Garden County Hospital & Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Oshkosh, Nebraska.
- Location
- 1100 West 2nd St, Oshkosh, Nebraska 69154
- CMS Provider Number
- 28E180
- Inspections on file
- 13
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Garden County Hospital & Nursing Home during CMS and state inspections, most recent first.
Two residents experienced significant weight loss due to the facility's failure to implement dietary recommendations and conduct timely assessments. One resident lost 15.83% of their weight over two months, while another lost 13.5% over six months. The facility did not update care plans or notify physicians, and lacked a nutrition policy.
The facility was found deficient in food handling, hygiene, and sanitation practices. Observations revealed expired and unlabeled food items, improper use of beard restraints, and inadequate hand hygiene during meal preparation and service. Additionally, the kitchen environment was unsanitary, with flies present and food preparation surfaces not being sanitized between tasks. These deficiencies had the potential to affect all 26 residents.
The facility failed to follow infection control practices during wound care for a resident with a pressure ulcer, as an LPN did not use a gown and improperly handled treatment supplies. Additionally, a laundry aide left the laundry cart open during distribution, risking cross-contamination, and placed laundry between their legs while performing hand hygiene.
The facility failed to protect private medical information for four residents, as their names were visible on medication containers from a public hallway window. This was confirmed by an LPN, violating the facility's policy on resident privacy.
A resident was not served their lunch meal simultaneously with their table mates, leading to a delay while they watched others eat. This was confirmed by an interview with a cook, who stated that all residents should be served at the same time.
Two residents experienced significant weight loss without their physicians being notified, as required by facility policy. One resident lost 13.5% of their weight over several months, while another lost over 8% in one month and an additional 8.2% the following month. Interviews confirmed the lack of notification to the physicians.
A facility failed to evaluate a resident's ability to remove a gait belt used as a physical restraint. Despite policy stating restraints should be a last resort and require a physician's order, the resident was not assessed for their ability to remove the belt. Observations confirmed the belt's use, and staff interviews revealed the lack of assessment.
The facility failed to develop comprehensive care plans for two residents, both requiring significant assistance with ADLs. Despite assessments indicating the need for total or substantial assistance, the care plans lacked specific details on the level of assistance required. An interview with the MDS Coordinator confirmed the care plans were not comprehensive or person-centered.
A resident with multiple diagnoses, including Congestive Heart Failure and Celiac Disease, experienced a significant weight loss of 13.5% over six months. Despite a dietician's recommendation to start Ensure Clear supplements, the facility did not update the care plan to include this intervention. The MDS Coordinator confirmed the oversight.
The facility failed to implement a physician-ordered ACE wrap for a resident with edema and improperly administered hypertension medication to another resident, despite specific instructions to hold the medication if systolic blood pressure was below 110. The DON confirmed these errors.
A resident's oxygen concentrator was left on and running at 3 LPM while the resident was not in their room, contrary to physician's orders and without specific guidance in the facility's policy. The MDS Coordinator confirmed the observation, highlighting a deficiency in ensuring a safe environment.
A resident with a history of UTIs and an indwelling catheter was prescribed Cephalexin prophylactically without a stop date, contrary to the facility's Antimicrobial Stewardship Program policy. Despite regular reviews by the pharmacist and PCP, the antibiotic continued to be administered, indicating a lapse in policy adherence.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and implement necessary interventions for two residents, leading to significant weight loss. Resident 11, who had severe cognitive impairment, experienced a weight loss of 15.83% over two months. Despite a dietitian's recommendation to increase Pro-stat intake, there was no evidence that this was implemented. Additionally, Resident 11's care plan and physician's orders were not updated to reflect these recommendations, and there was no documentation of the primary care provider being notified of the weight loss. Resident 8, who had moderate cognitive impairment and required substantial assistance with eating, experienced a severe weight loss of 13.5% over six months. The dietitian had not completed a Nutrition Risk Assessment or a quarterly nutrition assessment for Resident 8 since October 2023, and there was no evidence that the physician was informed of the weight loss. The facility's failure to conduct timely assessments and notify the physician contributed to the resident's nutritional decline. The facility's policy on resident assessments required dietary assessments to be completed annually and with significant changes, but there was no evidence of a nutrition or weight loss policy being located. Interviews with the MDS Coordinator confirmed the lack of assessments and notifications for both residents, highlighting the facility's failure to adhere to its own policies and ensure adequate nutritional care for its residents.
Deficiencies in Food Handling, Hygiene, and Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling and storage protocols, as evidenced by observations of expired and unlabeled food items. During a kitchen tour, various food items were found with expired use-by dates, and some were not sealed or labeled correctly. The Dietary Manager confirmed that items should be disposed of after preparation or opening within seven days and stored in enclosed containers. However, the facility's practices did not align with these standards, potentially affecting all 26 residents. Additionally, the facility did not enforce the use of beard restraints as required by their policy and the Nebraska Food Code. Observations revealed that both the Dietary Manager and a Dietary Aide were not wearing beard restraints while in the kitchen, despite having facial hair. The Dietary Manager believed that beard covers were only necessary during food preparation or service, indicating a misunderstanding of the policy requirements. The facility also failed to implement proper hand hygiene practices during meal preparation and service. A Medication Aide was observed sanitizing and reusing gloves while assisting multiple residents, contrary to the facility's hand hygiene policy. Furthermore, a cook did not perform hand hygiene after removing gloves and before applying new ones, and a Dietary Aide did not perform hand hygiene between resident contacts. The kitchen environment was also unsanitary, with flies present and food preparation surfaces not being sanitized between tasks, as observed with a cook preparing different foods on a contaminated table.
Infection Control Deficiencies in Wound Care and Laundry Distribution
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care for a resident with a stage 2 pressure ulcer. The resident, who had moderate cognitive impairment, required pressure injury care as per their admission Minimum Data Set. During an observation, an LPN did not don a gown as required by Enhanced Barrier Precautions while performing wound care. Additionally, the LPN contaminated the Thera honey cream by touching the tip of the tube to the Opti foam dressing and stored the unused dressing improperly, which violated infection control practices. The facility also failed to prevent potential cross-contamination during laundry distribution. A laundry aide was observed distributing personal laundry with the cart cover left open throughout the process, which could lead to contamination. The aide performed hand hygiene between rooms but placed laundry between their legs while doing so, further compromising infection control standards. These actions were confirmed by the laundry aide during an interview.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to protect private medical information for four residents, as observed during a survey. The facility's policy on resident rights, last reviewed in March 2013, mandates privacy for residents' medical information to ensure confidentiality. However, during an observation on July 18, 2024, at 2:30 PM, it was noted that the names of four residents were visible on medication containers from a public hallway window. Specifically, Resident 2's name was on a bottle of calmoseptine, Resident 15's name on an inhaler device, Resident 22's name on a bottle of glucose testing strips, and Resident 23's name on a bottle of MiraLAX. An interview with an LPN confirmed that these medications were in public view, constituting a violation of the residents' privacy.
Failure to Serve Meals Simultaneously at Resident's Table
Penalty
Summary
The facility failed to provide meal service that enhanced dignity for a resident, as observed during a lunch service. On the specified date, Resident 5 was seated at a table with four other residents. Observations revealed that the other four table mates were served their lunch meals while Resident 5 was left watching them eat. Subsequently, a table of three residents seated behind Resident 5 was also served their meals before Resident 5 received theirs. It was not until several minutes later that Resident 5 was finally served their lunch. An interview with Cook-B confirmed that all residents should be served at one table at the same time, indicating a lapse in the facility's meal service protocol.
Failure to Notify Physicians of Significant Weight Loss
Penalty
Summary
The facility failed to notify the attending physician of significant weight loss for two residents, as required by their policy on Notification of Change in Resident Condition. Resident 8 experienced a weight loss of 16.3 pounds, or 13.5%, over a period from January to July 2024. A review of Resident 8's medical records showed no evidence that the physician was informed of this severe weight loss. An interview with the MDS Coordinator confirmed the lack of notification and acknowledged that the physician should have been informed. Similarly, Resident 11 experienced a weight loss of 8.3% in one month and an additional 8.2% in the following month, without being on a prescribed weight loss plan. The review of Resident 11's electronic and paper health records revealed no evidence of notification to the primary care provider about the significant weight loss. The Director of Nursing confirmed the weight loss and the absence of notification. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicates that such weight changes should prompt a thorough assessment, which was not documented in this case.
Failure to Evaluate Use of Physical Restraint
Penalty
Summary
The facility failed to evaluate the use of a physical restraint for one resident, identified as Resident 13, out of a sample of two residents. The facility's policy on restraints, revised in September 1999, states that restraints should only be used as a last resort and require a physician's order unless in an emergency. However, the facility did not assess Resident 13's ability to remove a gait belt used for positioning around their legs, which was documented in the care plan as removable by the resident. The Minimum Data Set for Resident 13 indicated no restraints were in use, yet observations showed a gait belt secured around the resident's thighs. Interviews with facility staff, including a Medication Aide and the Director of Nursing, confirmed the use of the gait belt for positioning and the lack of assessment regarding the resident's ability to remove it independently. The Director of Nursing admitted to applying the gait belt without prior assessment of the resident's ability to remove it, indicating a failure to adhere to the facility's restraint policy and a lack of proper evaluation of the resident's needs and capabilities.
Inadequate Care Plans for ADLs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which is a requirement under the Activities of Daily Living (ADL) policy. Resident 1, who was admitted with diagnoses including Multiple Sclerosis, Dementia, contractures, and abnormal involuntary movements, had a care plan that lacked specific information regarding the level of assistance needed for eating, dressing, bathing, and personal hygiene. The Minimum Data Set (MDS) assessment indicated that Resident 1 required total assistance for these activities, yet the care plan did not reflect this level of detail. Similarly, Resident 8, who was admitted with diagnoses such as Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease, also had a care plan that was not comprehensive. The MDS assessment showed that Resident 8 required substantial assistance with eating and oral hygiene and total assistance for toileting, bathing, dressing, and personal hygiene. However, the care plan did not specify the level of assistance required for these activities. An interview with the MDS Coordinator confirmed that the care plans for both residents were not comprehensive or person-centered.
Failure to Revise Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced significant weight loss, despite recommendations from a dietician. The resident, admitted with diagnoses including Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease, showed a 13.5% weight loss over six months. A care conference report recommended starting Ensure Clear supplements, but this intervention was not reflected in the resident's care plan. An interview with the MDS Coordinator confirmed that the care plan was not updated to include the dietician's recommendation.
Failure to Implement Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to implement a physician-ordered treatment for a resident with edema and did not administer hypertension medication according to prescriber's orders for another resident. For the first resident, the provider had ordered an ACE wrap for the left arm due to swelling, along with other treatments such as blood work, x-rays, and Tylenol. However, observations over several days revealed that the ACE wrap was never applied, and the order was not entered into the resident's electronic health records. The Director of Nursing confirmed that the order for the ACE wrap was overlooked during the entry of other orders. For the second resident, who had a history of stroke, congestive heart failure, dementia, and high blood pressure, there was an order for Coreg to be administered twice daily with instructions to hold the medication if the systolic blood pressure was below 110. Despite this, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold. The Director of Nursing confirmed that the medication was given in error on numerous occasions, not adhering to the prescriber's specific instructions.
Oxygen Concentrator Left On Unattended
Penalty
Summary
The facility failed to ensure the safe use of an oxygen concentrator for a resident, identified as Resident 12, who was diagnosed with chronic respiratory failure with hypoxia and was receiving oxygen therapy. The deficiency was identified when the oxygen concentrator was observed to be left on and running at 3 liters per minute (LPM) while Resident 12 was not present in their room. This observation was confirmed by the MDS Coordinator, who noted that there was no one in the room at the time. The facility's policy on oxygen administration, last reviewed in 2013, did not provide guidance on turning off oxygen devices when not in use. Additionally, Resident 12's physician's orders specified that the oxygen should be turned off when not in use and the cannula and tubing should be stored in an infection prevention bag. The failure to adhere to these orders and the lack of specific guidance in the facility's policy contributed to the deficiency, creating a potential hazard in the resident's environment.
Failure to Ensure Antibiotic Stop Date for Resident
Penalty
Summary
The facility failed to ensure that an antibiotic prescribed to a resident had a stop date, which is a requirement to prevent unnecessary drug use. The resident, who had a personal history of urinary tract infections and an indwelling urinary catheter, had been taking Cephalexin prophylactically since November 2021. The facility's Antimicrobial Stewardship Program policy, revised in July, aims to ensure proper use and duration of antimicrobials to reduce resistance and adverse reactions. However, the resident's physician's orders did not include a stop date for the antibiotic, contrary to the facility's policy and CDC guidelines. During an interview, a registered nurse confirmed awareness of the resident's long-term use of Cephalexin and acknowledged that no attempt had been made to discontinue the medication. The nurse mentioned that both the pharmacist and the resident's primary care provider review medications regularly, implying that they would have discontinued the medication if deemed unnecessary. Despite these reviews, the antibiotic continued to be administered without a stop date, highlighting a lapse in the facility's adherence to its antimicrobial stewardship policy.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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