bag when not in use. The Director of Nursing confirmed that the tubing should have been stored in a bag to prevent contamination. Furthermore, the facility failed to utilize personal protective equipment (PPE) appropriately for a resident on Enhanced Barrier Precautions during wound care. Despite the presence of a sign indicating EBP and a cart with gowns and gloves, the LPN did not wear a gown while performing wound care on a resident with a pressure ulcer. The LPN acknowledged that a gown should have been worn during the procedure, as confirmed by the Director of Nursing.
Failure to Notify Provider of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify the medical provider of blood sugar levels that were outside of the specified parameters for one resident. The resident had a diagnosis of hyperglycemia and had orders to notify the provider if blood sugar levels were greater than 400 or less than 70. Despite multiple instances of blood sugar readings outside these parameters, the facility only documented notifying the provider on two occasions. Additionally, the resident's insulin administration times were altered without notifying the provider, and insulin doses were held based on nursing judgment without proper documentation or provider notification. A review of the resident's Medication Administration Record (MAR) revealed several instances where blood sugar levels exceeded 400 or dropped below 70, yet there was no documentation of provider notification. The resident's blood sugar levels were recorded as high as 535 and as low as 62 on various dates, but the provider was only notified on two specific dates. The facility's policy required timely communication with the physician for changes in a resident's condition, including extreme blood sugar levels, but this was not consistently followed. The Director of Nursing (DON) confirmed that there was no documentation of provider notification for the majority of the high and low blood sugar readings. The night nurse had held the resident's midnight insulin doses based on nursing judgment without notifying the provider. The facility's policies on notifying physicians of condition changes and administering medications were not adhered to, leading to a deficiency in the standard of care provided to the resident.
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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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