Hillcrest Country Estates-cottages
Inspection history, citations, penalties and survey trends for this long-term care facility in Papillion, Nebraska.
- Location
- 6082 Grand Lodge Avenue, Papillion, Nebraska 68133
- CMS Provider Number
- 285293
- Inspections on file
- 23
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hillcrest Country Estates-cottages during CMS and state inspections, most recent first.
Pharmacy recommendations from monthly drug regimen reviews were not completed in a timely manner for three residents, including those with dementia, depression, and multiple medication regimens. Despite repeated pharmacist notes and facility policy requiring follow-up within one week, recommendations such as reassessment of PRN medications and gradual dose reductions were not addressed for extended periods, as confirmed by DON interviews and record reviews.
Staff did not follow the RD-approved menu and recipes when preparing an Italian Tossed Salad, omitting required ingredients and altering the dish based on resident preferences without proper approval. This failure to adhere to established policies and recipes prevented confirmation of proper nutrition for residents in one cottage.
Surveyors found that the facility did not ensure proper cleanliness of food storage equipment, with a dried red substance left under ground beef in a freezer and standing water with food debris in a cooler where eggs and juice were stored. The Culinary Director confirmed the lack of cleaning schedules and improper food storage practices, in violation of facility policy.
A review of employee files revealed that several nurse aides did not receive required annual training in abuse prevention and dementia care, with documentation missing for both types of training in multiple cases. The facility's policy requires these annual in-services, but records did not show completion for the sampled staff.
Facility staff did not promptly notify the physician or responsible party when a resident with cognitive impairment and on anticoagulant therapy developed a large, painful bruise, nor did they ensure that abnormal lab results for another resident were reviewed by the provider. Staff interviews confirmed that required notifications were not made, in violation of facility policy.
A resident with cognitive impairment and on anticoagulant therapy was found with a large, unexplained bruise on the forehead. The facility did not submit the required investigation report to the state agency within five working days, and the DON confirmed there was no evidence of timely submission.
A resident with multiple complex medical conditions was admitted and did not have a baseline care plan developed within 24 hours as required by facility policy. The only care plan present was created several days after admission and addressed limited care areas, omitting required elements such as initial goals, ADL needs, and therapy plans.
The facility did not document or monitor specific behavioral symptoms to support the continued use of antidepressant medications for two residents with depression and dementia diagnoses. Both residents were receiving mirtazapine, but their medical records lacked evidence of behavioral monitoring, and the DON confirmed this omission during interviews.
Staff did not follow physician orders for respiratory equipment care, including failing to date nebulizer tubing and improperly storing a CPAP mask. Additionally, after a resident with cognitive impairment and on anticoagulants developed a head bruise, staff did not measure the injury, communicate with the practitioner, or initiate required neuro checks, delaying assessment and investigation.
The facility failed to maintain a medication error rate below 5%, resulting in a 9.8% error rate affecting four residents. Errors included administering medications without required vital sign checks, falsely documenting medication administration, and leaving medications at the bedside despite resident refusal.
The facility failed to follow the five rights of medication administration, resulting in significant medication errors for two residents. Both residents reported not receiving medications on time, causing severe pain and distress. The facility's management confirmed the errors and acknowledged that the medications were given outside of prescribed parameters. No medication error reports were found for the affected residents.
The facility failed to provide safe storage of drugs and biologicals, with medications found in unlocked cabinets and a scheduled II medication not stored under double lock. Additionally, a resident's eye drops were not in their original labeled container. Staff confirmed that these practices did not comply with the facility's policies.
The facility failed to perform proper hand hygiene during medication passes, affecting three residents. Observations revealed that a Medication Aide and an LPN did not adhere to the facility's 20-second handwashing policy and failed to wash hands after glove removal or before exiting residents' rooms. Both staff members were unaware of the correct hand hygiene procedures.
Failure to Complete Pharmacy Recommendations Following Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacy recommendations resulting from monthly drug regimen reviews were completed for three of five sampled residents. According to facility policy, a licensed pharmacist is required to conduct a medication regimen review for each resident, with any recommendations provided to the primary care provider and Director of Nursing (DON) for review and action prior to the next review. However, record reviews revealed that pharmacy recommendations for multiple residents were not addressed in a timely manner, as required by policy. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, pharmacy notes indicated repeated requests for reassessment of PRN Lorazepam over several months, with no evidence that facility staff followed up on these recommendations. Another resident, who had moderate cognitive impairment and was receiving several medications including an antidepressant, had repeated pharmacy recommendations for a gradual dose reduction (GDR) of Escitalopram that were not addressed for nine months. A third resident with dementia, chronic kidney disease, depression, and hypertension also had pharmacy recommendations for GDR of psychotropic medications that were not acted upon for three months. Interviews with the DON confirmed that the expectation was for pharmacy recommendations to be completed within one week of receipt, but this was not done for the residents in question. The lack of timely follow-up on pharmacy recommendations was confirmed through both record review and staff interviews, indicating a failure to comply with facility policy and regulatory requirements regarding medication regimen review and follow-up.
Failure to Follow RD-Approved Menus and Recipes During Meal Preparation
Penalty
Summary
Facility staff failed to follow the approved menu and recipes for meal preparation in one of three cottages, specifically during the preparation of an Italian Tossed Salad. Observations revealed that the cook did not use the recipe approved by the Registered Dietitian (RD) and omitted required ingredients such as red onion and parmesan cheese, instead only including lettuce and cucumber. The cook stated that menus were hardly ever used and that kitchen staff altered the salad based on resident preferences without following the proper process for menu changes. The Culinary Director (CD) and RD both confirmed that not following the RD-approved recipes prevents confirmation of proper nutrition and alters the nutritional value of the dish. The deficiency was identified through record reviews, staff interviews, and direct observation, affecting one cottage with 13 residents receiving food from that kitchen. The RD was unaware that recipes were not being followed and confirmed that any menu changes should be approved through the RD. The facility's policy requires that all food items be prepared using methods and recipes that conserve nutritional value and support the current menu, but this was not adhered to during the observed meal preparation.
Failure to Maintain Cleanliness of Food Storage Equipment
Penalty
Summary
The facility failed to maintain the cleanliness of food storage equipment in two separate kitchen areas, as observed during surveyor walkthroughs. In Cottage 80, a dried red substance was found beneath a roll of ground beef on the bottom shelf of a reach-in freezer, with no barrier in place. This condition persisted over multiple days, as confirmed by both observation and interview with the Culinary Director (CD). The CD acknowledged the issue and revealed that the facility had been without a CD for an extended period prior to their arrival, resulting in the absence of cleaning schedules in the culinary department. In the Rehab Cottage, a reach-in cooler was found to contain standing water with floating food debris on the bottom shelf. Initially, no food items were stored on this shelf, but later observations showed a cardboard box of eggs and a box of juice cartons placed directly in the standing water. The CD confirmed the presence of the standing water and the improper storage of food items. These findings were in direct violation of the facility's own Culinary Cleaning Policy, which requires thorough cleaning and sanitation of equipment and surfaces, as well as the use of cleaning checklists and regular audits.
Failure to Provide Annual Abuse and Dementia Training to Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received required annual training in abuse prevention and dementia care, as evidenced by a review of five employee files. Each file reviewed, including those for nurse aides hired as early as June 2022 and as recently as April 2024, lacked documentation of completed annual abuse and dementia training. Specifically, none of the five nurse aides had documentation of annual dementia training, and two did not have documentation of annual abuse training. An interview with the Regional Nurse Consultant confirmed the absence of these required trainings for the identified nurse aides. The facility's own policy mandates annual in-services for all team members, including abuse and neglect and dementia behavior management, but the records reviewed did not show compliance with this policy for the sampled staff.
Failure to Notify Physician and Responsible Party of Change in Condition and Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the attending physician and the resident's responsible party of a significant change in condition for a resident with cognitive impairment and multiple care needs. The resident, who had short and long-term memory problems, moderately impaired decision-making skills, and required extensive assistance with daily activities, was found to have a large, painful bruise on the forehead during a skin evaluation. Despite the resident being on anticoagulant medication, which increases the risk of complications from bruising, there was no documentation of communication with the physician or responsible party from the time the bruise was first identified until it was later noticed by the resident's daughter. Additionally, the facility failed to ensure that abnormal laboratory results for another resident with moderately impaired cognition and multiple chronic conditions were reviewed by the provider. The laboratory results included several abnormal findings, such as low red blood count, hemoglobin, hematocrit, and eGFR, as well as elevated glucose and hemoglobin A1c levels. There was no confirmation that these results were communicated to or reviewed by the provider as required by facility policy. Interviews with facility staff, including the Clinical Care Coordinator and Director of Nursing, confirmed that the required notifications to the physician and responsible party were not made in both cases. Facility policies clearly state the need for prompt notification of changes in condition, injuries, and abnormal laboratory results, but these procedures were not followed, resulting in deficiencies related to communication and timely notification.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to submit an investigation report to the state agency within five working days regarding an injury of unknown origin for one resident. The resident in question had short and long-term memory problems, moderately impaired decision-making skills, and required varying levels of assistance with daily activities. The resident was also on anticoagulant medication. On a specified date, staff identified a large bruise on the resident's forehead during a skin evaluation, with the cause of the injury unknown and unobserved by staff. Record review showed that the facility's investigation determined the bruise was of unknown origin, meeting the criteria for an injury of unknown source as outlined in the facility's policy. Despite this, there was no confirmation that the required investigation report was submitted to the state agency within the mandated timeframe. The DON confirmed that such a report should have been sent and that there was no evidence of submission via email or fax.
Failure to Complete Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 24 hours of admission for a resident who was admitted with multiple complex medical conditions, including unspecified encephalopathy, paroxysmal atrial fibrillation, an implantable cardiac defibrillator, essential hypertension, a history of transient ischemic attack, cerebral infarction without residual deficits, hemiplegia and hemiparesis affecting the right dominant side, dysphagia, and difficulty walking. The resident was a full code and required assistance from one person to ambulate with a walker. Upon review, the only care plan present was dated several days after admission and addressed only two care areas: risk for falls and risk of impaired nutritional status. Further review of the facility's Baseline Care Plan Policy revealed that a baseline plan of care should be developed within 24 hours of admission and must include specific elements such as initial goals for care, immediate ADL needs, initial orders, dietary orders, therapy plan, social services, and PASRR recommendations if applicable. An interview with the Regional Consultant confirmed that the baseline care plan was not developed within the required timeframe for this resident.
Failure to Monitor Behavioral Symptoms for Antidepressant Use
Penalty
Summary
The facility failed to identify and monitor specific behavioral symptoms to justify the continued use of antidepressant medications for two residents. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, the medical record showed ongoing administration of mirtazapine for depression, but there was no documentation of monitoring for specific behavioral symptoms related to the medication's use. The resident's Minimum Data Set (MDS) indicated receipt of antipsychotic, antianxiety, and antidepressant medications, as well as wandering behavior, but no behavioral monitoring was recorded in the electronic medical record. Similarly, another resident with diagnoses of dementia without behavioral disturbance, chronic kidney disease, depression, and hypertension was also receiving mirtazapine for depression. The MDS for this resident indicated no behavioral symptoms, and the medical record lacked documentation of monitoring for specific behavioral symptoms to support the continued use of the antidepressant. Interviews with the Director of Nursing confirmed that the facility did not identify or monitor specific behavioral symptoms for either resident, contrary to facility policy and expectations.
Failure to Follow Physician Orders and Post-Injury Monitoring Protocols
Penalty
Summary
The facility failed to follow physician orders and established protocols for the care and treatment of residents using respiratory equipment and for monitoring after a head injury. For one resident, staff did not change or date nebulizer tubing and masks as ordered, nor did they store the CPAP mask in a clean, dry area or use a respiratory setup bag when not in use. Multiple observations showed the nebulizer tubing was undated and the CPAP mask was improperly stored, with staff interviews confirming these lapses. Additionally, another resident with significant cognitive and physical impairments, who was on anticoagulant therapy, developed a large bruise on the forehead. Staff did not measure the bruise, communicate with the practitioner or responsible party, or initiate neurological checks as required by facility policy after a head injury. The etiology of the bruise was not investigated in a timely manner, and documentation of the injury and related assessments was delayed.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.8% error rate affecting four residents. For Resident 9, the medication aide administered Carvedilol without taking the required blood pressure or heart rate, despite the order specifying parameters for administration. The last recorded vital signs were from three days prior, and the Director of Nursing confirmed that the parameters were still in effect and should have been followed. Resident 7 was given a chewable tablet that was left at the bedside despite the resident's refusal to take it. The medication aide documented that the medication was ingested, which was later found to be false as the tablet remained untouched. The aide admitted to documenting the medication as taken without witnessing its consumption. Similarly, Resident 8 was given Metoprolol without the required blood pressure or pulse check, and Diclofenac gel was documented as applied when it was not. The medication aide later admitted to forgetting to check the vital signs and falsely documenting the application of the gel. Resident 2 was given scheduled medications, but the application of Betadine to a wound on the right great toe was documented without being performed. The Licensed Practical Nurse admitted to planning to do the treatment later but had already documented it as completed. The Director of Nursing confirmed that medications and treatments should not be documented until they are actually administered or completed. The facility's policies and competency checklists were reviewed, highlighting the requirements for proper medication administration and documentation, which were not followed in these instances.
Significant Medication Errors Due to Failure to Follow Administration Protocols
Penalty
Summary
The facility failed to follow the five rights of medication administration, resulting in significant medication errors for two residents. Resident 2, who has multiple diagnoses including multiple sclerosis, asthma, hypertension, and muscle weakness, reported not receiving medications on time, including pain medication, on several occasions. Specific instances in March 2024 were documented where medications were either given late or not at all, causing severe pain and distress to the resident. The resident's Medication Administration Record (MAR) showed multiple instances of late administration and missing documentation for medications that were supposed to be given at specific times. Resident 9, who has diagnoses of congestive heart failure, hypertension, edema, and macular degeneration, also reported not receiving medications timely. The resident's MAR for March 2024 revealed several instances where medications were administered hours late, causing distress and sleeplessness. There were also instances where medications were not documented as given at all. Both residents had no progress notes in their electronic health records related to the late administration or missed medications, and there was no documentation of updates to their medical doctors. An interview with the facility's management team, including the Assistant Administrator, Director of Nursing (DON), Clinical Coordinator, and other staff, revealed that no one in management reviews the MARs or Treatment Administration Records (TARs) for completeness and timeliness. The DON confirmed that the medications were given outside of the prescribed parameters and acknowledged that these were medication errors. The facility's policies on medication administration and error reporting were not followed, as there were no medication error reports for the affected residents in the facility's incident log.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to provide safe storage of drugs and biologicals, as observed during a survey. Medications were found in unlocked cabinets in rooms occupied by residents in Cottage 70. Specifically, an unlocked medication cabinet was observed during a morning medication pass, and further investigation revealed another unlocked cabinet in a different room. Interviews with a Medication Aide (MA) and a Licensed Practical Nurse (LPN) confirmed that the cabinets should be locked at all times, and a maintenance order was to be completed to fix the cabinet that would not lock. Additionally, a scheduled II medication was found in an unlabeled medication cup in a resident's cabinet, which was not in its original container and not under double lock as required. The LPN admitted to placing the medication in the cabinet earlier in the day, following instructions from a day nurse, but could not recall the exact time it was done. The narcotic count sheet confirmed the medication was pulled from a locked box at 6:00 PM, but it was not stored properly afterward. Furthermore, an observation revealed that a resident's eye drops were not in their original labeled container. The eye drops were found in a small open plastic package with a small label, but the package had no date. The MA confirmed that the eye drops should be in the original box with a label containing the resident's name and directions. Interviews with the Director of Nursing (DON) and other staff confirmed that all medication cabinets should be locked and medications should be kept in their original packages with labels. The facility's policies on medication administration and storage were reviewed, highlighting the requirements for safe and secure storage of medications, which were not followed in these instances.
Failure to Perform Proper Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to perform proper hand hygiene during morning and evening medication passes, which had the potential to affect three out of six sampled residents. Observations revealed that a Medication Aide (MA-C) did not perform hand hygiene after glove removal or upon exiting residents' rooms. Specifically, MA-C washed hands for only 10 seconds instead of the required 20 seconds and did not wash hands after removing gloves or before leaving the room. This was confirmed during an interview with MA-C, who was unaware of the facility's hand hygiene policy. The Director of Nursing (DON) confirmed that the facility policy requires 20 seconds of handwashing and that hand hygiene should be performed after glove removal and before exiting the resident's room. Additionally, during the evening medication pass, a Licensed Practical Nurse (LPN-D) also failed to adhere to the facility's hand hygiene policy. LPN-D washed hands for only 10 seconds at the kitchen sink and was unaware of the required 20-second handwashing policy. The facility's undated Handwashing Competency Checklist specifies that handwashing should be performed for at least 20 seconds and lists multiple instances when hand hygiene is necessary, including after glove removal and before and after elder contact.
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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