Hemingford Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemingford, Nebraska.
- Location
- 605 Donald Avenue, Hemingford, Nebraska 69348
- CMS Provider Number
- 285306
- Inspections on file
- 15
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Hemingford Care Center during CMS and state inspections, most recent first.
The facility did not employ a full-time Registered Dietitian or a certified Food Service Director, affecting 27 residents. The facility's assessment highlighted the need for a qualified nutrition professional. The Kitchen Supervisor lacked necessary certifications, and the dietitian had resigned.
The facility failed to store, label, and manage food items properly, risking foodborne illness for all residents. Observations included inadequately labeled garlic, unlabeled ground meat, improperly stored diced meat, outdated cooking wine, uncovered coffee carafes near a sink, and outdated sandwiches. The Kitchen Supervisor was unaware of these requirements.
The facility failed to prevent potential cross-contamination by not ensuring hand hygiene during laundry distribution and not using gowns as required by policy when sorting soiled linens. A staff member distributed laundry to residents without performing hand hygiene, and only gloves were used during sorting, contrary to the policy that required gowns.
The facility did not ensure a nurse aide completed initial orientation with abuse training, potentially affecting all 27 residents. The aide, employed since October, could not identify types of abuse or reporting procedures. The Administrator confirmed no evidence of completed training.
The facility did not develop and implement baseline care plans within 48 hours of admission for five residents, as required by policy. The DON confirmed the oversight, stating that the facility had never provided copies of the care plans to residents or their representatives. The residents had various medical conditions, including dementia and chronic pain, requiring timely care planning.
A resident with severe cognitive impairment and aggressive behaviors was involved in multiple altercations with other residents, resulting in injuries. The facility's interventions were inadequate and often duplicated, failing to prevent further incidents, as confirmed by the DON.
A resident alleged a theft of 4 million dollars, but the facility failed to report the incident to the state agency within the required 24 hours and did not submit an investigation report within 5 working days. The delay was confirmed through interviews with the DON and NHA, highlighting non-compliance with the facility's policy and state law.
The facility inaccurately coded the MDS for two residents, leading to errors in documenting active diagnoses and medication use. One resident was incorrectly noted as taking an anticoagulant instead of an antiplatelet, and a contraindicated GDR was not documented. Another resident was wrongly listed as having septicemia, despite no ongoing condition. An MDS-RN confirmed these discrepancies.
A facility failed to provide a complete discharge summary for a resident, omitting the recapitulation of stay. The facility's policy requires this summary to include a recap of the resident's stay and a final status summary at discharge. However, the discharge planning document was incomplete, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs, as two prophylactic antibiotics lacked stop dates and valid indications for use. The facility's policy required complete antibiotic orders, but a review revealed deficiencies in the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment. The DON confirmed these issues.
The facility failed to maintain the nutritive value of pureed food for two residents. Cook-A prepared meals by blending chicken and dumplings, peas, and cornbread with unmeasured hot water, affecting the food's nutritive value. The facility lacked recipes for diet modifications and a policy for preparing mechanically altered foods. The Kitchen Supervisor was unaware of the impact of adding water, and the Administrator confirmed the absence of relevant policies.
The facility failed to serve food in the texture ordered by medical providers for two residents. Despite orders for mechanical soft diets, the cook prepared and served pureed food. The facility lacked a policy for preparing modified texture foods, and the administrator was unaware of the inconsistency.
The facility did not perform required nurse aide registry checks for adverse findings on four employees, including a cook, an LPN, and two nurse aides, hired between August and October 2024. This oversight was confirmed by the Administrator and could potentially affect all 27 residents.
A resident's elopement was inaccurately reported by the DON, with inconsistencies in the dates and times of the incident and notifications to APS and the facility administrator. The report misstated the elopement date, notification times, and the resident's return time, as confirmed by the DON.
A resident with severe cognitive impairment and a history of wandering was moved from a locked Memory Care Unit to a non-locked unit, despite ongoing risk behaviors. The facility's interventions, including exit alarms and behavior logs, were insufficient, leading to the resident eloping and being found outside the facility. Safety checks were implemented post-incident but were later discontinued, highlighting inadequate supervision and intervention planning.
A resident experienced a 7.4% weight loss over one month, but the facility failed to notify the resident's POA or PCP as required by policy. The weight changes were documented, but staff did not report the significant change, leading to a deficiency in regulatory compliance.
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Despite the resident's need for total assistance and the facility's policy requiring timely response to call lights, staff did not provide the necessary help, leaving the resident without assistance for an extended period.
A resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility failed to follow its policy for significant weight changes, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident frequently refused meals, and there was no consistent documentation of their nutritional intake or the provision of high-calorie supplements.
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An LPN did not measure Diclofenac Gel 1% correctly for one resident and administered an incorrect amount of Miralax to another. The facility's policy on verifying medication details was not followed.
Failure to Employ Qualified Dietitian or Certified Food Service Director
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or have a certified Food Service Director, which had the potential to affect all 27 residents who consumed meals prepared in the kitchen. The facility's assessment identified the need for a qualified dietitian or clinically qualified nutrition professional to oversee the food and nutrition services. An interview with the Kitchen Supervisor revealed that they had been in the role for several months without completing any special certifications and were not a certified Food Service Director. Additionally, an interview with the Administrator confirmed that the dietitian had resigned and was no longer employed at the facility as of November 29, 2024.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to properly store, label, cover, and manage food and drink items, which could potentially lead to foodborne illness affecting all 27 residents. During an initial kitchen tour, several issues were observed: a half-full container of garlic in water was covered with foil and inadequately labeled; an unlabeled package of ground meat-like substance was found; a ziplock bag of loose raw meat-like substance was improperly labeled; and a tray with bags of diced meat sitting in liquid was incorrectly stored. Additionally, an opened container of cooking wine was past its best-if-used-by date, and a commercial coffee maker had uncovered carafes located next to a sink used for washing dirty dishes. A snack cart contained half-sandwiches in baggies with outdated labels. The Kitchen Supervisor was unaware of the requirement for coffee carafes to be covered and confirmed that the listed items should have been properly sealed, labeled, used, or discarded, and that bagged meats should not have been stored together in liquid.
Inadequate Infection Control in Laundry Handling
Penalty
Summary
The facility failed to handle contaminated linens in a manner that prevented potential cross-contamination and did not complete hand hygiene between distributing laundry for several residents. During an observation, a housekeeping/laundry staff member was seen distributing personal laundry to residents without performing hand hygiene between rooms. The staff member confirmed in an interview that they were unaware of the requirement to perform hand hygiene during the distribution of resident laundry. Additionally, the facility's policy on sorting soiled linen required employees to wear a gown and gloves. However, the housekeeping/laundry staff member stated that only gloves were worn during the sorting process, and no gowns were used. An observation of the laundry area revealed the presence of disposable exam gloves but no gowns, which was confirmed by the Administrator during an interview.
Failure to Provide Abuse Training During Orientation
Penalty
Summary
The facility failed to ensure that a nurse aide (NA-F) completed initial orientation with training on abuse, which had the potential to affect all 27 residents in the facility. A review of the facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised in April 2021, indicated that staff orientation should include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. However, during an interview, NA-F was unable to verbalize any types of abuse or identify when and whom to report to, despite being employed since October 2024. The Administrator confirmed there was no evidence that NA-F had completed the required abuse training during initial orientation.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five residents, as required by their policy. The policy mandates that a baseline care plan be developed for each resident within 48 hours of admission and that a copy of the summary be provided to the resident or their representative. However, record reviews revealed that no baseline care plans were developed for Residents 13, 16, and 22. For Residents 15 and 20, the baseline care plans were completed more than 48 hours after admission, and there was no evidence that copies were provided to the residents or their representatives. Interviews with the Director of Nursing (DON) confirmed the deficiencies, as the DON was unaware of the requirement to develop and implement baseline care plans within 48 hours and stated that the facility had never provided copies of the baseline care plans to residents or their representatives. The residents involved had various medical conditions, including dementia, Alzheimer's disease, chronic pain, and kidney disease, which necessitated timely and appropriate care planning to address their immediate needs upon admission.
Inadequate Supervision and Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to protect four residents from the adverse behaviors of another resident, identified as Resident 15, who was admitted with severe cognitive impairment and a history of wandering and aggression. Despite being aware of Resident 15's tendency to enter other residents' rooms and engage in altercations, the facility's interventions were inadequate and often duplicated, failing to prevent further incidents. Resident 15 was involved in multiple altercations with other residents, resulting in physical aggression and injuries, such as bruises and skin tears. The facility's care plan for Resident 15 included interventions like increased monitoring and redirection, but these measures were insufficient and inconsistently applied. The Director of Nursing confirmed that no new interventions were implemented after certain altercations, and some interventions were merely duplicates of previous ones. This lack of effective intervention and supervision led to repeated incidents of resident-to-resident altercations, highlighting a deficiency in the facility's ability to provide a safe environment for its residents.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property to the state agency within the required 24-hour timeframe and did not submit an investigation report within 5 working days. The incident involved a resident who alleged that someone had stolen 4 million dollars from them. The facility's policy, last revised in September 2022, mandates that any suspicion of misappropriation must be reported immediately, defined as within 24 hours, to the administrator and other officials according to state law. The deficiency was identified through interviews and record reviews. On August 7, 2024, the dialysis center informed the facility about the resident's allegation. However, the facility did not notify Adult Protective Services (APS) until August 13, 2024, and the investigation report was submitted to the state agency on August 19, 2024. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the delay in reporting and submission of the investigation, which did not comply with the facility's policy and state requirements.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Sets (MDS) for two residents, leading to discrepancies in the documentation of active diagnoses, medication use, and Gradual Dose Reduction (GDR) information. For Resident 9, the annual MDS inaccurately indicated the use of an anticoagulant, while the resident was actually taking an antiplatelet medication, clopidogrel. Additionally, the MDS did not document that a GDR for Zyprexa, an antipsychotic medication, was clinically contraindicated, despite this being noted in the resident's Medication Risk Benefit Evaluation. For Resident 17, the quarterly MDS incorrectly listed septicemia as an active diagnosis, although there were no indications of ongoing septicemia since before the resident's admission. An interview with the MDS-Registered Nurse confirmed these inaccuracies, acknowledging that Resident 9's MDS should have reflected the use of an antiplatelet and the contraindicated GDR, and that Resident 17's MDS should not have included septicemia as an active diagnosis.
Failure to Provide Complete Discharge Summary
Penalty
Summary
The facility failed to develop and provide a discharge summary that included a recapitulation of stay for a resident who was discharged. The facility's policy, revised in October 2022, mandates that the discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. Additionally, a copy of the evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary should be provided to the resident and filed in their medical record. However, upon reviewing the discharge planning document dated 10/7/2024, it was found that the section for the recap of the resident's stay was left blank. This was confirmed in an interview with the Director of Nursing, who acknowledged that the recapitulation of stay was not completed or provided to the resident.
Deficiency in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free from unnecessary drugs, specifically regarding the use of prophylactic antibiotics. A review of the facility's policy on Antibiotic Stewardship indicated that complete antibiotic orders should include the drug name, dose, frequency, duration of treatment, route, and indication. However, a review of Resident 2's Order Summary revealed that the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment lacked stop dates or durations. Additionally, the antibiotic eye drops did not have a valid indication for use. An interview with the Director of Nursing confirmed these deficiencies in the antibiotic orders for Resident 2.
Failure to Maintain Nutritive Value of Pureed Food
Penalty
Summary
The facility failed to maintain the nutritive value of pureed food, affecting two residents. During a meal service observation, Cook-A was seen preparing pureed meals by blending chicken and dumplings, seasoned peas, and cornbread with an electric blender. Unmeasured hot water from a coffee carafe was added to each food item to achieve the desired consistency, which was then served to the residents along with cooked canned sweet potatoes. A review of the facility's recipe for Chicken and Dumplings showed no guidance for mechanical soft or pureed diet modifications, and no recipes were available for the peas or cornbread. Interviews revealed that Cook-A prepared and served the pureed food to the two residents, and the Kitchen Supervisor was unaware that adding water could decrease the nutritive value of the food. The Administrator confirmed the absence of a facility policy for preparing mechanically altered texture foods for residents.
Failure to Serve Food in Ordered Texture
Penalty
Summary
The facility failed to provide food in the texture ordered by the medical provider for two residents, identified as Residents 5 and 15. Resident 5 had an active physician's order for a regular diet with mechanical soft texture and thin consistency liquids, while Resident 15 had an order for a liberalized diet with mechanical soft texture and regular consistency liquids. During an observation of meal service, it was noted that Cook-A prepared and served pureed food to both residents, despite their orders for mechanical soft diets. The cook blended chicken and dumplings, peas, and cornbread into a pureed consistency, which was not in accordance with the dietary orders. The facility lacked a policy for preparing modified texture foods, and the Nursing Home Administrator was unaware that the foods were being served at a different consistency than what was ordered. The facility's documents indicated that chicken and dumplings should be served as a ground texture, peas as pureed, and cornbread as a slurry for residents on a mechanical soft diet. However, the preparation observed did not align with these guidelines, leading to the deficiency in serving food in the correct texture as ordered by the medical provider.
Failure to Conduct Nurse Aide Registry Checks
Penalty
Summary
The facility failed to conduct required nurse aide registry checks for adverse findings for four out of five sampled employees, which could potentially affect all 27 residents within the facility. The facility's policy, revised in April 2021, mandates conducting employee background checks, including state nurse aide registry checks for any adverse findings. However, a review of personnel files revealed that no nurse aide registry checks were completed for a cook, an LPN, and two nurse aides hired between August and October 2024. This was confirmed in an interview with the Administrator, who acknowledged the oversight in conducting these checks.
Inaccurate Reporting of Resident Elopement Incident
Penalty
Summary
The facility failed to submit an accurate investigation report to the state agency following the elopement of a resident. The Director of Nursing (DON) submitted a report that contained several inconsistencies regarding the dates and times of the incident and notifications. The report inaccurately stated that the elopement occurred on a different date than it actually did, and it also provided incorrect times for when the Adult Protective Services (APS) and the facility administrator were notified. Additionally, the report misstated the time the resident returned to the facility with the DON. These discrepancies were confirmed during an interview with the DON, highlighting a failure in accurately documenting and reporting the incident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement adequate interventions to prevent elopements for a resident identified as at risk for wandering and elopement. The resident, who had severe cognitive impairment and a history of wandering, was initially residing in the Memory Care Unit (MCU) but was moved to a non-locked unit after the facility determined they were not at risk for elopement. Despite this, the resident continued to exhibit behaviors indicating a risk for elopement, such as making statements about leaving the facility and asking staff for help to leave. The resident's care plan included interventions like exit alarms, behavior logs, and personalization of their room, but these were not sufficient to prevent an elopement incident. On one occasion, the resident was found outside the facility in a park, indicating a failure in the supervision and interventions in place. Following this incident, the facility implemented 15-minute safety checks, which were later reduced to hourly checks and eventually discontinued, despite the resident's continued risk behaviors. Interviews with facility staff, including the Director of Nursing, revealed that the facility did not have a comprehensive plan to prevent further elopements after the initial incident. The care plan was updated to include a focus on elopement only after the resident had already eloped, and the interventions in place were not sufficient to prevent the resident from leaving the facility again. This lack of proactive measures and adequate supervision contributed to the deficiency identified in the report.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's representative of a significant change in condition for one of the sampled residents. The resident, who was admitted with a principal diagnosis of acute and chronic respiratory failure with hypoxia, experienced a 7.4% weight loss over one month. Despite the facility's policy requiring notification of significant changes in a resident's condition, there was no documentation that the resident's Power of Attorney (POA) had been informed of this weight loss. The resident's care plan included monitoring for signs of dehydration and malnutrition, which listed significant weight loss as a key indicator. However, the weight changes were documented in the electronic health record system without any corresponding notification to the POA or primary care provider (PCP). Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the weight loss was not noticed or reported as required. The LPN did not recall noticing the weight change, and the DON confirmed that such a significant weight loss should have been reported to the resident's POA and PCP. The DON also stated that they had not been made aware of the weight loss and, therefore, had not taken the necessary steps to monitor the resident or notify the appropriate parties. This failure to communicate a significant change in the resident's condition constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Assist Dependent Resident with Toileting
Penalty
Summary
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Resident 2, who was admitted with diagnoses including left side hemiplegia, paraplegia, epilepsy, Spina Bifida, and muscle weakness, required total assistance for all Activities of Daily Living (ADLs) according to their Care Plan. On 3/26/2024, Resident 2 reported to an LPN that Nurse Aides had entered the room, shut off the call light, and left without providing assistance for toileting. Despite the LPN's acknowledgment, no staff provided the necessary assistance from 11:57 AM to 12:25 PM. Resident 2 later confirmed that it was common for staff to shut off the call light without offering help. Interviews with staff, including a Nurse Aide and the Director of Nursing (DON), confirmed that Resident 2 was dependent for all care and that the facility's policy required timely response to call lights and adherence to care plans for toileting assistance. The facility's policy on Activities of Daily Living (ADLs), last revised in March 2018, mandates that appropriate care and services be provided to dependent residents in accordance with their care plans, including toileting. The policy also states that staff should not assume residents are refusing care if they resist. Despite these guidelines, the facility failed to meet the care needs of Resident 2, as evidenced by the lack of timely assistance and the common practice of shutting off call lights without providing the required help. This deficiency was identified through record reviews, observations, and interviews with the resident and staff.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify a significant weight loss for one resident, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation and that the dietitian be notified immediately. However, this procedure was not followed, and the resident's significant weight loss went unreported to the dietitian, primary care provider (PCP), and the resident's power of attorney (POA). Additionally, there was no documentation of the resident's fluid or meal intake for the prior 30 days in the electronic health record (EHR), despite the resident frequently refusing meals and showing signs of decreased appetite and malnutrition. The resident's care plan included monitoring for signs of dehydration and malnutrition, such as significant weight loss, but these signs were not adequately documented or reported by the staff. Interviews with nursing aides and licensed practical nurses (LPNs) revealed that the resident's weights were obtained and given to the nurse on duty, but there was no clear process for reviewing and acting on significant weight changes. The Director of Nursing (DON) confirmed that a significant weight loss should be considered a change in condition and reported to the PCP and POA, but this did not occur for the resident in question. The DON also stated that the facility's electronic health record system should flag significant weight changes, but this warning was not observed for the resident. The resident had a history of declining meals and requesting only desserts in the evenings, which was known to the staff. Despite this, there was no consistent documentation of the resident's meal refusals, alternative food offerings, or the provision of high-calorie supplements. The resident was eventually sent to the emergency room for evaluation, where they were diagnosed with diverticulitis and dehydration. The lack of proper documentation and communication regarding the resident's weight loss and nutritional intake contributed to the deficiency in maintaining the resident's health through adequate food and fluids.
Medication Dosage Errors
Penalty
Summary
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An observation revealed that an LPN prepared an unmeasured amount of Diclofenac Gel 1% for Resident 8, despite the order specifying 2 grams to be applied to both knees. The LPN admitted to not knowing how to measure the gel. Additionally, the same LPN administered 17 grams of Miralax to Resident 12 instead of the ordered 2 tablespoons. The facility's policy on administering medications, which includes verifying the right medication, dosage, time, and method, was not followed. The facility had a census of 27 residents at the time of the survey.
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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