Heritage Of Webster County
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Cloud, Nebraska.
- Location
- 636 North Locust Street, Red Cloud, Nebraska 68970
- CMS Provider Number
- 285225
- Inspections on file
- 15
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Heritage Of Webster County during CMS and state inspections, most recent first.
Surveyors identified that staff failed to properly date and discard glucometer testing supplies, did not follow manufacturer instructions for calibration and cleaning, and lacked adequate training in the use of CGM systems. Additionally, insulin was not always administered or withheld according to prescriber orders, and documentation was incomplete when deviations occurred. These deficiencies affected all diabetic residents, including those using CGMs and receiving insulin.
A resident with severe cognitive impairment and dementia spilled hot coffee on themselves, resulting in a minor burn. Although the incident was documented and monitored, the DON confirmed that the required investigation report was not submitted to the state agency within the mandated timeframe.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and inadequate supervision protocols.
The facility did not notify the state agency within the required timeframe after hiring a new DON, as confirmed by interviews with the DON and Administrator. The Administrator acknowledged that the notification had not been completed, despite the new DON having started about a month earlier.
The facility did not employ a qualified Infection Preventionist separate from the DON, who was serving in both roles without the necessary training. An LPN with the required training was not overseeing the infection control program, potentially affecting all 26 residents.
The facility failed to update care plans for residents, leading to deficiencies in addressing their needs. A resident with muscle weakness had an outdated care plan that did not reflect their inability to ambulate. Another resident, severely cognitively impaired, had no new interventions after a fall, and a cognitively intact resident's care plan lacked focus after sliding out of a recliner. The DON confirmed the care plans were not updated to reflect current needs.
The facility failed to involve a resident in their care plan development and did not address their high risk for elopement. Another resident's care plan was not updated to reflect hospice admission, and two other residents had care plans that did not address specific health issues. The DON confirmed these omissions, indicating a pattern of inadequate care plan updates.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents, leading to potential cross-contamination. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for three residents with open wounds. Observations showed that gowns were not used, and staff were unaware of EBP. The Director of Nursing confirmed the lack of a policy for EBP and acknowledged the necessity of proper infection control measures.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents, informing them of charges for non-covered care items and services prior to a change in Medicare A coverage. Both residents were discharged from Medicare A services with benefit days remaining and continued to reside in the facility without receiving the required notice, as confirmed by the Director of Nursing.
A resident with hemiplegia and cognitive intactness was observed with a wheelchair strap they could not unfasten, indicating restraint use without evaluation. Interviews confirmed the resident's inability to remove the strap independently, and records lacked documentation of evaluation or consent. The facility's guidelines require such evaluations, but none were completed.
The facility failed to document weekly non-pressure wound assessments for two residents, affecting their care planning and monitoring. One resident had multiple leg wounds, while another had a buttock wound, both without recent measurements. The DON confirmed the lapse in documentation.
A resident with multiple health issues, including a Stage 3 pressure ulcer, did not receive documented weekly assessments as required by the facility's policy. The DON monitored wounds but failed to document them in the medical record, using Risk reports instead. This led to a deficiency in adhering to the facility's Skin and Wound Management Standard.
Deficient Glucose Monitoring and Insulin Administration Practices
Penalty
Summary
The facility failed to ensure proper management and use of glucometer testing supplies and continuous glucose monitoring (CGM) systems for residents with diabetes. Surveyors found that glucometer testing solutions and test strips were not dated when opened, and expired supplies were not discarded according to manufacturer instructions. Staff were observed using control solutions and test strips beyond the recommended 90-day period after opening, and the required dating of these items was not consistently performed. Additionally, staff did not follow proper procedures for mixing and applying control solutions during calibration, and cleaning protocols for testing equipment were not adhered to as specified by the manufacturer. Nursing staff lacked adequate training and competency in the use of CGM systems and glucometers. Interviews revealed that staff had only received brief, informal instruction on CGM use, without review of manufacturer guidelines or formal documentation of competency. There were no records of staff training or competency assessments related to insulin administration, insulin pens, CGM systems, or glucometer calibration. Staff demonstrated inconsistent understanding of when and how to calibrate CGMs with glucometer readings, and there was confusion regarding the frequency and documentation of calibration checks. The Infection Control Coordinator and the DON confirmed the absence of training records and acknowledged that staff were not following established protocols. The facility also failed to ensure that insulin was administered or withheld in accordance with prescriber orders for a resident with diabetes. Medical records showed that insulin was sometimes given when blood glucose levels were below the physician-ordered threshold, and documentation was lacking when insulin was administered outside of prescribed parameters. The DON confirmed that staff should have followed physician orders and documented rationale when deviations occurred. These deficiencies affected all residents with diabetes in the facility, including those using CGM systems and those receiving insulin therapy.
Failure to Timely Report Investigation of Resident Injury
Penalty
Summary
The facility failed to submit a written investigation of a possible instance of abuse or neglect to the state agency within the required 5 working days. According to facility policy, all alleged violations of abuse or neglect must be reported within 24 hours, and the results of the investigation must be submitted within 5 working days. However, for one resident with severe cognitive impairment and a diagnosis of dementia, the facility did not follow this protocol after an incident occurred. The resident, who was at risk for hot liquid accidents due to impaired cognition and confusion, spilled coffee on themselves while sitting at the dining room table. The incident resulted in a light pink area on the resident's abdomen, and an order was placed to monitor the burn. Despite this, the Director of Nursing confirmed that the investigation into the incident was not submitted to the state agency as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific hazards, the nature of the supervision lapse, or information about the residents involved were provided in the report.
Failure to Notify State of Change in DON
Penalty
Summary
The facility failed to notify the state department of a change in the Director of Nursing (DON) within the required 5 working days. Observations and interviews revealed that the current DON began their position approximately one month prior to the survey, having previously worked as a floor nurse for about a year. The Administrator confirmed that the previous DON left about a month ago and a new DON was hired and is currently active. During interviews, the Administrator admitted that the department had not yet been notified of the change in DON and acknowledged that this notification was overdue. The facility census at the time was 28 residents.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) who is not the Director of Nursing (DON), as required for the infection prevention and control program. The DON was listed as both the Director of Nursing and the Infection Control Coordinator on the Licensed Personnel and Consultants sheet, as well as the Infection Control Nurse on the Quality Assurance Performance Improvements (QAPI) Committee Members sheet. During an interview, the DON confirmed they had not completed the necessary course for the Infection Preventionist role and were serving full-time as both the DON and the Infection Preventionist. Although a Licensed Practical Nurse (LPN) from the hospital had the required training for infection control, they had not been overseeing the infection control program at the facility. This deficiency had the potential to affect all 26 residents in the facility, which had a census of 26.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to develop and update care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #7, who was admitted with multiple diagnoses including muscle weakness and difficulty in walking, had a care plan that included a goal to prevent decline through ambulation. However, observations and interviews revealed that the resident had not ambulated for over six months and required assistance from two staff members for transfers, indicating that the care plan was outdated and not reflective of the resident's current condition. Similarly, Resident #18, who was severely cognitively impaired and had a history of falls, did not have any new interventions added to their care plan following a fall incident. The resident's walker was found out of reach, contributing to the fall. Resident #25, who was cognitively intact, also experienced a fall after sliding out of a recliner, yet their care plan lacked any focus, goals, or interventions to address this incident. Interviews with the Director of Nursing confirmed that the care plans for these residents were not updated to reflect their current needs and incidents.
Care Plan Deficiencies in Resident Involvement and Updates
Penalty
Summary
The facility failed to involve Resident #26 in the development of their Comprehensive Care Plan (CCP) and did not address their high risk for elopement. Despite being cognitively intact with a BIMS score of 15, Resident #26 was not aware of the care plan or invited to the care plan meeting. The facility also did not document the meeting in the progress notes or have a signed care plan acknowledgment form. Additionally, although Resident #26 was identified as a high risk for elopement and wore a wanderguard bracelet, their CCP lacked focus, goals, or interventions related to this risk. Resident #18, who was severely cognitively impaired with a BIMS score of 4, was admitted to hospice services, but this was not reflected in their CCP. The Director of Nursing confirmed that the care plan had not been updated to include hospice admission. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's current care needs and services. Resident #11 and Resident #17 also had deficiencies in their care plans. Resident #11's CCP did not address a bruise on their right hand middle digit, and Resident #17's CCP failed to include an open area on their right buttock, which was identified as moisture damage. The facility's Skin and Wound Management Standard requires that non-pressure skin conditions be assessed and documented in the care plan, but this was not done for Resident #17. The DON confirmed these omissions, highlighting a pattern of inadequate care plan updates for residents with changing health conditions.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents, leading to potential cross-contamination. Observations revealed that an LPN did not change gloves or perform hand hygiene between removing old dressings, cleaning wounds, and applying new dressings. The LPN also reached into a package of clean gauze with soiled gloves, which is against standard infection control practices. These actions were confirmed by the LPN during interviews, acknowledging the failure to adhere to the required 20-second handwashing protocol. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for three residents with open wounds, which is a critical infection control measure to prevent the transmission of multidrug-resistant organisms. Observations showed that gowns were not used during wound care, and there were no signs indicating the need for EBP in the residents' rooms. Interviews with staff, including a Medication Aide, a Nurse Aide, and the LPN, revealed a lack of awareness and understanding of EBP, further contributing to the deficiency. The Director of Nursing confirmed that the facility lacked a policy for EBP and had not been implementing it for the affected residents, despite their open wounds. This oversight was acknowledged during interviews, highlighting a significant gap in the facility's infection prevention and control program. The DON also confirmed the necessity of EBP for residents with open wounds and the importance of proper hand hygiene practices, which were not being followed by the staff.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents, Resident 9 and Resident 21, or their representatives, to inform them of charges for non-covered care items and services prior to a change in Medicare A coverage. This deficiency was identified during a review of records and interviews conducted by surveyors. Resident 9 was discharged from Medicare A services on April 22, 2024, with benefit days remaining, and continued to reside in the facility. The facility did not provide a SNF ABN to Resident 9, as confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident 21 was discharged from Medicare A services on June 20, 2024, also with benefit days remaining, and remained in the facility. The facility again failed to provide a SNF ABN to Resident 21, as confirmed by the DON. The absence of the SNF ABN meant that both residents were not informed in advance about the potential denial of Medicare coverage for the services they were receiving, which is a requirement to allow beneficiaries to make informed decisions about their care options.
Failure to Evaluate Need for Physical Restraints
Penalty
Summary
The facility failed to evaluate the need for physical restraints for a resident, identified as Resident 2, who was observed with a strap on their wheelchair that they could not unfasten without assistance. Resident 2, who was admitted with diagnoses including hemiplegia, hemiparesis, unspecified kyphosis, and generalized muscle weakness, was cognitively intact with a BIMS score of 14. Observations on two separate occasions revealed the resident sitting in a wheelchair with a strap that went under the left arm and over the left shoulder, which the resident confirmed they could not remove without help. The resident stated the strap was to help them sit up straight, but they would still be unable to get out of the wheelchair without it. Interviews with the resident and a medication aide confirmed the resident's inability to unfasten the strap independently. A review of the resident's electronic health record showed no documentation of an evaluation for the use of the wheelchair strap or any discussion of risks and benefits with the resident or their representative. The facility's guidelines require evaluation of devices that may impede movement before application, but the Director of Nursing confirmed that no such evaluation or consent form was completed for the shoulder strap, indicating it was used as a restraint without proper assessment or consent.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to complete and document weekly non-pressure wound assessments for two residents, Resident 15 and Resident 17, as required by their Skin and Wound Management Standard. Resident 15, who was cognitively intact, had multiple wounds on both lower legs, with no measurements documented since early June 2024. Despite attending a wound clinic weekly, the facility did not maintain up-to-date records of the wound assessments. Resident 17, also cognitively intact, had a wound on the right buttock, initially noted as a blister, which was documented as moisture damage. However, the last recorded assessment was in early June 2024, with no subsequent weekly documentation. Interviews with the Director of Nursing (DON) confirmed that the facility's wound documentation was not current, and non-pressure skin issues were not being assessed and documented weekly as required. The DON acknowledged the lapse in maintaining up-to-date wound records, which affected the care planning and monitoring of residents with impaired skin integrity. This deficiency was identified through observations, record reviews, and interviews, impacting the quality of care provided to the residents.
Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to complete weekly pressure ulcer assessments for a resident, identified as Resident 3, who was admitted with multiple diagnoses including respiratory failure, COPD, heart failure, and peripheral vascular disease. The resident had a Stage 3 pressure ulcer on the left heel, first noted on 03/12/2024, with the last documented assessment on 06/11/2024. Despite the facility's policy requiring weekly assessments, there was no documentation of wound assessment after this date. The Director of Nursing (DON) admitted to monitoring wounds but not documenting them in the medical record, instead using Risk reports as a tracking tool. This lack of documentation and adherence to the facility's Skin and Wound Management Standard, which mandates formal assessment and documentation every seven days, led to the deficiency. The facility census at the time was 26, and the failure to document wound assessments was identified during a review of the resident's progress notes and interviews with the DON.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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