Eventide Prairie Commons Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Island, Nebraska.
- Location
- 3490 Ewoldt Street, Grand Island, Nebraska 68803
- CMS Provider Number
- 285307
- Inspections on file
- 11
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eventide Prairie Commons Care Center during CMS and state inspections, most recent first.
Two residents had discrepancies between their signed advance directives and the code status listed in the EMR, care plans, and staff reference materials. Staff relied on inconsistent sources to determine code status, leading to confusion and the potential for care that did not align with residents' wishes. The issue was confirmed by nursing leadership and involved residents with complex medical histories.
The facility exceeded the acceptable medication error rate, with multiple errors involving late administration and omission of medications. Errors occurred when an LPN administered a Parkinson's medication late to a resident, gave all morning medications late to another due to incorrect EMAR times, and failed to give a scheduled dose of pantoprazole to a third resident. Staff and pharmacy were aware of the EMAR timing issues but did not correct them promptly, resulting in a high error rate.
An LPN assisted multiple residents during meal service, including helping a resident who eats with their hands and handling soiled clothing protectors, without performing hand hygiene between contacts. The LPN only used alcohol-based hand sanitizer after assisting several residents, contrary to facility policy, as confirmed by interviews with the ADON and the LPN.
Two residents were not given the required SNF ABN (CMS-10055) and NOMNC (CMS-10123) forms when discharged from Medicare Part A skilled services, despite having benefit days remaining. Facility staff could not locate documentation of these notices, and interviews revealed that changes in social services contributed to lapses in providing the required notifications.
A resident with an unstageable pressure ulcer on the left heel did not have required weekly wound evaluations and measurements documented in the EMR, despite facility policy and care plan directives. Multiple record reviews and staff interviews confirmed the absence of necessary wound assessment documentation, preventing proper monitoring of the wound's healing status.
A resident with multiple health conditions experienced delays in call light response and did not receive routine bathing as per their preference and facility standards. The resident waited 23 minutes for assistance, and records showed only two baths or showers in a month. The facility lacked a standard for call light response times, and the DON confirmed the resident did not receive weekly bathing as required.
A resident with multiple diagnoses received Digoxin without proper pulse monitoring, contrary to physician orders, and insulin pens were improperly labeled and primed. The Medication Aide and LPN failed to follow required procedures, as confirmed by the DON.
The facility failed to use recipes during meal preparation, affecting all residents who ate food prepared by the kitchen. Cook-A prepared a substituted soup without a visible recipe, relying on memory and making unauthorized ingredient changes. The DM confirmed that recipes must be approved by a remote RD, but no recipe was available at the time of observation.
The facility failed to maintain required food temperatures during meal service and did not remove foods stored beyond 7 days, affecting all 18 residents. The Certified Dietary Manager acknowledged the difficulty in maintaining appropriate temperatures and the need for more staff education. Additionally, the walk-in refrigerator contained items stored beyond the facility's policy limit.
The facility failed to store medications by route, administer eye drops correctly, and ensure accurate narcotic counts. An MA-C stored inhalation and topical medications with oral ones, administered eye drops incorrectly, and an LPN found a discrepancy in a controlled substance count.
The facility failed to document advanced directives and obtain physician signatures for two residents regarding their DNR status. This led to confusion and inappropriate medical interventions, including EMS performing CPR on a resident who was identified as DNR but lacked the necessary signed documentation.
The facility failed to honor a resident's preference for two baths per week, providing only one bath since admission. Despite the resident's care plan and documented preferences, the facility did not adhere to the requested bathing frequency, as confirmed by interviews with staff and the resident's spouse.
The facility failed to ensure routine bowel movements for a resident with severe cognitive impairment by not following the established Bowel Care Protocol. Despite the resident going multiple days without a bowel movement, required interventions were not documented or administered.
The facility failed to update or change fall prevention interventions for a resident with multiple falls, despite having a policy requiring care plan updates after each fall. The resident, with severe cognitive impairment and multiple diagnoses, continued to be at risk due to the lack of effective fall prevention measures.
The facility failed to ensure that medications used together for a resident did not lead to adverse consequences and that all medications had adequate indications for use with an appropriate diagnosis code. The resident was prescribed Trazodone and Buspirone, which can cause drowsiness and potentially lead to serotonin syndrome. Despite monthly reviews, there was no evidence of a review for reduction or discontinuation of these drugs. The resident did not have a diagnosis of major depressive disorder, which is a primary indication for Trazodone. Observations and interviews revealed the resident was frequently drowsy, had a significant decrease in food intake, and showed little interest in activities, suggesting the medications may have contributed to these issues.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that the code status for life-saving measures, including CPR, was accurately documented and consistently reflected for all residents, as required by policy and regulation. Specifically, for two residents, the electronic medical record (EMR), care plans, and physical indicators (such as door stickers and staff pocket care plans) did not match the residents' signed advance directives or physician orders. In one case, a resident who had a signed directive requesting full code status (CPR to be performed) was listed as Do Not Resuscitate (DNR) in the EMR and had a red dot on the door indicating DNR, while the daily staff pocket care plan listed the resident as full code. In another case, a resident who had a signed DNR order and advance directive was listed as full code in the EMR and on the staff pocket cheat sheet, contrary to the resident's wishes and physician's order. Interviews with staff revealed inconsistent knowledge and practices regarding how to verify and act on residents' code status. Medication aides and nurses relied on various sources, such as EMR, door stickers, and pocket care plans, but these sources were not always accurate or up to date. Some staff did not routinely check the code status before acting in an emergency, and there was confusion about which source was definitive. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that discrepancies existed between the signed code status documents and what was recorded in the EMR and other reference materials used by staff. The affected residents had significant medical histories, including conditions such as Parkinson's disease, diabetes, heart disease, and a history of heart attack. One resident was legally blind and had cognitive impairment, while the other had a history of cardiac issues and cancer. Both residents had clearly expressed their wishes regarding resuscitation, but the facility's failure to accurately document and communicate these wishes across all systems and to all staff created a situation where staff could have provided care that was contrary to the residents' directives.
Medication Error Rate Exceeds 5% Due to Late and Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 37.04% error rate based on 27 opportunities with 10 errors. Errors included administering medications at the wrong time and omitting doses. For one resident with Parkinson's Disease, carbidopa/levodopa was scheduled for specific times but was administered late and not properly documented. Another resident had all morning medications scheduled for 6:00 AM, but these were administered late due to incorrect times in the electronic medication administration record (EMAR), which staff acknowledged had not been updated to reflect the facility's standard medication administration window. A third resident did not receive a scheduled dose of pantoprazole at the specified time because they had not yet come to the dining room for breakfast. Staff interviews confirmed awareness of the discrepancies between scheduled and actual administration times, as well as the inability to update the EMAR without pharmacy intervention. The Assistant Director of Nursing and the consulting pharmacist both acknowledged that the medications were given late according to the EMAR, and that the issue with incorrect times should have been addressed sooner. These actions and inactions led to multiple medication errors affecting at least three residents, in violation of the facility's medication error policy.
Failure to Perform Hand Hygiene Between Resident Contacts During Meal Assistance
Penalty
Summary
During a survey, it was observed that a Licensed Practical Nurse (LPN) failed to perform hand hygiene between assisting multiple residents during breakfast in the dining room. The LPN assisted one resident who frequently eats with their hands, then proceeded to assist several other residents, including helping with clothing protectors and touching residents' shoulders, without using alcohol-based hand sanitizer (ABHS) or washing hands between contacts. The LPN only used ABHS after assisting several residents and then continued to assist more residents before using ABHS again. A review of the facility's Hand Hygiene policy indicated that hand hygiene is required in all situations, especially when handling food or assisting residents, and that supplies are to be readily accessible. Interviews with the Assistant Director of Nursing (ADON) and the LPN confirmed that hand hygiene was not performed between resident contacts, and the LPN stated they did not have their usual personal bottle of ABHS that day. The deficiency had the potential to affect all nine sampled residents who were assisted during the meal.
Failure to Provide Required Medicare Beneficiary Notices Upon Discharge from Skilled Services
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to two residents who were discharged from Medicare Part A skilled services. For one resident, Medicare Part A skilled services began on 10/16/2024 and ended on 01/01/2025 due to a facility-initiated discharge. Although the resident remained in the facility and had additional benefit days available, the facility did not provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) to inform the resident that Medicare would no longer pay for their services. Staff explained that the resident did not indicate a desire to continue therapy at the time, but no documentation of the required notice was found. Similarly, another resident began Medicare Part A skilled services on 10/17/2024 and was discharged from these services on 11/20/2024, also through a facility-initiated process with benefit days remaining. The facility did not provide the SNF ABN, Form CMS-10055, nor the Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123), which is required to inform beneficiaries of their right to appeal the termination of Medicare coverage. Staff interviews confirmed that documentation for these notices could not be located, and the Assistant Administrator acknowledged that changes in social services had led to lapses in required documentation.
Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer was evaluated and monitored at least weekly, as required by both facility policy and regulatory standards. The resident in question had an unstageable pressure ulcer with eschar on the left heel that was present upon admission. The care plan specified that the location, size, and treatment of the skin injury should be monitored and documented, with weekly treatment documentation to include measurements and descriptions of the wound. Despite these requirements, multiple record reviews revealed a lack of documentation regarding the evaluation, measurement, or description of the left heel pressure ulcer. The electronic medical record, skin checks, total body skin assessments, progress notes, and medication administration records all failed to include the necessary details about the wound's size or condition. Observations confirmed the ongoing presence of the wound, but there was no evidence that staff had completed or recorded the required weekly assessments. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that the expected documentation was missing. The DON acknowledged that there was no documentation of evaluations or measurements for the resident's left heel wound, despite the facility's policy and the ongoing presence of the unhealed pressure ulcer.
Failure to Respond to Call Lights and Provide Routine Bathing
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, as observed on multiple occasions. The resident, who was cognitively intact and had a history of multiple sclerosis, malnutrition, type 2 diabetes, neurogenic bladder, and enterocolitis due to clostridium difficile, was seen waiting in their wheelchair beside their bed with the call light activated. Despite the call light being on, the resident reported having to wait long periods for assistance, including a specific instance where the call light was activated for 23 minutes before being answered. The facility's Assistant Director of Nursing confirmed that there was no set standard for call light response times, but acknowledged that 23 minutes was longer than expected. Additionally, the facility did not ensure that the resident received routine bathing as per their preference and the facility's standard. The resident expressed a preference for bathing or showering twice a week upon admission, but records showed that they only received a bath or shower twice in a month-long period. The Director of Nursing confirmed that the facility's standard was for residents to receive a choice of bathing at least weekly, and acknowledged the lack of documentation indicating that the resident did not receive weekly bathing as outlined in the facility's Resident Handbook. These deficiencies highlight the facility's failure to provide timely assistance for activities of daily living and to adhere to their own standards for resident care. The resident's needs for assistance with bathing and timely response to call lights were not met, as evidenced by the observations and interviews conducted during the survey.
Medication Administration and Insulin Pen Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for Resident 1, who was admitted with diagnoses including hypertensive heart disease, type 2 diabetes, and atrial fibrillation. The resident's care plan required diabetic medication as ordered by the physician. During an observation, a Medication Aide (MA-B) administered Digoxin to the resident without obtaining an apical pulse as required by the physician's order. The MA-B used an electronic pulse oximeter and recorded a pulse of 59 beats per minute, which should have prompted the medication to be held and the provider notified, as per the order. However, the medication was administered, and the MA-B was unaware of the requirement to hold the medication for a pulse below 60 beats per minute. Additionally, the facility failed to ensure proper labeling and priming of an insulin pen for Resident 1. During an observation, an LPN used an insulin pen that was not labeled with the resident's identification, pharmacy label, expiration, or open date. The LPN confirmed that the insulin pens were not labeled correctly and should have been discarded. Furthermore, the LPN did not follow the manufacturer's recommendation or facility policy for priming the insulin pen, which required dialing two units and pressing the button to shoot insulin into the air. Instead, the LPN turned the dial randomly and depressed the plunger until insulin appeared. The Director of Nursing (DON) confirmed that the insulin pens should be properly labeled with the resident's information and open or discard date before use. The DON also confirmed that the LPN did not follow the correct procedure for priming the insulin pen. These deficiencies highlight the facility's failure to ensure that medications are administered according to physician orders and manufacturer guidelines, potentially compromising resident safety.
Failure to Use Recipes During Meal Preparation
Penalty
Summary
The facility failed to use recipes during meal preparation to ensure the nutritional adequacy of dishes served, affecting all residents who ate food prepared by the facility kitchen. During an observation, Cook-A was seen preparing a substituted soup of the day, Ham and Beans, without a visible recipe. The Certified Dietary Manager (DM) confirmed that recipes are generated from their Dining Manager computer program and must be approved by a remote Registered Dietician (RD). However, no recipe for the Ham and Beans soup was available at the time of observation, and the cook relied on memory to prepare the dish. Additionally, the weight and amount of diced ham were not measured, and the soup included ingredients not listed in the original recipe, such as carrots. Further interviews revealed that the facility uses a remote RD who visits every six months, with weekly remote calls. The DM stated that the facility is continually evolving due to frequent changes in resident census, requiring constant adjustments in the kitchen. The DM also mentioned that Cook-A is undergoing DM training. A record review indicated that the recipe for Ham and Bean soup served previously had unauthorized substitutions and additions, and the recipe had not been updated to reflect these changes. The DM confirmed that Cook-A did not follow a printed recipe, leading to the deficiency.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to ensure that foods were maintained at the required temperatures to prevent foodborne illnesses during meal service and did not remove and destroy foods that were in the refrigerator longer than 7 days. During an observation in the satellite kitchen of the LTC area, it was noted that the temperature of the turkey ham and cheese sandwich alternative was 135 degrees Fahrenheit, which is the minimum required temperature. However, by the end of the meal distribution, the temperature had dropped to 131 degrees Fahrenheit. The Certified Dietary Manager (DM) acknowledged the difficulty in maintaining the appropriate temperatures and indicated a need for more education on this matter. Additionally, during an inspection of the walk-in refrigerator, items such as sausage, mashed potatoes, and apples were found to be stored beyond the 7-day limit, contrary to the facility's policy of refrigerating leftovers for no longer than 3 days. The DM confirmed that the facility follows the leftover guidelines for food safety, but the observation revealed non-compliance. The DM also noted that some teaching had been done with the staff regarding maintaining temperatures and food storage. Despite this, the walk-in areas had not been cleaned or swept, indicating a lapse in maintaining cleanliness and proper food storage practices. These deficiencies had the potential to affect all 18 residents who consumed food from the facility kitchen.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to store medications administered by different routes separately for one resident. During a medication pass observation, a Medication Aide (MA-C) was seen retrieving both inhalation and topical medications from the same drawer as oral medications. The MA-C confirmed that these medications should be stored separately by route, as per the facility's policy. Additionally, the facility failed to administer eye drops following current professional standards of care for another resident. The MA-C incorrectly administered the eye drops by pulling up on the upper eyelid and placing the drop on the eyeball at the inner corner of the eye, instead of pulling down on the lower eyelid and instilling the drop close to the outer corner of the eye, as per the facility's policy on ophthalmic eye drop administration. The facility also failed to ensure accountability of a controlled substance for one resident. An LPN was observed preparing to administer a controlled substance liquid and found a discrepancy in the narcotic count. The LPN noted that the amount of medication in the bottle did not match the recorded amount in the narcotic record book. The Director of Nursing (DON) confirmed the discrepancy, noting that the amount of medication in the bottle was less than what was documented. The facility's policy requires accurate documentation and verification of controlled substances, which was not adhered to in this instance.
Failure to Document Advanced Directives and Obtain Physician Signatures
Penalty
Summary
The facility failed to obtain and document the advanced directives for two residents regarding their code status. For Resident 61, the facility did not have a completed Advanced Directives form or a signed Physician's Do Not Resuscitate (DNR) Order. This led to confusion when Resident 61 was found unresponsive and not breathing. Despite the nurse identifying the resident as DNR, Emergency Medical Services (EMS) initiated CPR due to the absence of a signed DNR form, and Resident 61 was transported to the hospital where they later died. Interviews with the Social Services Director, Assistant Administrator, and Director of Nursing confirmed the absence of the necessary documentation for Resident 61's DNR status. For Resident 68, the facility had a Physician's Do Not Resuscitate (DNR) Order form signed by the resident but lacked the physician's signature. Despite having an active physician order for DNR in the medical records, the absence of the physician's signature on the DNR form meant that the resident's wishes were not fully documented. The Director of Nursing confirmed the missing physician signature during an interview. These deficiencies highlight the facility's failure to properly document and honor residents' advanced directives, specifically regarding their code status. The lack of signed physician orders for DNR in both cases resulted in potential miscommunication and inappropriate medical interventions, as evidenced by the events involving Resident 61 and Resident 68.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of Resident 71, who was admitted on 05/01/2024. Resident 71, with a BIMS score of 10 indicating mild cognitive impairment, expressed a preference for two baths per week, which was confirmed by both the resident and their spouse during an interview. However, a review of the resident's bathing task report and progress notes revealed that only one bath was documented since admission, with no records of refusals or additional baths provided. The resident's care plan also indicated a need for two baths per week, but this was not adhered to by the facility staff. Interviews with the Bath Aide and the Director of Nursing revealed that the facility's process for documenting and following resident preferences was not effectively implemented. The Bath Aide confirmed that Resident 71 had only received one bath since admission, and the Director of Nursing acknowledged that preferences are documented on a personal preference sheet and a bathing schedule, but there was no policy in place to ensure these preferences were consistently followed. The lack of proper documentation and adherence to the resident's care plan led to the failure in providing the requested bathing frequency for Resident 71.
Failure to Follow Bowel Care Protocol
Penalty
Summary
The facility failed to ensure routine bowel movements for Resident 2, who had severe cognitive impairment and required substantial assistance with daily activities. Despite having a Bowel Care Protocol in place, the facility did not follow the protocol for Resident 2, who went multiple days without a bowel movement on several occasions in April 2024. The protocol required specific interventions after three days without a bowel movement, but these interventions were not documented or administered for Resident 2. Interviews with the Registered Nurse and the Director of Nursing confirmed that the facility's bowel protocol was not followed. The night shift was responsible for creating a list of residents who had not had a bowel movement in three days, and the day shift was supposed to administer the necessary interventions. However, Resident 2 was listed as not having a bowel movement for five days, and no interventions were documented in the medication administration record or progress notes for the entire month of April 2024.
Failure to Update Fall Prevention Interventions
Penalty
Summary
The facility failed to update or change interventions to prevent falls for one resident, identified as Resident 2, who had multiple falls. Resident 2, admitted with diagnoses including dementia, mood disturbance, anxiety, type 2 diabetes, muscle weakness, and pain, had a severe cognitive impairment and required substantial assistance with daily activities. Despite having documented falls on 12/11/2023, 01/27/2024, 02/17/2024, and 02/26/2024, the facility did not update the resident's care plan with new or changed interventions to prevent further falls. Observations on 04/29/2024 and 04/30/2024 showed Resident 2 in precarious positions in bed, indicating a lack of effective fall prevention measures. Interviews with staff, including a Medication Aide, Registered Nurse, MDS Coordinator, and Director of Nursing, confirmed that fall prevention interventions were not adequately updated on the care plan after each fall. The facility's policy required the care plan to be reviewed and updated after each fall, but this was not done for Resident 2. The Post-Fall Checklist dated 02/12/2023 also indicated that the care plan should be updated with new interventions and goals after a fall. Despite these requirements, the care plan for Resident 2 did not reflect new or changed interventions after the falls, and the interventions documented were already present on the care plan. This failure to update the care plan with new interventions after each fall contributed to the continued risk of falls for Resident 2.
Failure to Ensure Safe Medication Use and Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that medications used together for Resident 3 did not lead to adverse consequences and that all medications had adequate indications for use with an appropriate diagnosis code. Resident 3 was prescribed Trazodone and Buspirone, both of which can cause drowsiness and have the potential to lead to serotonin syndrome when used together. Despite being reviewed monthly for gradual dose reductions, there was no evidence that these two drugs were reviewed for reduction or discontinuation. Additionally, Resident 3 did not have a diagnosis of major depressive disorder, which is a primary indication for Trazodone use, as per the order summary and Minimum Data Set (MDS) records. The resident's diagnosis was listed as dementia with mood disturbances, insomnia, restlessness, and agitation, but not major depressive disorder. This discrepancy indicates a lack of appropriate diagnosis for the prescribed medication. Observations and interviews revealed that Resident 3 was frequently drowsy, slept a lot, and had a significant decrease in food intake, leading to weight loss. The resident's spouse confirmed that Resident 3 had stopped eating and required assistance with drinking water. The resident was observed to be sleeping frequently, both in bed and in a wheelchair, and showed little interest in activities. These observations suggest that the medications may have contributed to the resident's lethargy and decreased appetite, further highlighting the need for a thorough review of the drug regimen. The facility's failure to review and adjust the medications appropriately for Resident 3, considering the potential adverse interactions and the lack of a proper diagnosis for Trazodone, led to the deficiency noted in the report.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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