Hillcrest Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellevue, Nebraska.
- Location
- 1702 Hillcrest Drive, Bellevue, Nebraska 68005
- CMS Provider Number
- 285133
- Inspections on file
- 19
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Hillcrest Health & Rehab during CMS and state inspections, most recent first.
Two residents at risk for pressure ulcers did not receive timely or appropriate interventions, including the use of pressure-relieving devices and specific care plan updates. One resident developed new pressure ulcers without the ordered Roho cushion or air mattress in place, while another was transferred without protective footwear, contributing to ulcer development. Additionally, practitioner-ordered wound care was not consistently provided or documented for a resident with a foot ulcer.
Staff did not consistently wear required masks during a COVID-19 outbreak, failed to implement Enhanced Barrier Precautions for a resident with a chronic wound, and allowed damaged recliners in a common area to remain in use despite being unable to be fully cleaned, as confirmed by direct observation and staff interviews.
The facility did not complete required neurological checks after unwitnessed falls for two residents, including one with significant cognitive impairment and another with mobility issues. Additionally, a resident was not provided with PRN bowel medications or monitored for bowel movements as required by facility policy, despite extended periods without a bowel movement. Staff interviews and documentation confirmed these deficiencies.
Two residents with significant fall risks and physical impairments were not adequately protected from accidents. One resident experienced a fall during an attempted transfer without proper staff assistance or a thorough post-fall investigation, while another resident was repeatedly observed without access to a call light or bell as required by their care plan, leaving them unable to request help for over an hour.
A resident with chronic heart failure and a prosthetic heart valve experienced multiple episodes of low oxygen saturation, with readings documented below facility alert thresholds. Staff failed to consistently notify a nurse or provider of these changes, and critical low readings were not escalated as required by facility policy. The resident was later found unresponsive, and interviews confirmed that protocols for monitoring and responding to changes in condition were not followed.
Two residents with severe cognitive impairment experienced multiple falls due to the facility's failure to ensure fall prevention measures, such as bed and wheelchair alarms, were consistently in place and functioning. Despite care plans indicating the need for alarms, incidents revealed that these interventions were not properly implemented, leading to falls and injuries.
A facility failed to comply with CMS regulations by extending a PRN order for Lorazepam without a rationale and did not identify target behaviors for Quetiapine Fumarate and Lorazepam for a resident. The DON confirmed the absence of a rationale and target behaviors, indicating a lapse in monitoring and managing the resident's conditions.
The facility's MRR Policy lacked specific time frames for each step of the process and did not outline steps for pharmacists when immediate action is required. The DON confirmed the policy was considered complete despite these omissions.
Failure to Implement Pressure Ulcer Prevention and Wound Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the prevention of pressure ulcers and did not provide practitioner-ordered wound care for two residents. One resident, who was at moderate to high risk for pressure ulcer development due to limited mobility, incontinence, and cognitive impairment, experienced a decline in skin integrity. Despite worsening Braden Scale scores and the development of a stage 2 pressure ulcer and an unstageable heel ulcer, the care plan was not updated in a timely manner to reflect new interventions. Observations revealed that ordered pressure-relieving devices, such as a Roho cushion and air mattress, were not in place, and heel protectors were only implemented after the heel wound developed. Staff interviews confirmed delays in obtaining and implementing these interventions. Another resident, who had multiple comorbidities and was dependent on staff for transfers and mobility, developed an unstageable pressure ulcer on the left foot related to not wearing appropriate footwear during transfers. The care plan did not include specific interventions addressing the cause of the ulcer, such as the requirement to wear shoes during all transfers. Observations showed that staff continued to transfer the resident using a sit-to-stand lift while the resident wore only socks, and staff interviews confirmed a lack of awareness regarding the need for protective footwear during transfers. The resident also confirmed that staff had not provided instructions to change transfer practices after the ulcer was identified. Additionally, the facility failed to consistently provide and document practitioner-ordered wound care for the resident with the left foot ulcer. Review of treatment records revealed multiple missed wound care treatments on specified dates, and staff interviews confirmed that these treatments were not completed as ordered. The wound nurse acknowledged that wound care was not always documented or performed according to the physician's orders.
Failure to Follow Infection Control Protocols During Outbreak and Inadequate Equipment Maintenance
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies during a COVID-19 outbreak. Despite the facility's policy requiring all staff to wear source control (surgical mask or N-95 respirator) during outbreak status, multiple staff members, including nurse techs, an LPN, and an environmental services tech, were observed in various hallways and resident rooms without masks. This occurred even in areas with confirmed COVID-19 positive residents and in rooms with droplet precautions signage. Interviews with staff and the administrator confirmed that guidance had been provided to wear masks, but compliance was not maintained. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, as required by policy. The resident had an unstageable pressure ulcer and required EBP, including the use of gowns and gloves during high-contact care and appropriate signage outside the room. Observations revealed that no EBP signage was posted, gowns were not available, and staff, including the wound nurse, did not don gowns during wound care. Staff were observed performing wound care without proper PPE and then moving throughout the facility, and interviews confirmed that EBP was not in place as required. Additionally, six recliners in a commons area had vinyl coverings that were peeling away from the armrests and seats, making them unable to be fully cleaned. The Environmental Services Director confirmed that the damaged chairs could not be properly sanitized, increasing the potential for cross contamination in the shared area.
Failure to Complete Neuro Checks and Bowel Management Interventions
Penalty
Summary
The facility failed to implement required neurological checks following unwitnessed falls for two residents. For one resident with a history of infection, myasthenia gravis, and impaired mobility, neurological checks were ordered after an unwitnessed fall, but several scheduled assessments were missed over multiple days. Documentation confirmed that these checks were not completed as expected, and there was no additional evidence of the assessments being performed. Another resident, who was severely cognitively impaired, required extensive assistance with activities of daily living, and was receiving hospice care, experienced two unwitnessed falls. Record review and staff interviews confirmed that neurological checks were not conducted after either incident, despite facility policy requiring such assessments for unwitnessed falls. Additionally, the facility did not monitor or intervene appropriately for bowel management for the same cognitively impaired resident. Bowel records showed extended periods without a bowel movement, and the Medication Administration Record indicated that no PRN bowel medications were administered during these times. Staff interviews confirmed that the resident should have received PRN bowel medications according to facility policy, but this did not occur.
Failure to Prevent Accidents and Ensure Adequate Supervision for Residents at Risk of Falls
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for two residents with significant fall risks and physical impairments. One resident, admitted with multiple diagnoses including infection due to a knee prosthesis, bacteremia, myasthenia gravis, essential tremors, and gait abnormalities, was dependent on staff for transfers and had impaired range of motion. Despite these risks, the resident experienced a fall while attempting to transfer from a recliner to bed. Documentation revealed that staff were aware the resident needed assistance and instructed the resident to wait, but upon returning, found the resident on one knee at the bedside. The incident was not fully investigated, as required by facility policy, with no comprehensive documentation, staff statements, or root cause analysis completed. Progress notes did not reflect the fall, and there was no evidence of a formal review during clinical meetings. Another resident, assessed as severely cognitively impaired and at high risk for falls, required extensive assistance with activities of daily living and had a history of multiple falls. The resident's care plan included interventions such as keeping a call light and bell within reach, frequent rounding, and environmental modifications to reduce fall risk. However, multiple observations showed the resident's bell was consistently out of reach, and at times, the call light was not accessible. Staff confirmed the call light was broken and a work order was supposedly placed, but the Environmental Service Director reported no such work order had been submitted. The resident was left without access to a call light or bell for over an hour, contrary to the care plan interventions. These events demonstrate lapses in both the implementation of individualized fall prevention interventions and the facility's investigative processes following incidents. The lack of thorough documentation, failure to ensure assistive devices were within reach, and incomplete post-fall investigation contributed to the deficiencies identified for both residents.
Failure to Evaluate and Respond to Change in Condition for Resident with Low Oxygen Saturation
Penalty
Summary
The facility failed to properly evaluate and respond to a change in condition for a resident with a history of infection related to a hip prosthesis, chronic systolic heart failure, and a prosthetic heart valve. The resident had moderately impaired cognitive function and was being monitored for oxygen saturation, with facility parameters indicating that levels below 90% required attention. Over several days, the resident's oxygen saturation levels fluctuated, with multiple documented readings below the facility's threshold, including a reading as low as 54%. Despite these low readings, there was no physician order for oxygen, and staff did not consistently notify a nurse or provider of the resident's declining oxygen saturation. On one occasion, a nurse aide recorded a critically low oxygen saturation but became busy and failed to report it to the nurse. Other staff members noted low oxygen levels but did not observe respiratory distress and did not escalate the issue appropriately. The situation escalated when dietary staff alerted a registered nurse that the resident was unresponsive, at which point the resident was found without signs of life. Facility policy required detailed observation and provider notification in the event of a change in condition, but this was not followed. Interviews with staff confirmed that expected protocols, such as rechecking oxygen saturation, ensuring oxygen was administered as ordered, and notifying the physician, were not consistently implemented. The failure to recognize and respond to the resident's significant change in condition directly contributed to the deficiency cited in the report.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, leading to multiple incidents of falls. Resident 4, who was admitted with a displaced fracture and severe cognitive impairment, was identified as high risk for falls. Despite having a care plan that included a bed alarm and physical therapy consult, Resident 4 experienced falls on two occasions. On the second incident, the resident was found on the floor with a hip fracture, and it was confirmed that the bed alarm was not functioning as it should have been. Resident 7, also with severe cognitive impairment and dependent for transfers, had a care plan that included alarms on the wheelchair and bed. However, Resident 7 experienced multiple falls, including sliding out of the wheelchair and being found on the floor by the bed. The incidents revealed that the alarms were not consistently in place or functioning, as evidenced by the lack of initialing on the treatment administration record to confirm alarm checks. Interviews with staff, including a Medication Aide and the Director of Nursing, confirmed that the alarms were not in place or functioning during the falls. The Clinical Care Coordinator also acknowledged the absence of functional alarms and the need for staff education on ensuring fall interventions were in place. These deficiencies highlight a failure in the facility's fall prevention measures, leading to repeated falls for the residents involved.
Failure to Provide Rationale and Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with CMS regulations regarding the use of psychotropic medications for a resident. Specifically, a PRN order for Lorazepam, an antianxiety medication, was extended for 365 days without providing a rationale for its continued use beyond the 14-day limit set by CMS. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a rationale for the PRN Lorazepam order. Additionally, the facility did not identify target behaviors for the use of Quetiapine Fumarate, an antipsychotic medication, and Lorazepam for the resident. The orders required monitoring for target behaviors related to the resident's schizoaffective disorder and panic disorder, respectively. However, the Director of Nursing confirmed that target behaviors were not identified for either medication, indicating a failure to properly monitor and manage the resident's conditions as per the prescribed orders.
Deficiency in Medication Regimen Review Policy
Penalty
Summary
The facility failed to ensure that its Medication Regimen Review (MRR) Policy included the required procedural steps, as mandated by licensure reference number 175 NAC 12-006.12(A)(vi). A record review of the facility's MRR policy dated January 1, 2023, revealed that the policy lacked specific time frames for each step of the MRR process. Additionally, the policy did not outline the steps the pharmacist must take when an irregularity requires immediate action. During an interview on December 16, 2024, the Director of Nursing confirmed that the MRR Policy was considered complete as written, despite these omissions.
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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