Hillcrest Millard Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 13225 Westwood Lane, Omaha, Nebraska 68144
- CMS Provider Number
- 285302
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hillcrest Millard Llc during CMS and state inspections, most recent first.
Surveyors identified that resident rooms, bathrooms, the dining room, and common areas were not maintained in a clean and sanitary condition. Multiple rooms had floors soiled with debris, dried liquids, popcorn, candies, tissues, and small paper pieces, while several toilets and toilet risers had dried brown substances, brown stains, and white creamy substances on the seats, bowls, and surrounding floors. Trash cans were observed full with used briefs, and paper towels and meal trays were left on floors. A white powdery substance under a bed remained over several days with only partial cleaning. Common and dining areas had a large dark carpet stain, a red stain under a dining table, debris on the dining room floor, and a green-stained drain area under an ice machine, all of which were confirmed by the Administrator during a tour.
The facility failed to prepare food according to the recipe, potentially affecting all residents. Chef A was observed making Salisbury steak patties without measuring ingredients or following the recipe, and did not weigh the patties to meet the required ounces. The Culinary Director confirmed that this practice could alter the nutritional value of the food.
A long-term care facility failed to respond to call lights in a timely manner, with residents experiencing delays ranging from 20 minutes to over an hour. The issue was exacerbated by staff not carrying or being trained to use cell phone pagers, leading to prolonged wait times for assistance with personal care needs. Despite a performance improvement project, the facility's efforts to address the problem were ineffective.
A resident with a history of pressure ulcers reported a new ulcer, but the facility failed to notify the physician and obtain treatment orders in a timely manner. Despite a scheduled skin assessment, no treatment was documented, and the issue was only addressed after several days. The facility's policy on skin integrity was not followed.
A resident with a history of COPD, respiratory failure, and amputation required supervision and assistance with personal care. The resident sustained multiple skin tears on the right elbow, reportedly from bumping into a handrail. The facility failed to conduct an event report or investigate the causal factors, contrary to its policy on skin integrity and wound care.
The facility did not identify or monitor specific target behaviors for two residents using antidepressant medications. Both residents, diagnosed with Major Depressive Disorder and Anxiety Disorder, had physician orders and care plans lacking specific target behaviors. Generalized behavior monitoring was documented, but no individualized monitoring was conducted, as confirmed by the Regional Nurse Consultant.
The facility failed to maintain a clean and safe environment, with deficiencies observed in four resident rooms. Issues included worn bathroom door frames, stained carpets, damaged floors, and a blood-stained urinary catheter bag left in a bathroom. Staff interviews confirmed these observations, and the Facility Administrator admitted to a lack of housekeeping schedules.
The facility failed to complete comprehensive baseline care plans for two residents within 48 hours of admission. One resident's BCP lacked information on monitoring for hypertension, diabetes, antidepressant use, and pain, while another's omitted details on blood sugar, depression, and pain monitoring. The Regional Nurse Consultant confirmed these omissions, indicating a failure to meet regulatory requirements for initial care.
Two residents in the facility were not provided timely and adequate care for pressure ulcers. One resident, who was cognitively intact, had excoriation and an open wound to the sacrum, but no treatment was recorded until hospital discharge. Another resident, with a history of pressure ulcers, was admitted without a skin assessment, and despite reporting a pressure ulcer and requesting an air mattress, no treatment was documented until days later. Facility staff confirmed that necessary interventions and treatment orders were delayed.
The facility failed to notify the medical provider of abnormal blood sugar levels for a resident with end-stage renal disease and type 2 diabetes. Despite blood sugar readings of 67 and 59 on separate occasions, the medical provider was not informed as required by the facility's policy.
The facility failed to coordinate medication administration with the dialysis schedule for two residents, resulting in multiple missed doses of critical medications. Interviews with staff revealed a lack of clear protocol for managing medication administration for residents who leave early for dialysis, leading to deficiencies in care and documentation.
The facility failed to label insulin pens with the date they were opened for three residents, leading to the disposal of undated pens and the need to obtain new ones from emergency stock. Interviews confirmed that insulin pens are required to be dated when first used.
Failure to Maintain Clean and Sanitary Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms, bathrooms, common areas, and the dining room in a clean and sanitary condition, as required by licensure regulations. Surveyors observed multiple resident rooms with visibly soiled floors, dried liquid spills, debris, popcorn, M&M candies, tissues, and small pieces of paper throughout rooms and bathrooms. Several toilets and toilet risers were noted to have dried brown substances, brown splatters, brown stains, and white creamy substances on the seats, bowls, and surrounding floors. Trash receptacles were observed full with used briefs, and paper towels and meal trays were left on floors. In one room, a white powdery substance was scattered on the floor under the head of the bed and remained over several days, only partially cleaned with smears still visible on subsequent observations. Additional observations extended beyond individual rooms to common and dining areas. Surveyors noted a large dark stain on the carpet near seating in a common area, a red stain under a dining room table near the kitchen entrance, and dining room floors soiled with debris throughout. In the Railroad common area, the drain area in the cabinet under the ice machine was soiled with a green stain. These conditions were repeatedly observed over multiple days, and during a facility tour the Administrator confirmed the presence of the soiled floors, stained carpet, stained area under the ice machine, and the soiled toilets and floors in multiple identified rooms.
Improper Food Preparation Practices
Penalty
Summary
The facility failed to ensure that food was prepared according to the recipe, which could potentially affect all residents consuming meals from the facility kitchen. During an observation, Chef A was seen preparing Salisbury steak patties without measuring the ingredients or following the recipe as written. Chef A mixed unmeasured amounts of various ingredients, including beef base, tomato ketchup, Worcestershire sauce, garlic, liquid eggs, mustard, breadcrumbs, onion powder, chopped onions, bell peppers, and ground beef, and formed them into patties without weighing them to meet the required ounces specified in the recipe. An interview with Chef A confirmed the deviation from the recipe, and a subsequent interview with the Culinary Director acknowledged that using unmeasured items not in the recipe could alter the nutritional value of the food.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for multiple residents, leading to significant delays in providing necessary assistance. Residents, including those with conditions such as Diabetes Mellitus, COPD, and arthritis, reported waiting times ranging from 20 minutes to over an hour for assistance with transfers, toileting, and other personal care needs. These delays were documented through interviews with residents and review of the facility's Device Activity Logs, which recorded numerous instances of prolonged call light response times. Observations and interviews with staff revealed systemic issues contributing to the delays. Nurse aides and other staff members were not consistently carrying cell phone pagers, which are used to alert them to active call lights. Some staff members reported not being trained on the use of these pagers, while others cited technical issues such as dead batteries. The Director of Nursing confirmed that the facility's expectation was for call lights to be answered within 15 minutes, but acknowledged that this standard was not being met. The facility had previously identified call light response times as a problem and implemented a performance improvement project in an attempt to address the issue. However, the Director of Nursing admitted that the project had been ineffective, as evidenced by the continued long response times. The deficiency was further highlighted by grievances from residents and their families, who expressed concerns about the impact of these delays on resident care and safety.
Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician and obtain treatment orders for a pressure ulcer for a resident, identified as Resident 61. The resident was admitted with a history of pressure ulcers and required staff assistance with bed mobility and transfers. Despite being cognitively intact, as indicated by a BIMS score of 14, the resident reported having a pressure ulcer to the buttocks. A scheduled skin assessment was not completed, and no treatment was documented for the pressure ulcer in the Treatment Administration Record. Observations revealed that a dressing was applied to the resident's buttocks, and the pressure ulcer was confirmed by a Licensed Practical Nurse (LPN) during wound care. The facility's Regional Nurse Consultant confirmed that the physician was not notified, and treatment orders were not obtained until several days after the ulcer was reported. The facility's policy on skin integrity and wound care emphasizes the importance of obtaining correct treatment orders and communicating skin integrity issues to the physician, which was not adhered to in this case.
Failure to Investigate Resident's Skin Tears
Penalty
Summary
The facility failed to investigate and identify causal factors for injuries sustained by a resident, leading to a deficiency. The resident, who has a medical history of Chronic Obstructive Pulmonary Disease, respiratory failure, right below the knee amputation, and anxiety, required supervision with transfers and assistance with personal care. An observation revealed a foam island dressing on the resident's right elbow, which the resident reported was due to bumping the elbow on a handrail. Despite the presence of skin tears, the facility did not conduct an event report or investigation into the causal factors. Further observations and record reviews showed that the resident had multiple skin tears on the right elbow, with no measurements or documentation of an investigation into the cause. The facility's policy required event reports and causal factor investigations for skin tears, but this was not followed. The Director of Nursing confirmed that no investigation was conducted, highlighting a lapse in adherence to the facility's skin integrity and wound care policy.
Failure to Monitor Specific Target Behaviors for Antidepressant Use
Penalty
Summary
The facility failed to identify and monitor specific target behaviors for the use of antidepressant medications for two residents, both diagnosed with Major Depressive Disorder and Anxiety Disorder. Resident 58 was admitted with a physician order for Mirtazapine, an antidepressant, but the physician orders and the Comprehensive Care Plan (CCP) did not specify target behaviors to be monitored. The Medication Administration Record (MAR) documented generalized behavior monitoring without individualized target behaviors, and the Electronic Medical Record (EMR) lacked documentation of specific target behaviors and monitoring. Similarly, Resident 73, who was also diagnosed with Major Depressive Disorder and Anxiety Disorder, was prescribed Escitalopram Oxalate. The physician orders and CCP did not identify specific target behaviors for monitoring. The MAR showed generalized behavior monitoring, and the EMR did not document specific target behaviors or monitoring. An interview with the Regional Nurse Consultant confirmed the absence of resident-specific target behaviors and monitoring for both residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed in four resident rooms. In one room, the bathroom door frame had scratches with paint and drywall worn away. Another room had a noticeable carpet stain right inside the resident's room. Additionally, a toilet riser in a different room had its foot pegs sunken into the floor, with the cement around them worn away, and the floor around the toilet was stained. Furthermore, a urinary catheter bag stained with blood was found sitting on a shower chair in a bathroom, which should have been removed. Interviews with facility staff confirmed these observations. The Maintenance Director, who had recently accepted the position after a three-month vacancy, acknowledged the issues with the bathroom door frame, carpet stain, and floor condition. The Regional Nurse Consultant confirmed that the blood-stained urinary catheter bag should not have been left in the room. The Facility Administrator admitted that there had been no housekeeping schedules in place, and they had been overseeing maintenance, laundry, and housekeeping during the absence of a Maintenance Director.
Incomplete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that the baseline care plan (BCP) for two residents was completed with significant medical information within 48 hours of admission. Resident 58, who was admitted with diagnoses including Diabetes Mellitus Type 2, Hypertension, Atrial Fibrillation, and Major Depressive Disorder, had physician orders for monitoring various conditions such as blood glucose levels, antidepressant behavior, and side effects of diuretic medication. However, the BCP for Resident 58 did not include necessary information related to monitoring for hypertension, diabetes, antidepressant use, bleeding risk from anticoagulant use, diuretic medication, or pain monitoring. Similarly, Resident 73, admitted with Diabetes Mellitus Type 2, Hypertension, and Major Depressive Disorder, had physician orders for monitoring blood glucose levels, antidepressant behavior, and pain. The BCP for Resident 73 only identified a fall risk and failed to include information on blood sugar monitoring, depression monitoring, or pain monitoring. The Regional Nurse Consultant confirmed the absence of these critical details in the BCPs for both residents. The deficiency was identified through record reviews and interviews, highlighting the facility's failure to develop comprehensive baseline care plans that address the immediate and significant medical needs of newly admitted residents. This oversight in the BCPs for Residents 58 and 73 indicates a lack of adherence to regulatory requirements for providing initial effective and person-centered quality care.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to identify, evaluate, and provide timely treatment for pressure ulcers in two residents, leading to deficiencies in care. Resident 155, who was cognitively intact and required assistance with mobility and dressing, was admitted with blanchable redness on the buttocks. Despite this, the baseline care plan did not document any skin issues, and a subsequent skin evaluation revealed excoriation and an open wound to the sacrum. However, no treatment was recorded until the resident was discharged to the hospital, indicating a lack of timely intervention. Similarly, Resident 61, who had a history of pressure ulcers and required staff assistance for mobility, was admitted without a skin assessment being conducted. The resident, who was also cognitively intact, reported having a pressure ulcer and requested an air mattress, which was not provided. A Braden Scale assessment indicated a moderate risk for pressure sore development, yet no treatment was documented until several days later when a dressing was observed on the resident's buttocks. The resident's healthcare practitioner later confirmed the presence of a stage 2 pressure ulcer. Interviews with facility staff, including a Regional Nurse Consultant, confirmed that necessary interventions and treatment orders were not obtained in a timely manner for both residents. The facility's policy on skin integrity and wound care was not followed, as evidenced by the lack of documentation and communication regarding the residents' skin conditions and the absence of appropriate preventive measures.
Failure to Notify Medical Provider of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to ensure the medical provider was notified of blood sugar levels outside of the specified parameters for one resident. Resident 4, who had diagnoses of end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus without complications, had orders for blood glucose monitoring four times per day with instructions to notify the physician if blood sugars were less than 70 or greater than 400. On two occasions, the resident's blood sugar levels were outside these parameters, but the medical provider was not notified as required by the facility's policy and the resident's care plan. On 4/8/24, Resident 4's blood sugar was recorded at 67, and on 4/4/24, it was recorded at 59. In both instances, the resident was given a snack, and the blood sugar levels were subsequently rechecked and found to be within normal limits. However, there was no documentation indicating that the medical provider was informed of these abnormal blood sugar levels. The Director of Nursing confirmed the lack of notification during an interview, acknowledging that the medical provider should have been notified according to the facility's policy.
Failure to Coordinate Medication Administration with Dialysis Schedule
Penalty
Summary
The facility failed to ensure the coordination of medication administration with the dialysis schedule for two residents requiring dialysis. Resident 2, who had diagnoses including pneumonia, type 2 diabetes mellitus, and end-stage renal disease, had multiple instances where medications were not administered due to being out of the facility for dialysis. Specifically, medications such as Amlodipine Besylate, Aspirin, Calcitrate Plus D, Cholecalciferol, Glargine insulin, Potassium Chloride ER, Toresemide, Valsartan, Acidophilus, Amoxicillin-Pot Clavulanate, Carvedilol, Entresto, Insulin Aspart, and sliding scale insulin were not given on several occasions. Interviews with staff revealed that there was no clear protocol for administering medications to residents who leave early for dialysis, leading to missed doses and lack of proper documentation in the care plan and MAR (Medication Administration Record). Resident 2's blood sugar was also not checked before leaving for dialysis, and insulin was not administered as scheduled, resulting in a high blood sugar level upon return from dialysis. Similarly, Resident 4, who had diagnoses including end-stage renal disease and type 2 diabetes mellitus, also missed several doses of medications due to being out of the facility for dialysis. Medications such as CertaVite Senior Oral Tablet, Sertraline, Tracrolimus, Calcium Citrate plus D, Cholestyramine, Medroxyprogesterone, Mycophenolate sodium, Nystatin Powder, Aspart insulin, and Sildenafil Citrate were not administered on multiple occasions. Interviews with staff indicated that there was no established procedure for administering medications to residents who leave early for dialysis, leading to missed doses and lack of proper documentation in the care plan and MAR. Resident 4's blood sugar was also not checked before leaving for dialysis, and insulin was not administered as scheduled. The facility's policy on dialysis monitoring, dated 1/1/2023, stated that the facility would coordinate care with the dialysis provider to develop an appropriate plan of care, including any recommended medication schedule changes. However, the facility failed to implement this policy effectively, resulting in missed medication doses and inadequate care for residents requiring dialysis. Interviews with the Director of Nursing and other staff members revealed that there was no consistent approach to managing medication administration for residents going to dialysis, leading to deficiencies in care and documentation.
Failure to Label Insulin Pens with Date Opened
Penalty
Summary
The facility failed to ensure that insulin pens were labeled with the date they were opened for three residents. During observations, it was noted that Resident 2's Aspart and Glargine insulin pens were not dated with the date opened. LPN A had to obtain a new Aspart insulin pen from the facility's emergency medication stock for administration to Resident 2. Similarly, Resident 3's Glargine insulin pen was also found to be undated, and a new pen had to be obtained from the emergency stock. Additionally, Resident 3's Aspart pen was not labeled with the resident's name or the date it was opened, leading to its disposal and replacement with a new pen from the medication refrigerator. Resident 4's insulin pen was also found to be undated and was discarded accordingly. Interviews with LPN A and RN Consultants E and F confirmed that insulin pens are required to be dated when first used. The review of the Medication Administration Records (MAR) for Residents 2, 3, and 4 indicated that insulin pens should be discarded 28 days after initial use. The facility's failure to label the insulin pens with the date they were opened led to the unnecessary disposal of medication and potential risks to the residents' health management.
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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