Hillcrest Shadow Lake Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Papillion, Nebraska.
- Location
- 1507 E Gold Coast Road, Papillion, Nebraska 68046
- CMS Provider Number
- 28E299
- Inspections on file
- 23
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hillcrest Shadow Lake Llc during CMS and state inspections, most recent first.
Two residents at risk for pressure ulcers did not receive consistent prevention, assessment, or wound management in accordance with facility policy. One resident with quadriplegia and moderate cognitive impairment had no documented weekly skin evaluations for a two-week period after admission, did not receive pressure-reducing surfaces until after a stage 2 buttock ulcer developed, and later developed additional pressure ulcers without timely measurements or new care plan interventions; this resident’s air mattress was repeatedly set for a much higher weight than recorded, with no practitioner order for the mattress or its settings. Another resident, cognitively intact but with incontinence and decreased mobility, had a history of heel and foot ulcers and was care planned for weekly skin monitoring, yet went 11 days without a documented weekly skin evaluation before hospital transfer; hospital records then identified a full-thickness posterior thigh wound with purulent, malodorous drainage and additional pressure ulcers to the heel and top of the foot that were not fully captured in facility documentation. Staff interviews confirmed missed weekly skin evaluations, lack of identified causal factors for certain wounds, and uncertainty about whether treatments were in place prior to hospital transfer.
A resident with bilateral venous ulcers, cognitively intact but dependent for most ADLs, had a care plan and facility policy requiring initial and weekly wound measurements (length, width, depth) and ongoing documentation of wound status. However, over several months, the EHR contained no wound assessments or measurements, and progress notes lacked wound evaluations. The resident’s legs were observed wrapped in gauze, and the ADON and DON acknowledged that wound assessments were being done only at an outside vascular clinic and that the facility neither obtained wound descriptions or measurements from those visits nor performed its own weekly evaluations, despite the Director of Compliance confirming that weekly in-house monitoring was required.
Surveyors found that three residents receiving diuretic medications for conditions such as chronic kidney disease and congestive heart failure did not have appropriate monitoring in place. Despite care plans referencing the need for lab work and symptom monitoring, there were no orders or documentation of monitoring, and staff confirmed the absence of such orders. The DON indicated that pharmacy recommendations are made, but monitoring is only implemented if ordered by the provider.
Staff did not follow hand hygiene and gloving protocols during meal service, with a nurse aide delivering multiple meal trays to different rooms without removing gloves or performing hand hygiene between rooms. The aide also carried a tray of uncovered cinnamon apples into resident rooms, contrary to facility policy. This affected 44 residents who received food from the tray cart.
A resident with cognitive intactness and multiple medical conditions alleged being physically abused by staff, including being grabbed and forced to take a shot. The facility failed to notify the State Agency of this abuse allegation within the required timeframe, only reporting it after a significant delay.
Staff did not measure and record pulse rates before and after nebulizer treatments for a resident with heart and kidney conditions, despite facility procedures requiring this monitoring. Instead, the resident's pulse was only recorded once daily during the treatment period, and the DON confirmed the expected process was not followed.
Staff failed to perform hand hygiene before and after glove use during medication administration for two residents. A medication aide and an RN both administered medications without using hand sanitizer or washing hands as required by facility policy, despite being aware of the protocol.
A resident with Alzheimer's disease was not properly positioned in their wheelchair, leading to a fall and injury. The care plan required the resident to be in a tilt position except during meals, but observations showed the resident's legs were unsupported, causing them to dangle. Staff interviews revealed that wheelchair pedals were removed, contradicting the need for leg support.
Two residents were transferred using methods not aligned with their care plans, which specified the use of a Hoyer lift with two-person assistance. Despite the care plans, staff used alternative transfer methods, such as a gait belt and sit-to-stand lift, based on discretion and resident behavior. This discrepancy was confirmed by a Physical Therapy Assistant and acknowledged by the Director of Nursing.
Two instances of resident safety lapses were identified. Resident 48, with dementia and seizure disorder, fell and sustained a head injury requiring stitches during a bath due to an unsecured safety belt and insufficient supervision. Resident 94, with cognitive deficits and hemiplegia post-cerebral infarction, suffered a left femur fracture after a fall in the dining area. Despite a fall prevention care plan, interventions like non-slip socks and staff assistance were inconsistently applied, leading to multiple falls.
The facility failed to maintain proper hand hygiene during food preparation, ensure staff did not touch drinking surfaces while serving beverages, and maintain cleanliness in the main kitchen and Evergreen/Memory unit kitchen. Additionally, items in the Evergreen/Memory Care unit refrigerator and freezer were not labeled and dated as required.
The facility failed to ensure staff consistently wore masks correctly, performed hand hygiene, and followed proper infection control procedures. Multiple instances were observed where staff did not wear masks properly, did not perform hand hygiene between resident contacts, and did not follow proper procedures during medication administration and catheter care. These deficiencies were confirmed by staff interviews.
The facility staff failed to ensure the venting system was functional in four rooms, affecting seven residents, and did not maintain the Heating and Cooling unit in good repair, as evidenced by a missing front cover in one room. These issues were observed and confirmed by the Maintenance Director.
The facility staff failed to provide rationale for the continued use of an antianxiety medication for three residents and did not complete behavioral monitoring for one resident. Additionally, the facility did not document non-pharmacological interventions before administering Lorazepam to another resident and failed to document the rationale for extending PRN orders beyond 14 days.
The facility staff failed to ensure proper labeling and security of medications in the memory care unit. Unlabeled medications were found in a medication cart, and the medication refrigerator was unsecured. Additionally, a resident's blood pressure medication was left unsupervised on top of the medication cart, and the cart was found unlocked with Metoprolol tablets on top. Staff confirmed these actions did not meet facility expectations and posed a danger to residents.
The facility staff failed to protect four residents from abuse. One resident reported being verbally abused by an NA, causing significant distress. Another LPN reported that an NA was verbally inappropriate and rough with three residents. The facility did not take immediate protective actions, leaving the residents unprotected during the delay.
The facility failed to ensure competencies in insulin administration for five CMAs and three licensed nurses, affecting 13 residents. Interviews and record reviews revealed that these staff members had not been assessed for competency, despite facility policy requiring such assessments.
The facility failed to update the care plan for a resident with severe cognitive impairment and multiple diagnoses, including COPD, to reflect a new oxygen order. Despite a verbal order to increase oxygen to 5 l/m, the care plan still indicated 2 l/m continuously.
The facility staff failed to follow practitioners' orders for medication administration for a resident with multiple diagnoses, including Diabetes, and failed to implement treatment orders for another resident with skin impairment risks. Observations and interviews confirmed the deficiencies.
The facility failed to notify the provider when a resident's oxygen level dropped below the ordered parameter. The resident, with COPD and other respiratory issues, had multiple instances of oxygen saturation below 90%, but the provider was not informed until much later, resulting in a delayed adjustment of oxygen levels.
The facility staff failed to evaluate and implement interventions for a resident with PTSD. Observations and interviews revealed a lack of awareness and understanding of the resident's diagnosis and care plan, including the use of male caregivers despite the care plan's directive for female caregivers.
Failure to Provide Timely Pressure Ulcer Prevention, Assessment, and Wound Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and wound care for two residents, despite facility policy requiring comprehensive skin assessments, staging by licensed staff, and routine wound measurements documented on wound progress forms. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 states that all team members are responsible for preventing and treating altered skin integrity, that wounds must be measured in three dimensions upon identification and at admission, and that measurements must be completed routinely and documented for all impaired skin integrity issues. For Resident 3, who was admitted with intact skin, quadriplegia, multiple sclerosis, moderate cognitive impairment, total dependence for ADLs, and a Braden score of 13 indicating moderate risk, the baseline care plan identified risk for skin breakdown and called for repositioning, nutritional support, and notification of the PCP for skin changes, but did not initially include pressure-reducing surfaces for the bed or wheelchair. For Resident 3, the record showed no weekly skin evaluation between admission and 05-23-2025, a 14‑day gap, despite the resident’s identified risk. Interventions for pressure ulcer prevention, including a pressure reduction mattress and wheelchair cushion, were not implemented until 05-21-2025, after a stage 2 pressure ulcer to the left buttock had already developed. The initial wound evaluation for this ulcer was not conducted, and early documentation lacked wound measurements and descriptions. Progress notes later documented a stage 2 pressure ulcer to the left buttock and an additional pressure ulcer to the left heel, again without measurements. By late July, documentation showed a new stage 3 pressure ulcer to the right buttock with full-thickness skin loss and tunneling, with measurements recorded on 07-28-2025, but the comprehensive care plan contained no new interventions specific to this stage 3 ulcer. During observation of wound care, surveyors noted a right gluteal wound with tunneling and drainage, and the ADON acknowledged that causal factors for the right buttock ulcer had not been identified. The DON confirmed that Resident 3 had two separate pressure ulcers, one on each buttock. Additional deficiencies for Resident 3 involved the use and management of an air mattress. The Protekt Aire 4000DX/5000DX operating manual indicates that mattress settings should be adjusted according to the user’s weight or a health care professional’s suggestion. Resident 3’s most recent recorded weight was 178 lbs, but observations on multiple occasions showed the air mattress set at 240 lbs and later at 270 lbs. There was no physician order in the electronic health record for the air mattress or its settings. The DON confirmed that setting the mattress for a much higher weight would increase pressure for a lighter resident, and the Director of Compliance confirmed that air mattresses should be set according to the resident’s weight or practitioner-ordered settings. For Resident 1, who was cognitively intact, required assistance with mobility and ADLs, was always incontinent of bladder, frequently incontinent of bowel, at risk for pressure ulcers, and had a Braden score of 13, the comprehensive care plan identified risk for impaired skin integrity due to incontinence, decreased mobility, Braden risk, prior MASD, and excoriation to the buttocks. The care plan included interventions such as repositioning, nutrition and hydration support, keeping skin clean and dry, weekly monitoring and documentation of skin injuries with measurements, and use of pressure reduction mattress and wheelchair cushion. On 04-22-2025, an unstageable pressure ulcer to the right heel was documented, with treatment orders and a protective boot, and the care plan was updated to include heel protectors and treatment as ordered. Subsequent progress notes in December documented a stage 2 pressure ulcer to the right heel with serial measurements and a large fluid-filled blister on the top of the right foot, which later opened and increased in size. A weekly skin evaluation on 12-04-2025 noted a diabetic foot ulcer and buttock redness, but there was no weekly skin evaluation documented on or around 12-11-2025, resulting in an 11‑day gap between 12-04-2025 and the resident’s transfer to the hospital. Hospital records for Resident 1 revealed additional wounds that had not been fully documented in the facility’s records. The emergency department noted a wound to the right posterior thigh with surrounding redness, foul rotting fruit odor, mild drainage, and additional skin breakdown to the right posterior heel and a large fluid-filled blister on the lateral right foot. The hospital wound ostomy care consult described three wounds: a full-thickness wound of unknown etiology on the right posterior thigh with boggy center, dark purple/maroon discoloration, slough, eschar, indurated and reddened surrounding skin, and moderate purulent, malodorous exudate; a chronic stage 2 pressure ulcer on the right posterior heel; and a stage 2 pressure ulcer on the top of the right foot. A hospital progress note identified a soft tissue infection of the pressure ulcer to the hip, and an operative note documented surgical debridement of the right posterior thigh wound with removal of necrotic skin and exposure of thigh fascia. Facility staff interviews indicated that a NA was aware of a skin issue to the right thigh near the buttocks covered with a bandage before hospital transfer, and an RN knew the resident was starting to get a pressure ulcer to the thigh but could not recall whether a treatment was in place. The DON confirmed that a weekly skin evaluation should have been completed on 12-11-2025 and that it was not, and the ADON acknowledged that causal factors for the wound on the top of the right foot had not been identified. The Director of Compliance confirmed that weekly skin evaluations were required and that the facility could not provide additional information regarding the wounds for either resident prior to survey exit.
Failure to Monitor and Document Venous Ulcers Between Vascular Clinic Visits
Penalty
Summary
The facility failed to monitor and document vascular wounds for a resident with venous ulcers to both lower extremities, contrary to its own wound care policy and the resident’s comprehensive care plan. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy required that wounds be measured in three dimensions (length, width, depth) upon identification and routinely thereafter, with documentation on a wound progress assessment form for all impaired skin integrity issues. The resident’s MDS showed the resident was cognitively intact, dependent for most ADLs, and had two venous and/or arterial wounds. The comprehensive care plan identified venous ulcers on both lower extremities, with the right worse than the left, and included interventions to monitor and document the location, size, and treatment of any skin injury or change when noted and then weekly until healed, and to report abnormalities or failure to heal to the physician. Despite these requirements, record review of the resident’s EHR assessments and progress notes over several months revealed no wound evaluations with descriptions or measurements of the venous ulcers. Documents from the vascular clinic visits contained treatment orders and follow-up dates but did not include wound descriptions or measurements. The resident reported going to a vascular clinic for management of venous ulcers, and observation showed both lower legs wrapped with gauze bandages from ankles to knees. The ADON stated the resident’s venous ulcers were measured and assessed at the vascular clinic and confirmed that this was why there were no wound evaluations in the facility’s EHR. The DON confirmed the facility had not obtained wound descriptions or measurements from the vascular clinic visits, and the Director of Compliance confirmed the venous ulcers should have been evaluated weekly and monitored between clinic appointments, but staff were unable to provide additional wound information before survey exit.
Failure to Monitor Residents on Diuretic Therapy
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate monitoring for residents receiving diuretic medications. For one resident with chronic kidney disease and an order for Furosemide, there were no laboratory orders or care plan interventions in place to monitor the effects of the medication. This was confirmed by a registered nurse who acknowledged the absence of monitoring orders. Another resident with chronic kidney disease and congestive heart failure was prescribed Torsemide, but there were no orders or documentation for monitoring the medication's effects, and the resident reported not having any blood tests while in the facility. The care plan referenced monitoring lab work and symptoms of hypokalemia, but no pharmacy recommendations or orders for monitoring were present. A third resident with congestive heart failure was prescribed Spironolactone, and while the care plan included interventions to monitor for hypokalemia and other lab values, there was no documentation in the medication administration record indicating that monitoring occurred. The registered nurse confirmed the lack of monitoring orders. The Director of Nursing stated that pharmacy recommendations for monitoring are made to the primary care provider, but it is ultimately up to the provider to order such monitoring. These findings demonstrate a lack of consistent monitoring for residents on diuretic therapy, as required by facility policy and regulatory standards.
Failure to Follow Hand Hygiene and Food Handling Protocols During Meal Service
Penalty
Summary
Facility staff failed to follow proper hand hygiene and gloving procedures during meal service, as observed during continuous monitoring in the assisted dining room and Evergreen Hall. Specifically, a nurse aide (NA-K) was seen delivering meal trays to multiple resident rooms without removing gloves or performing hand hygiene between rooms, contrary to facility policy. NA-K also handled a tray of sliced cinnamon apples, some of which were uncovered, and carried the entire tray into resident rooms, increasing the risk of potential contamination. These actions were confirmed by NA-K during an interview, acknowledging the failure to doff gloves and perform hand hygiene as required. Record review of the facility's policy on meal tray delivery and infection control outlined the necessity for staff to apply hand sanitizer after each tray delivery and to repeat handwashing procedures upon returning to the kitchen. Despite these policies, the observed practices did not align with the established protocols. The Clinical Care Coordinator confirmed that 44 residents received food from the affected tray cart during the period in question. The facility census at the time was 103 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe for one resident. According to facility policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported to the appropriate agencies not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, a resident with a history of fibromyalgia, depressive episodes, cognitive deficits following a stroke, and insomnia, who was assessed as cognitively intact, reported being grabbed, held down, and forced to take a shot at the end of March. The resident also reported to police that she had been beaten by a nurse, tied up, and had blood drawn. Facility documentation showed that the Administrator or DON were notified of the allegation on April 1, but there was no evidence that the State Agency was notified at that time. The surveyor was made aware of the allegation during an interview with the resident, who displayed a purple discolored area on her right upper arm. The facility staff did not report the allegation to the State Agency until April 16, well after the required reporting timeframe. The delay in reporting was confirmed by the Administrator, who acknowledged that the allegation was not reported as required when it was initially made by the resident.
Failure to Record Pulse Before and After Nebulizer Treatments
Penalty
Summary
Facility staff failed to measure and record pulse rates before and after administering nebulizer treatments for a resident with diagnoses including congestive heart failure, atrial fibrillation, and chronic kidney disease. The facility's Nebulizer Competency procedure required staff to take the resident's pulse prior to and at the completion of each nebulizer treatment. However, record review showed that the resident's pulse was only measured and recorded once daily, rather than before and after each treatment, during the period the resident was receiving albuterol sulfate inhalation nebulization. The DON confirmed that there was no facility policy for nebulized medication administration and that staff were expected to follow the Nebulizer Competency, which was not done in this case.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration for two residents. In one instance, a medication aide donned gloves to assist a resident with sitting up, administered medication and nasal spray, applied powder, and assisted the resident to lie down. The aide then removed gloves and exited the room without performing hand hygiene before donning gloves, after removing them, or upon leaving the room. The aide later confirmed awareness of the hand hygiene requirement but stated they forgot to perform it. In another instance, a registered nurse donned gloves to administer eye drops to a resident without performing hand hygiene beforehand. The nurse also confirmed knowledge of the hand hygiene protocol but did not follow it. Review of the facility's hand hygiene policy indicated that staff are required to use hand sanitizer or wash hands before and after glove use, and immediately before and after patient contact.
Failure to Ensure Proper Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure proper positioning to maintain body alignment for a resident diagnosed with Alzheimer's disease, who was at risk for falls. The resident's care plan included an intervention for staff to ensure the resident was in a tilt position in their wheelchair at all times, except during meals. However, observations revealed that the resident was often seated in a wheelchair without leg rests or foot pedals, causing their legs to dangle unsupported. This improper positioning was noted during various times of the day, both in the dining room and common areas. The deficiency was highlighted by an incident where the resident fell out of their wheelchair after putting their feet down and leaning forward, resulting in a nose fracture. Interviews with staff confirmed that the resident's wheelchair pedals had been removed to prevent the resident from scooting back, but this removal contradicted the need for leg support when the wheelchair was tilted or being pushed. The occupational therapist acknowledged that leg rests or foot pedals should be used, and the Director of Nursing confirmed the necessity of using wheelchair pedals when transporting the resident.
Failure to Adhere to Resident Transfer Care Plans
Penalty
Summary
The facility failed to ensure that residents were transferred in accordance with their care plans, leading to deficiencies in the care of two residents. Resident 3, who was admitted with Parkinson's Disease and unspecified dementia, was observed being transferred using a gait belt and pivot transfer by the Director of Nursing and Nurse Aide A, despite the care plan indicating the need for a Hoyer lift with two-person assistance. This discrepancy was confirmed by a Physical Therapy Assistant who noted that Resident 3's transfer status had been downgraded to a Hoyer lift due to decreased weight-bearing ability and safety concerns. The Director of Nursing acknowledged awareness of the transfer status change but allowed staff discretion in transfer decisions. Similarly, Resident 1, diagnosed with Alzheimer's disease, was observed being transferred using a sit-to-stand lift by Nurse Aide A and Nurse Aide F, contrary to the care plan requirement for a Hoyer lift with two-person assistance. The Physical Therapy Assistant confirmed that Resident 1's transfer status remained as a Hoyer lift with two-person assistance, and the Director of Nursing indicated that the transfer method could vary based on the resident's behavior. These actions demonstrate a failure to adhere to the prescribed care plans, potentially compromising resident safety.
Resident Safety Incidents Highlighted in Deficiency Report
Penalty
Summary
The report highlighted two instances where the facility failed to ensure resident safety, resulting in deficiencies. In the case of Resident 48, who had a complex medical history including dementia and seizure disorder, the facility did not secure the safety belt during the bathing process, leading to a fall that resulted in the resident hitting their head and requiring stitches. Despite being on hospice care and requiring a 2-person assist for activities of daily living, the resident fell while being bathed, indicating a lack of proper supervision and adherence to safety protocols. On the other hand, Resident 94, who had diagnoses of cognitive deficits and hemiplegia following a cerebral infarction, experienced a fall in the dining area that resulted in a left femur fracture. The facility's care plan for fall prevention included interventions such as X-rays and evaluations after falls, but key interventions like non-slip socks and staff assistance to the bathroom were not consistently implemented. Despite being identified as high risk for falls, Resident 94 experienced multiple falls, including one that led to a significant injury, indicating gaps in supervision and intervention implementation.
Failure to Maintain Proper Hygiene and Cleanliness in Food Preparation Areas
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during food preparation, as observed on multiple occasions. The Chef did not wash hands after returning from the dry storage area, walk-in refrigerator, and freezer, and after touching potentially contaminated items such as boxes and bags. The Chef also used bare hands to insert the blade into the blender, which is a violation of sanitary practices. These actions were confirmed by the Dietary Manager (DM) during an interview, who acknowledged that the Chef should have performed hand hygiene at various stages of the food preparation process. Additionally, the facility did not ensure that staff avoided touching the drinking surfaces of cups and straws while serving beverages to residents. A Dietary Aide (DA) was observed delivering beverages by touching the drinking surfaces of the cups and the straw for one resident. This was confirmed by the Registered Dietician (RD), who stated that the DA should not have touched the drinking surfaces. The facility also failed to maintain cleanliness in the main kitchen and the Evergreen/Memory unit kitchen. Observations revealed scattered food debris, sticky substances, and crusty residues on various surfaces, including floors, refrigerators, ovens, and other kitchen equipment. The DM confirmed these observations and acknowledged that the items should have been cleaned but were not. Furthermore, the facility did not label and date all items in the Evergreen/Memory Care unit refrigerator and freezer, as required by their Proper Food Storage policy. This was also confirmed by the DM during an interview.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that staff consistently wore surgical masks correctly, performed hand hygiene, and followed proper infection control procedures. Observations revealed multiple instances where staff members, including medication aides, registered nurses, and administrative assistants, wore masks below the nose or mouth while in close proximity to residents. This was confirmed by the Regional Nurse Consultant, who stated that all staff should have worn masks properly at all times due to the presence of COVID-19 positive residents in the facility. Additionally, staff failed to perform hand hygiene between resident contacts and glove changes. For example, a nursing assistant was observed assisting two residents with meals without changing gloves or performing hand hygiene between contacts. Similarly, the Activities Director was seen assisting multiple residents with meals and adjusting their clothing without performing hand hygiene. These actions were confirmed by the Registered Dietician and the Regional Nurse Consultant, who acknowledged that hand hygiene should have been performed between resident contacts. Further deficiencies were noted in the administration of medication and catheter care. A Certified Medication Assistant did not perform hand hygiene before and after glove changes while administering insulin and performing blood glucose testing for a resident. Another instance involved improper hand hygiene and glove use during wound care and catheter care for multiple residents. Staff members were observed not changing gloves or performing hand hygiene between different tasks, leading to potential cross-contamination. These observations were confirmed by interviews with the staff involved, who acknowledged the lapses in proper infection control procedures.
Non-Functional Venting System and PTAC Maintenance Issues
Penalty
Summary
The facility staff failed to ensure the venting system was functional in four rooms (B-004, C-010, C-015, and C-017), affecting seven residents who resided in those rooms. Additionally, the Heating and Cooling unit (commonly called PTAC) was not maintained in good repair, as evidenced by the missing front cover in room C-011. These deficiencies were observed during a survey on 04/01/2024 and confirmed by the Maintenance Director on 04/04/2024. The facility had a census of 92 residents at the time of the survey.
Failure to Document Rationale and Behavioral Monitoring for Psychotropic Medications
Penalty
Summary
The facility staff failed to provide rationale for the continued use of an antianxiety medication for three residents and did not complete behavioral monitoring for one resident. Specifically, Resident 21, who is severely cognitively impaired, was prescribed Lorazepam without documented rationale for its continued use. The Director of Nursing (DON) confirmed the absence of documentation from the pharmacy or physician regarding the PRN Lorazepam order for 365 days. Additionally, the facility's Medication Regimen Review Policy requires the duration of therapy to be indicated and appropriate for the resident, which was not adhered to in this case. Resident 57, who has a history of depression and other mood disorders, was on Mirtazapine for a mood disorder. However, the facility failed to specify the target behaviors for monitoring the effectiveness of the antidepressant. Interviews with nursing staff revealed uncertainty about the target behaviors related to the resident's depression. The DON confirmed that the provider's documentation was not specific about the reason for ordering Mirtazapine or the behaviors being exhibited by the resident, which should have been clearly documented. Resident 25 had orders for Lorazepam as needed for anxiety but the facility did not document the non-pharmacological interventions attempted before administering the medication. The resident's care plan included various interventions to manage anxiety and behavioral issues, but the facility did not consistently implement these interventions before resorting to medication. Additionally, Resident 1 had an order for Lorazepam extended beyond 14 days without documented rationale, and there was no documentation to support the increase in dosage of Sertraline for this resident. The DON confirmed the lack of documentation for both the extended use of Lorazepam and the increased dosage of Sertraline.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility staff failed to ensure proper labeling and security of medications in the memory care unit. During an observation, an undated and unlabeled generic bottle of Cough DM and a bottle of Neomycin and Polymyxin B Sulfates and Dexamethasone Ophthalmic Suspension were found in the medication cart on hall E. The Certified Medication Assistant (CMA) interviewed did not know who the medications belonged to or how long they had been in the cart. Additionally, the medication refrigerator in the memory care unit was found to be unsecured, and the Registered Nurse (RN) confirmed that the office door and refrigerator should be locked at all times due to the presence of ambulatory residents in the unit. The Regional Nurse Consultant (RNC) also confirmed that the presence of undated and unlabeled medications in the cart and an unlocked medication refrigerator did not meet the facility's expectations and posed a danger to residents. Further observations revealed that a Licensed Practical Nurse (LPN) left a resident's blood pressure medication unsecured and unsupervised on top of the medication cart in the memory care unit. Another observation found the medication cart unlocked and unsupervised, with Metoprolol tablets left on top of the cart. The LPN confirmed that the cart should not have been left unlocked and the medication should not have been left on top of the cart. The facility's policy states that medication carts should be kept closed and locked when out of sight of the medication team member, and no medications should be left on top of the cart or in the medication cabinet without supervision.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility staff failed to protect four residents (Resident 32, 92, 342, and 33) from abuse. Resident 32 reported being verbally abused by Nursing Assistant (NA)-EE, who made derogatory comments about Resident 32's marital status and family situation. This incident caused Resident 32 significant distress, affecting their ability to sleep. Resident 32 did not report the incident immediately due to not knowing whom to tell and feeling fearful of NA-EE's strong personality. The facility Administrator was informed of the incident but did not take immediate action to address the situation. Additionally, Licensed Practical Nurse (LPN) QQ reported that NA-PP was verbally inappropriate and rough with Residents 92, 33, and 342. The Director of Nursing/Administrator was notified approximately nine hours after the initial report. There was no documentation of immediate protective actions taken for Residents 92, 33, and 342. The facility's policy requires immediate removal of the accused team member from resident care and initiation of an investigation, but these steps were not followed promptly, leaving the residents unprotected during the delay.
Failure to Ensure Competency in Insulin Administration
Penalty
Summary
The facility staff failed to ensure competencies in insulin administration were completed for five Certified Medication Assistants (CMAs) and three licensed nurses. This deficiency was identified during interviews and record reviews, revealing that the CMAs and nurses had not been assessed for competency in administering insulin. The Director of Nursing (DON) and the facility Administrator confirmed that competency assessments were required but had not been completed for these staff members. The facility's policy stated that only licensed nurses or certified personnel could administer injections, with insulin administration by competent medication techs using insulin pens only. However, the competency assessments for insulin administration were missing for several staff members, including those from staffing agencies, affecting 13 residents who receive insulin in the facility, which had a census of 92 residents. Interviews with the CMAs and nurses confirmed that they had administered insulin without being assessed for competency. The facility Administrator was unable to provide evidence of completed competency assessments for these employees. The record review of the facility's CMA and nurse competency checklists further confirmed the lack of insulin administration competency assessments. This deficiency had the potential to impact the well-being of the residents receiving insulin, as the staff administering the medication had not been properly evaluated for their competency in this critical task.
Failure to Update Care Plan for Oxygen Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident (Resident 77) who had a change in their oxygen order. The resident, who was admitted on 02/17/2024, had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, and Dependence on Supplemental Oxygen. The resident's Minimum Data Set (MDS) dated 02/23/2024 indicated severe cognitive impairment and dependence on staff for various activities of daily living. Observations on 04/01/2024 revealed the resident was using an oxygen concentrator set at 5 liters per minute (l/m), despite the care plan indicating an oxygen setting of 2 l/m continuously. A review of the Order Summary Report and Medication Administration Record (MAR) confirmed the resident had an order for oxygen at 2 l/m, but a verbal order on 03/22/2024 had increased the oxygen to 5 l/m due to low oxygen levels. This change was not reflected in the care plan, which still showed the outdated intervention of 2 l/m continuously. In an interview on 04/02/2024, the Regional Nurse Consultant (RNC-A) confirmed that the care plan had not been updated to reflect the new oxygen order from 03/22/2024. The facility's Comprehensive Care Planning policy stated that care plans should be revised as information about the resident's condition changes, but this was not followed in the case of Resident 77. The failure to update the care plan to reflect the new oxygen order constitutes a deficiency in the facility's care planning process.
Failure to Follow Medication and Treatment Orders
Penalty
Summary
The facility staff failed to follow practitioners' orders for medication administration for Resident 93 and failed to implement treatment orders for Resident 25. Resident 93, diagnosed with Dementia, Diabetes, Hypertension, Major Depressive Disorder, and Functional Quadriplegia, had an order to hold insulin if meals were not eaten. However, on 3/16/2024, RN-SS administered insulin without documentation of food intake, resulting in a morning blood glucose level of 58 on 3/17/2024. The Director of Nursing confirmed the failure to follow the practitioner's orders during an interview on 04/04/2024. Resident 25, diagnosed with Dementia, Heart Failure, Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Peripheral Vascular Disease, had a comprehensive care plan to maintain clean, intact skin. The treatment orders included wound care for both legs and the use of Geri Sleeves/Tubi Grip for protection. However, the treatment was not documented as completed on multiple dates in March 2024, and observations on 4/01/2024 and 4/02/2024 revealed outdated dressings and the absence of Geri Sleeves. Interviews with the Regional Nurse Consultant confirmed the lack of completed treatments and the absence of Geri Sleeves, contrary to the care plan and facility policy.
Failure to Notify Provider of Low Oxygen Levels
Penalty
Summary
The facility failed to ensure the provider was notified when a resident's oxygen level dropped below the ordered parameter. Resident 77, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, and dependence on supplemental oxygen, was observed with an oxygen concentrator set at 5 liters per minute (l/m) despite an order for 2 l/m. The resident's care plan specified oxygen at 2 l/m continuously, with instructions to notify the physician if oxygen saturation fell below 90%. However, records revealed multiple instances where the resident's oxygen saturation dropped below 90%, and the provider was not notified until much later, on 03/22/2024, when the oxygen was increased to 5 l/m by a verbal order from the Nurse Practitioner. The Medication Administration Record and Treatment Administration Record (MAR & TAR) showed that the resident's oxygen saturation was below 90% on several occasions, including 85% on 02/20/2024, 88% on 02/23/2024, and 76% on 03/22/2024, among others. Despite these low readings, there was no documentation in the Electronic Medical Record or Progress Notes indicating that the provider was notified of these critical values. It was only on 03/22/2024 that the Nurse Practitioner was contacted, and a new order was given to adjust the oxygen levels to maintain saturations above 88%.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility staff failed to evaluate and implement interventions to manage triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident's Minimum Data Set (MDS) indicated an active diagnosis of PTSD, and the care plan included interventions such as providing reassurance, encouraging expression of needs, and ensuring female caregivers for toileting and bathing. However, observations revealed that the resident frequently packed their belongings and placed them in the hallway, indicating distress. Interviews with staff members, including Nursing Assistants, the Director of Nursing, Social Services, and the Administrator in Training, revealed a lack of awareness and understanding of the resident's PTSD diagnosis and the specific care plan interventions. Additionally, the Director of Nursing confirmed that a Trauma Informed Care Assessment had not been completed for the resident. Further interviews with staff members indicated that some were unaware of the resident's PTSD diagnosis, while others were unsure of the specific interventions required. Despite the care plan's directive to provide female caregivers for toileting and bathing, it was reported that the resident had male caregivers. This lack of awareness and implementation of the care plan interventions highlights a significant deficiency in providing trauma-informed and culturally competent care for the resident with PTSD.
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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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