Heritage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairbury, Nebraska.
- Location
- 909 17th Street, Fairbury, Nebraska 68352
- CMS Provider Number
- 285262
- Inspections on file
- 21
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Heritage Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Surveyors found that food was not prepared or cooked according to recipes or required temperatures, with incomplete temperature logs and malfunctioning ovens contributing to undercooked meals. Food items in storage were not consistently labeled, dated, or sealed, and kitchen cleaning was inadequate, with food debris and spills observed on equipment, floors, and ceilings. These deficiencies affected all residents receiving meals from the kitchen.
The facility did not ensure that kitchen ovens were maintained in safe and working condition, resulting in food not being cooked to required temperatures, incomplete temperature logs, and verified resident complaints about food quality. Staff and maintenance confirmed ongoing oven malfunctions, and some menu items could not be safely served due to these deficiencies.
Two residents with Type 2 Diabetes received rapid-acting insulin after meals instead of before, contrary to facility policy and manufacturer guidelines. Nursing staff confirmed this practice, resulting in two medication errors out of 25 observed administrations and an 8% medication error rate, exceeding the acceptable threshold.
Two residents with Type 2 Diabetes did not receive their rapid-acting insulin as ordered, with nursing staff administering insulin after meals instead of before, as required by facility policy and physician orders. Staff interviews confirmed this was a routine practice, and the DON acknowledged these were significant medication errors.
The facility failed to notify medical practitioners of positive COVID-19 test results in a timely manner for two residents and incorrectly notified a practitioner of another resident's test result. One resident's positive result was not addressed by the practitioner due to a lack of documentation, and another resident's practitioner was notified nearly a month late. Additionally, a resident who tested negative was incorrectly reported as positive, leading to an unnecessary medication order.
A resident received Paxlovid for COVID-19 treatment despite not testing positive for the virus. A miscommunication led to the resident's medical practitioner receiving incorrect information, resulting in an unnecessary prescription. The resident's roommate was the one who tested positive, but the medication was administered to the wrong individual.
A resident with multiple diagnoses experienced a decline in functional abilities and was ordered both PT and OT services by a physician. However, the facility failed to provide the ordered OT services due to an oversight, as confirmed by the DON and a COTA. The resident's decline was attributed to a lack of independent activity and increased anxiety about transfers.
The facility failed to perform proper hand hygiene during catheter care for a resident. Two NAs did not adhere to hand hygiene protocols, touching various surfaces and handling supplies without sanitizing their hands. Interviews confirmed these lapses, and the DON acknowledged the lack of a specific catheter care policy.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient monitoring or preventive measures to address these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing the necessary supervision to safeguard residents from potential accidents.
Deficiencies in Food Preparation, Storage, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that food was prepared, cooked, stored, and served in accordance with professional standards and facility policies. During food preparation, the Dietary Manager (DM) did not follow recipes as written, including not weighing ingredients, using incorrect ingredient substitutions, and failing to measure or time cooking steps. The DM also did not ensure that food items reached the required minimum internal cooking temperatures, as evidenced by multiple instances where turkey, squash, and sweet potatoes were not cooked to the appropriate temperatures before being placed on the steam table or served. Temperature logs were incomplete, with many days missing required entries, and some food items, such as fish, were documented as being cooked below the required temperature. Staff interviews confirmed that food temperatures were often not checked or recorded, and that malfunctioning ovens contributed to undercooked food being served. The facility also failed to properly label, date, and seal food items in storage. Observations revealed multiple opened containers of food in refrigerators and dry storage that were not labeled with the date of opening or use-by dates, and some items were not sealed. The DM confirmed that all items should have been labeled, dated, and sealed according to facility policy, but this was not consistently done. Additionally, resident complaints were documented regarding food being overcooked, undercooked, not warm enough, and not fresh, and facility investigations verified these complaints. Cleaning and sanitation practices in the kitchen were also deficient. Cleaning logs did not include tasks for key equipment and areas, such as oven surfaces, behind cooking equipment, or ceilings. Observations found food debris, spills, and stains on kitchen equipment, floors, and ceilings, as well as a buildup of debris and a gray fuzzy substance behind the range. The DM and staff confirmed that these areas should have been clean, but were not. These failures in food preparation, storage, and kitchen cleanliness had the potential to affect all residents consuming food from the kitchen.
Failure to Maintain Safe and Functional Kitchen Ovens
Penalty
Summary
The facility failed to maintain its kitchen ovens in a safe and operating condition, which impacted the preparation and serving of food to all residents. Multiple recipes required specific cooking temperatures, but review of temperature logs showed that food temperatures were not consistently recorded for all meals, and some food items, such as oven fried fish and baked fish, were not cooked to the required internal temperature of 165 degrees Fahrenheit. Additionally, complaints from 12 residents regarding food being overcooked, undercooked, not warm enough, and not fresh were verified by the facility, and staff were found to be inadequately recording food temperatures and not completing temperature logs as expected. Observations of food preparation revealed that the Dietary Manager repeatedly had to return food items to the oven because they did not reach the required temperatures, and some food was dropped on the floor during the process. The ovens were unable to bring certain menu items, such as turkey, to the necessary internal temperature, resulting in those items not being served. Staff interviews confirmed ongoing issues with the ovens, including malfunctioning pilot lights and inaccurate temperature settings, and maintenance staff reported that repairs were delayed due to backordered parts and uncertainty about the functionality of replacement ovens in storage. The Administrator and Dietary Manager acknowledged the persistent oven issues and the impact on meal preparation.
Failure to Administer Insulin at Correct Times Results in Elevated Medication Error Rate
Penalty
Summary
The facility failed to ensure that medications, specifically rapid-acting insulin, were administered at the correct times for two residents diagnosed with Type 2 Diabetes. Observations and record reviews revealed that insulin was routinely given after meals rather than within the recommended timeframe before meals, as outlined in both facility policy and manufacturer instructions. For one resident, insulin was administered over an hour after breakfast, and for another, insulin was given nearly two hours after the scheduled time and after lunch. Both nurses involved confirmed during interviews that their usual practice was to perform blood glucose checks before meals but to administer insulin after the residents had eaten. These actions resulted in two medication errors out of 25 observed opportunities, leading to a medication error rate of 8%, which exceeds the acceptable threshold of less than 5%. The Director of Nursing confirmed that such insulin administration errors are considered significant and that insulin should be given as ordered and before meals. The facility's failure to adhere to its own policies and accepted standards for timely medication administration directly contributed to the identified deficiency.
Failure to Administer Insulin as Ordered Before Meals
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors related to insulin administration for two residents with Type 2 Diabetes. Facility policy and insulin manufacturer guidelines require that rapid-acting insulin, such as Novolog (Insulin Aspart), be administered within 15 minutes before a meal. However, observations and record reviews revealed that both residents received their insulin after meals, contrary to physician orders and best practice guidelines. For one resident, insulin was administered over an hour after the scheduled time and after the resident had already eaten lunch. For the other resident, insulin was given after breakfast, despite the blood sugar check being performed before the meal. Interviews with nursing staff confirmed that it was their usual practice to administer insulin after meals, rather than before as required. The Director of Nursing also acknowledged that these instances constituted significant medication errors and that insulin should be administered as ordered and prior to meals. The facility census at the time was 50, and the findings were based on direct observation, record review, and staff interviews.
Failure in Timely and Accurate COVID-19 Test Result Notification
Penalty
Summary
The facility failed to notify the medical practitioner of a positive COVID-19 test result in a timely manner for two residents and incorrectly notified the medical practitioner of another resident's COVID-19 test result. Resident 1 tested positive for COVID-19 on December 27, 2024, but there was no documentation that the medical practitioner addressed the Physician Visit/Communication Form regarding the positive test. The Director of Nursing confirmed that the medical practitioner's office had no record of receiving the form. Resident 4 also tested positive on the same day, but the medical practitioner was not notified until January 25, 2025, nearly a month later. Additionally, Resident 3, who tested negative for COVID-19, was incorrectly reported as positive to the medical practitioner, resulting in an unnecessary order for Paxlovid. The Director of Nursing confirmed the error in notification. These deficiencies highlight a failure in the facility's communication process regarding COVID-19 test results, impacting the timely and accurate notification of medical practitioners and potentially affecting resident care.
Unnecessary Administration of Paxlovid to a Resident
Penalty
Summary
The facility administered Paxlovid, a medication used to treat COVID-19, to Resident 3 despite the resident not testing positive for COVID-19. This was based on a miscommunication where a fax was sent to Resident 3's medical practitioner indicating that the resident had tested positive for COVID-19, which was incorrect. The medical practitioner then provided an order for Paxlovid, which was administered to Resident 3 from December 27, 2024, to January 3, 2025, as per the Electronic Medication Administration Record (EMAR). Resident 3's roommate, Resident 4, was the one who had tested positive for COVID-19 on December 27, 2024, as confirmed by the progress notes and EMAR. The Director of Nursing confirmed that Resident 3 received the doses of Paxlovid as indicated on the EMARs, which should not have occurred since Resident 3 was not positive for COVID-19. The administration of Paxlovid to Resident 3 was unnecessary and not in accordance with the medication's intended use, as confirmed by the Paxlovid.com website.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to ensure that Occupational Therapy (OT) services were provided to a resident as ordered by the physician. Resident 3, who had diagnoses including major depressive disorder, chronic obstructive pulmonary disorder, type 2 diabetes mellitus, and arthritis, experienced a decline in the ability to stand and transfer independently. Despite a physician's order for both Physical Therapy (PT) and OT on 03/08/2024, only PT services were initiated. The OT evaluation and treatment were not conducted, as confirmed by the Director of Nursing (DON) and a Certified Occupational Therapy Assistant (COTA). The oversight was due to the therapy department being unaware of the OT order, even though it was on the same page as the PT order. Interviews with Resident 3, the DON, and a Nurse Aide (NA) revealed that the resident's decline was attributed to a lack of independent activity, leading to increased weakness. The resident had become anxious about transfers and required more assistance. Despite being placed back on the therapy workload, the OT services were not provided as ordered. The DON confirmed that the OT evaluation ordered on 03/08/2024 was not performed, and the COTA acknowledged that the OT order was overlooked, resulting in the deficiency.
Failure to Perform Proper Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to perform proper hand hygiene during catheter care for a resident. During an observation, two nursing assistants (NAs) were seen completing catheter care without adhering to hand hygiene protocols. NA-B and NA-H initially performed hand sanitization and donned gloves but failed to maintain hand hygiene throughout the procedure. NA-H touched their face and a door handle before handling supplies, and both NAs did not perform hand hygiene after various tasks, including handling a dirty graduate, touching a bed remote that fell on the floor, and touching a garbage can. NA-B also failed to perform hand hygiene after wiping the resident's groin and before continuing with catheter care. Additionally, NA-B handled a cleansing bottle and returned it to the cabinet without sanitizing it or performing hand hygiene. Interviews with the Director of Nursing (DON) and the NAs confirmed these lapses in hand hygiene. The DON acknowledged that the facility did not have a specific policy for catheter care, only a competency. Both NAs admitted to not performing hand hygiene at critical points during the procedure. The resident involved was lying in bed and had a catheter drainage bag, which was handled without proper hand hygiene, potentially compromising the resident's care and safety.
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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