Florence Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 7915 North 30th Street, Omaha, Nebraska 68112
- CMS Provider Number
- 285173
- Inspections on file
- 18
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Florence Home during CMS and state inspections, most recent first.
A resident reported to an LPN that a nurse aide had thrown them against the wall, but the LPN did not immediately report the allegation to the DON or remove the accused aide from duty. The aide continued to work on the same hall, potentially affecting other residents, in violation of the facility's abuse prevention policy.
A resident alleged that a nurse aide physically abused them, but the assigned LPN did not immediately report the incident to the DON or remove the aide from duty. The DON only learned of the allegation the next day through documentation, and the aide continued to work with other residents during the shift, contrary to facility policy requiring immediate reporting and intervention.
A resident with a physician order to hold Midodrine if systolic blood pressure (SBP) was above 120 received the medication multiple times when their SBP exceeded this threshold. The DON confirmed the medication should have been held, and facility policy requires staff to follow such orders, but this was not done, resulting in a medication discrepancy.
The facility failed to properly seal, label, and date food items in storage, and did not maintain cleanliness in the kitchen, as observed during a survey. Numerous unlabeled and undated food items were found, and the kitchen had unclean equipment and fixtures. The Dietary Manager confirmed these deficiencies, and cleaning records showed incomplete adherence to the cleaning schedule.
The facility failed to ensure proper infection control practices in COVID-19 isolation rooms. Staff did not don the correct PPE, failed to doff PPE inside isolation rooms, and left room doors open. Additionally, hand hygiene was not performed during glove changes while providing peri-care to two residents. The Director of Nursing confirmed these practices were not in line with facility policies.
A facility failed to update the care plan for a resident on NPO status, who was dependent on a g-tube for nutrition due to a stroke, aphasia, and dysphagia. The care plan included inappropriate interventions such as meal assistance and snacks, which were not applicable. The DON confirmed the care plan was confusing and did not reflect the resident's needs.
A resident with multiple medical conditions, including Parkinson's and chronic heart failure, was not placed on the Restorative Nursing Program (RNP) despite recommendations from OT and PT. The resident, who had impairments in range of motion, was not receiving any assistance with exercises, as confirmed by observations and interviews. The Director of Nursing admitted the oversight, and facility records did not show the resident was on the RNP.
A resident with multiple chronic conditions and a recent urinary tract infection did not receive the required catheter care as per physician orders and care plans. Despite preparations by an LPN and NA to perform catheter care, the task was not completed, as confirmed by the LPN.
The facility's admission policy failed to ensure it did not waive liability for losses of residents' personal property. The policy, acknowledged and signed by residents or their representatives, stated that the home would not be liable for any loss or damage to personal property. This deficiency had the potential to affect all 77 residents.
Failure to Remove Accused Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect residents from potential abuse when an employee accused of abuse by a resident was allowed to continue working their shift. Specifically, a resident reported to an LPN that they did not want a particular nurse aide to provide care because the aide allegedly threw them against the wall. The LPN assigned another staff member to care for the resident for the remainder of the evening but did not immediately report the allegation to the Director of Nursing (DON) or send the accused aide home. The DON only became aware of the incident the following day after reading the progress notes and confirmed that the LPN had not followed the facility's abuse policy, which requires immediate intervention and reporting of abuse allegations. The accused nurse aide continued to work on the 200 hall, covering multiple rooms and potentially affecting several residents during the shift in question. The facility's abuse policy outlines the need for immediate action to protect residents and prevent further abuse while an investigation is conducted, but this protocol was not followed. The DON acknowledged that the LPN received only undocumented verbal education regarding the reporting process after the incident, and there was no evidence of immediate intervention or removal of the accused staff member from resident care duties at the time of the allegation.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe. On the evening in question, a resident stated they did not want a particular nurse aide to provide care, alleging that the aide had thrown them against the wall. The assigned LPN reassigned another employee to care for the resident for the remainder of the evening but did not immediately notify the Director of Nursing (DON) about the allegation. The DON only became aware of the incident the following day after reading the resident's progress notes and subsequently contacted the LPN for a verbal report. The nurse aide in question continued to work their assigned shift and was not removed from duty after the allegation was made. The facility's abuse policy requires immediate intervention, reporting to proper authorities, and prevention of further potential abuse while an investigation is in process. However, the LPN did not follow these procedures, as they neither reported the incident to management immediately nor removed the accused aide from resident care. The DON confirmed that the LPN had only received undocumented verbal education regarding the need to report such incidents promptly. The nurse aide had access to multiple residents during the shift in question, potentially affecting other individuals in the facility.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
Facility staff failed to follow physician orders regarding the administration of Midodrine for a resident who required extensive assistance with daily activities and had a pressure ulcer. The resident's medication order specified that Midodrine 5 mg should be held if the systolic blood pressure (SBP) was above 120. However, medication administration records for August and September showed that the drug was administered multiple times when the resident's SBP exceeded the prescribed threshold. The Director of Nursing confirmed that the medication should have been held on the identified dates when the SBP was above 120, as per the physician's order. Facility policy requires staff to follow physician and non-physician provider orders, and failure to do so may result in a medication discrepancy. The report documents that the staff did not adhere to these guidelines, resulting in the administration of unnecessary medication.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure that all food items in the refrigerators, freezers, and dry storage were properly sealed, labeled, and dated, as observed during a survey. The survey revealed numerous unlabeled and undated food items, including chocolate-covered cakes, mixed vegetables, breaded items, various substances in steam pans, and several other food items in both the walk-in refrigerator and freezer. The Dietary Manager confirmed that these items should have been sealed, labeled, and dated according to the facility's guidelines. Additionally, the facility did not maintain cleanliness in the kitchen, as evidenced by observations of unclean equipment and fixtures. The ice maker had a gray fuzzy substance and a black slimy substance, the steam table had a brown crusty substance, and the toaster had crumbs. The walk-in freezer floor was sticky, and various kitchen appliances and surfaces had food splatters and sticky residues. The Dietary Manager acknowledged that these areas were not clean and should have been maintained according to the facility's cleaning checklists. The facility's cleaning records indicated that several cleaning tasks were not completed as required. The Cooks Weekly Clean List showed that essential cleaning tasks, such as sweeping and mopping the storeroom, cleaning underneath shelves, deliming the steam table, and cleaning the hot box, ovens, and ice machine, were either not done or only partially completed. The Dietary Manager confirmed the lack of adherence to the cleaning schedule, which contributed to the unsanitary conditions observed during the survey.
Infection Control Deficiencies in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in COVID-19 isolation rooms. Observations revealed that staff did not don the correct personal protective equipment (PPE) and failed to doff gowns and gloves inside the resident's COVID-19 isolation rooms. Specifically, a Nursing Assistant and a Unit Manager were observed exiting isolation rooms while still wearing PPE and disposing of it in the hallway, contrary to the facility's policy that required PPE to be removed inside the room. Additionally, a Nursing Assistant was seen entering a COVID-19 isolation room with a surgical mask instead of the required N-95 mask, and the Director of Nursing confirmed that PPE should have been removed before exiting the room. The facility also did not ensure that COVID-19 isolation room doors remained closed. Multiple observations noted that staff left the doors open after exiting the rooms, and one instance involved a resident taking a nebulizer treatment with the door partially open. The facility's Administrator confirmed that staff were expected to keep the doors closed when not entering or exiting. Furthermore, the facility did not ensure proper hand hygiene during glove changes while performing peri-care on two residents. Observations showed that Nursing Assistants changed gloves multiple times without performing hand hygiene in between, despite the facility's policy requiring hand hygiene with each glove change. Interviews with the Nursing Assistants and the Director of Nursing confirmed that hand hygiene should have been performed with every glove change.
Failure to Revise Care Plan for NPO Resident
Penalty
Summary
The facility failed to revise the care plan for a resident who was on NPO (nothing by mouth) status. The resident, who had a history of a stroke affecting his dominant side, aphasia, and dysphagia, was admitted on 2/21/2024 and was unable to complete the Brief Interview of Mental Status due to communication difficulties. The resident was entirely dependent on a gastrointestinal tube for nutrition and medication due to his inability to swallow. Despite this, the care plan dated 5/8/2024 included interventions such as assisting with meals, monitoring meal intake, and providing snacks and supplements, which were inappropriate for a resident on NPO status. The Director of Nursing confirmed that the care plan interventions were confusing and not applicable to the resident's needs, as the resident did not eat meals, did not require assistance at mealtimes, and would not be given snacks or supplements. The care plan failed to accurately reflect the resident's nutritional needs and the method of feeding, which was entirely through a g-tube. This oversight in updating the care plan to match the resident's current medical status and needs constituted a deficiency in the facility's care planning process.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 30, was placed on the Restorative Nursing Program (RNP) following discharge and recommendations from Occupational Therapy (OT) and Physical Therapy (PT). Despite being identified as a candidate for the RNP based on therapy referrals and facility screenings, Resident 30 was not enrolled in the program. The resident had a history of several medical conditions, including encephalopathy, Parkinson's disease with dyskinesia, epilepsy, chronic diastolic heart failure, chronic kidney disease stage 3, and morbid obesity. The resident's Minimum Data Set (MDS) indicated cognitive awareness and dependence on staff for various activities, with impairments in range of motion (ROM) on one side of the upper and lower extremities. Observations and interviews revealed that Resident 30 had difficulty moving both upper and lower extremities and was not receiving any OT, PT, or staff assistance with exercising the extremities. The resident confirmed willingness to perform the exercises if offered. The Director of Nursing acknowledged that Resident 30 was not placed on the RNP as recommended by OT and PT, which was a failure on the facility's part. The facility's records, including the resident's electronic medical record and hard chart, did not indicate that the resident was receiving the RNP, highlighting a lapse in implementing the recommended care plan.
Failure to Provide Catheter Care for a Resident
Penalty
Summary
The facility staff failed to provide appropriate catheter care for a resident, leading to a deficiency in care. The resident, who was admitted to the facility following orthopedic surgery, had a history of chronic kidney disease, chronic atrial fibrillation, diabetes mellitus, spinal stenosis with prior spinal fusion, and chronic diastolic congestive heart failure. The resident was noted to be always incontinent of bladder and bowel, and a urinary tract infection caused by Klebsiella pneumoniae was identified. Despite physician orders and care plans indicating the need for catheter care twice daily, observations revealed that catheter care was not performed as required. On a specific observation, a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA) were seen preparing to perform catheter care for the resident. Although they gathered the necessary supplies and began personal care tasks, they failed to complete the catheter care. An interview with the LPN confirmed that catheter care had not been completed for the resident, highlighting a lapse in following the established care protocol for catheter maintenance.
Facility's Admission Policy Waives Liability for Residents' Personal Property
Penalty
Summary
The facility failed to ensure its admission policy did not waive the potential liability for losses of a resident's personal property for three residents. The facility's Admission Agreement and Personal Property policy, both revised in January 2024, explicitly stated that the home would not be liable for loss or damage to any personal property belonging to the residents. This policy was acknowledged and signed by the residents or their representatives upon admission. During an interview, the Social Services confirmed that the facility's policies indeed waived the liability of the facility for losses of residents' personal property. This deficiency had the potential to affect all 77 residents in the facility.
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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