Hillcrest Firethorn
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 8601 Firethorn Lane, Lincoln, Nebraska 68520
- CMS Provider Number
- 285300
- Inspections on file
- 21
- Latest survey
- April 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hillcrest Firethorn during CMS and state inspections, most recent first.
Surveyors found that food items in the walk-in freezer and refrigerator were not properly labeled, dated, or covered, and some processed foods were not discarded after the required period. The Dietary Manager confirmed these lapses, which were not in accordance with facility policy or the Nebraska Food Code, potentially affecting all residents.
Two residents were allowed to self-administer medications, including inhalers and nebulizer treatments, without documented assessments of their competency or physician orders as required by facility policy. One resident had an intact cognitive status and the other had moderate cognitive impairment, but neither had the necessary documentation for self-administration. Staff confirmed that these assessments and orders had not been completed.
Three residents were found with medications unsecured in their rooms, including artificial tears, nasal spray, eye drops, antifungal powder, and topical cream. In two cases, there was no completed assessment or physician order for self-administration or to keep medications at bedside, and in another, the medication was not stored in a locked container as required. Staff confirmed that one resident was not capable of self-administration and that medications should not have been left unsecured.
Staff did not consistently use gowns and gloves as required for Enhanced Barrier Precautions during high-contact care activities, such as wound care, catheter care, and resident transfers. In several cases, staff failed to change gloves or perform proper hand hygiene between tasks, and shared equipment was not disinfected after use. These actions were not in accordance with the facility's infection prevention policies and care plans for residents with indwelling devices, wounds, or other risk factors.
The facility failed to follow its bowel management program for a resident, leading to discomfort from unauthorized digital stimulation. Another resident experienced an inadvertent removal of a suprapubic catheter due to a misinterpreted order, resulting in delayed medical attention and additional surgery. These incidents highlight lapses in care protocols and communication within the facility.
A resident's suprapubic catheter was mistakenly removed by an LPN who misread the order. The error was not immediately communicated to the resident's family or healthcare provider, leading to a delay in addressing the medical issue. The facility's policy required notification of significant changes within 24 hours, but the emergent nature of the situation warranted immediate communication, which did not occur.
The facility failed to perform proper hand hygiene during catheter and wound care for a resident with multiple fractures, parkinsonism, chronic kidney disease, and a pressure ulcer. Both an NT and an LPN did not perform hand hygiene after removing soiled gloves and before applying new gloves, and the NT reached into a package of wipes with soiled gloves. Interviews confirmed that hand hygiene should have been performed between glove changes.
The facility kitchen staff failed to label and date opened packages of food and did not dispose of expired food. Additionally, a Dietary Aide was observed engaging in unsanitary practices while prepping room trays, including licking fingers and touching hair without proper hand hygiene. These actions were confirmed by the Dietary Manager as inappropriate.
The facility failed to complete a Level II PASARR for a resident who received new diagnoses of PTSD, Major Depressive Disorder, and Anxiety Disorder. Despite the facility's policy requiring PASRR screenings for changes in diagnosis, the necessary Level II PASARR was not initiated, as confirmed by the Director of Transitions.
A facility failed to update the care plan for a resident with multiple diagnoses and moderate cognitive impairment after a fall resulting in a rib fracture. Despite being identified as at risk for falls, no new interventions were added to the care plan, and staff were unaware of the resident's fall risk.
Improper Food Storage and Labeling in Dietary Services
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's walk-in freezer and refrigerator. Specifically, open boxes of beef patties, chicken patties, chicken fillets, and breakfast potatoes were found in the freezer without labels, dates, or proper sealing, leaving them exposed to air. In the walk-in refrigerator, a serving pan of soup dated 3/16 and a serving pan of rice dated 3/17 were found uncovered or inadequately covered, with the rice appearing dried out. These observations were confirmed by the Dietary Manager, who acknowledged that the items should have been labeled, dated, and sealed according to facility policy. A review of facility policy and the Nebraska Food Code revealed requirements for all food products to be covered, clearly labeled with preparation and expiration dates, and for perishable foods to be discarded after three days. The surveyors found that processed food items were not discarded after the required seven-day period, and food was not stored in accordance with professional standards, creating the potential for foodborne illness. The deficiency had the potential to affect all 56 residents in the facility.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to safely self-administer medications and did not obtain the required physician orders for bedside medication administration. Facility policy requires that residents may self-administer medications only if deemed competent by the nursing team, with a completed assessment and a physician's order documenting the resident's capability. However, for both residents in question, there was no evidence in the medical records of a self-administration assessment or a physician's order permitting self-administration. One resident, admitted with diagnoses including a right lower leg fracture, depression, anxiety, hypertension, and edema, was observed with multiple medications at bedside, including pills, an inhaler, eye drops, a nebulizer, and nasal spray. The resident confirmed self-administration of these medications. The resident's cognitive status was assessed as intact, but no formal assessment or physician order for self-administration was present in the records. Staff interviews confirmed that these steps had not been completed as required. Another resident, admitted with pneumothorax, bronchiectasis, respiratory failure, and anxiety disorder, was observed with a nebulizer and medication at bedside and confirmed self-administration of nebulizer treatments. This resident had moderate cognitive impairment according to the BIMS score. Again, there was no documentation of a self-administration assessment or physician order for self-administration. Staff confirmed that no such orders or assessments were in place for this resident or others on the long-term care side.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments as required, resulting in unsecured medications for three residents. Facility policy states that residents may self-administer medications only if deemed competent by the nursing team, with a completed self-administration assessment and a physician order specifying that medications may be kept at bedside. Additionally, all medications for self-administration should be stored in a lockbox issued to the resident. For one resident with intact cognition, artificial tears were found unlabeled and unsecured on the nightstand, and the resident self-administered the drops without a completed self-medication assessment or a physician order permitting the medication to be kept at bedside. Another resident, also with intact cognition, had a bottle of nasal spray on the tray table in the room, which was not secured, although there was a physician order allowing the medication to be kept at bedside and self-administered. However, the medication was not stored in a locked container as required by policy. A third resident, who had moderate cognitive impairment and multiple medical conditions including respiratory failure, heart failure, glaucoma, and diabetes, had multiple medications including eye drops, antifungal powder, and a topical cream found unsecured in the bathroom. There were no physician orders permitting these medications to be kept at bedside or self-administered, and no assessment of the resident's ability to self-administer medications. Staff confirmed that the resident was not capable of self-administration and that the medications should not have been unsecured in the room.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP), specifically the use of gowns and gloves, for several residents requiring such precautions due to the presence of indwelling medical devices, wounds, or other risk factors. Observations revealed that staff did not consistently don gowns and gloves during high-contact resident care activities, such as wound care, catheter care, and transfers, despite facility policies and signage indicating the need for EBP. For example, during peri-care and suprapubic catheter care for a resident with severe cognitive impairment and a suprapubic catheter, staff wore gowns and gloves but failed to clean the lift sling after use, which was then returned to common use without disinfection. In another instance, an LPN providing suprapubic catheter care to a resident with multiple urinary and kidney diagnoses did not change gloves after handling a soiled dressing and before placing hands into a clean water basin, contrary to infection control protocols. The staff member should have performed hand hygiene and donned clean gloves before proceeding with the next step of care, as confirmed by a clinical care coordinator. This lapse in glove use and hand hygiene increased the risk of cross-contamination during the procedure. Additionally, a resident with multiple chronic conditions, including pressure ulcers, colostomy, and urostomy, was observed receiving wound care and assistance with transfers without staff wearing gowns, despite clear care plan instructions and signage for EBP. Staff confirmed that gowns were not worn due to access issues and lack of awareness, and that wound care was performed without first cleaning off old barrier cream. These failures to follow established infection prevention and control policies contributed to the deficiency cited by surveyors.
Failure in Bowel Management and Catheter Care
Penalty
Summary
The facility failed to adhere to its bowel management program for Resident 3, who was subjected to digital stimulation without proper authorization or necessity. Despite having moderate cognitive impairment, Resident 3 expressed discomfort and a preference for using a bedpan while sitting up, which was not honored. The facility's records showed no bowel toileting program or constipation issues for Resident 3, and no bowel medications were administered as needed. Interviews with staff confirmed that digital stimulation was not appropriate for Resident 3, and the facility's policy did not support such an intervention. Additionally, there was no staff education on bowel management or digital stimulation, leading to discomfort and improper care for Resident 3. In another incident, the facility failed to provide prompt medical attention for Resident 1, who had a suprapubic catheter (SP cath) inadvertently removed instead of just the suture. The error occurred due to a misinterpretation of the physician's order by LPN-E, who did not enlarge the order on the computer screen to see the full instructions. This mistake led to Resident 1 experiencing discomfort and requiring a Foley catheter insertion, which was delayed until the family intervened. The facility did not promptly notify the family or the urologist about the error, and the resident had to undergo additional surgery to replace the SP cath, causing further distress and financial burden. The facility's lack of a policy for following provider's orders and the absence of timely communication with the resident's family and healthcare providers contributed to the deficiencies. The staff's failure to recognize and address the removal of the SP cath in a timely manner resulted in unnecessary pain and complications for Resident 1. These incidents highlight significant lapses in the facility's adherence to care protocols and communication standards, leading to adverse outcomes for the residents involved.
Failure to Notify of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's provider and representative of an emergent significant change in the resident's medical condition. Resident 1, who had a history of neuromuscular dysfunction of the bladder, paraplegia, and spinal stenosis, was admitted with a suprapubic catheter. The catheter was inadvertently removed by LPN-E, who misread the order to remove only the suture. This error was not immediately communicated to the resident's family or healthcare provider. The incident occurred when LPN-E, while administering medication, removed the suprapubic catheter instead of just the suture, as per the order. The resident did not question the removal, and LPN-E did not realize the mistake until later. RN-F, who was informed of the removal during a shift change, did not take immediate action to verify the order or notify the appropriate parties. The error was discovered by APRN-D during a routine assessment, who then facilitated communication with the urologist and the resident's family. The facility's administration was notified of the catheter removal, but the resident's family was not informed until they arrived at the facility later that day. The delay in communication and the failure to immediately address the medical error led to the resident experiencing discomfort and requiring additional medical intervention. The facility's policy required notification of significant changes within 24 hours, but the emergent nature of the situation warranted immediate communication, which did not occur.
Failure to Perform Proper Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to perform proper hand hygiene during catheter care and wound care for Resident 14, who had multiple fractures, parkinsonism, chronic kidney disease, and an in-house acquired pressure ulcer. During an observation, NT-C and LPN-B did not perform hand hygiene after removing soiled gloves and before applying new gloves. NT-C also reached into a package of incontinence wipes with soiled gloves and did not perform hand hygiene after cleaning the resident's groin and genitalia. LPN-B similarly failed to perform hand hygiene between cleansing the sacral area and applying a clean dressing. Interviews with the CCC-A, ADM, and DON confirmed that hand hygiene should have been performed between glove changes. NT-C admitted to not realizing the proper times for glove removal and hand hygiene, and expressed reluctance to break contact with the resident to use hand sanitizer. The facility's Hand Hygiene Policy, dated 2/23/2022, outlines the necessity of hand hygiene before and after glove use, and between tasks involving different body sites, which was not followed in this instance.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility kitchen staff failed to label and date opened packages of food in the walk-in refrigerator and dry storage, and did not dispose of expired food from the walk-in refrigerator. Observations revealed several opened and undated food items, including jalapeno peppers, lemons, dried out carrots, and various other perishable items. Additionally, expired food items such as coleslaw and baby spinach were found in the refrigerator. The dry storage room also contained improperly stored and undated food items, such as fettucine and ziti noodles. The Dietary Manager confirmed these findings and acknowledged that the expired food should not have been available for use. Furthermore, a Dietary Aide was observed engaging in unsanitary practices while prepping room trays for lunch. The aide licked their fingers to separate meal tickets, rubbed their nose with the back of their hand, and touched their hair without performing proper hand hygiene. Despite washing their hands briefly, the aide continued to engage in these unsanitary practices, which were confirmed by the Dietary Manager as inappropriate. These actions were in violation of the Nebraska Food Code, which mandates proper hand hygiene to prevent cross-contamination during food preparation.
Failure to Complete Level II PASARR for Resident with New Diagnoses
Penalty
Summary
The facility failed to ensure a Level II PASARR was completed after Resident 28 received new diagnoses of PTSD, Major Depressive Disorder, and Anxiety Disorder. Resident 28 was admitted with a primary diagnosis of Spinal Stenosis and had a BIMS score of 15, indicating full cognitive function. Initially, the Level I PASARR indicated no mental illness or intellectual disability. However, the new diagnoses required a Level II PASARR, which was not initiated at the time of diagnosis in August 2023. The deficiency was confirmed during an interview with the Director of Transitions, who acknowledged that a Level II PASARR should have been initiated in August 2023 but was not. The facility's policy mandates that an identification screen (PASRR) be completed for changes in diagnosis or condition, which was not adhered to in this case. This oversight was identified during a record review and subsequent interviews, highlighting a lapse in the facility's compliance with federal requirements for PASARR screenings.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the baseline care plan for Resident 68 after a fall with a major injury. Resident 68, who was admitted with multiple diagnoses including a ground-level fall, fracture of the second cervical vertebra, and congestive heart failure, exhibited moderately impaired cognition with a BIMS score of 8. Despite being identified as at risk for falls with a score of 10 on the Fall Risk assessment, the resident's Comprehensive Care Plan (CCP) initiated on 3/28/2024 had no focus, goals, or interventions for falls. After a fall on 4/1/2024 resulting in a rib fracture, the Incident Report indicated that the plan of care would be updated with interventions for frequent checks and offering the bathroom. However, a review on 4/9/2024 revealed no new fall interventions were added to the Baseline Care Plan (BCP) or CCP. Interviews with staff, including a Nurse Tech and the Director of Nursing (DON), revealed a lack of awareness and action regarding the resident's fall risk and the necessary updates to the care plan. The facility's policy on Fall Risk Management and Comprehensive Care Planning mandates that care plans be reviewed and updated as the resident's condition changes, but this was not adhered to in Resident 68's case. The failure to update the care plan after the fall with a major injury indicates a significant lapse in following established protocols for resident safety and care planning.
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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