Holdrege Memorial Homes, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Holdrege, Nebraska.
- Location
- 1320 11th Avenue, Holdrege, Nebraska 68949
- CMS Provider Number
- 285067
- Inspections on file
- 18
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Holdrege Memorial Homes, Inc during CMS and state inspections, most recent first.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent reporting, and unclear protocols, leaving residents unprotected from these risks.
The facility did not include the actual hours worked by RNs, LPNs, or nurse aides on its daily posted nurse staffing reports, as required by policy. The posted reports only listed the number of staff per shift and the resident census, and this omission was confirmed by the DON.
The facility failed to complete required pre-employment health screenings for a re-hired nurse aide, did not enforce hand hygiene or personal grooming standards among dietary staff during meal service, and did not maintain sanitary storage or proper documentation for oxygen and nebulizer equipment for two residents. Additionally, enhanced barrier precautions and PPE availability were not consistently implemented for residents at risk for MDROs, with staff lacking awareness of protocols.
The facility did not submit MDS assessments for several residents within the required 14-day period after completion. Due to the MDSC's frequent absences and lack of backup, assessments were either finalized but not transmitted or submitted but not reviewed and accepted on time, affecting all sampled residents.
The facility did not ensure that care plans were individualized, person-centered, or included measurable goals and interventions for residents with complex needs such as respiratory infections, diabetes, nutrition, UTIs, and fluid restrictions. For example, a resident with ongoing respiratory issues had a care plan that only addressed antibiotics and oxygen, while another with diabetes and significant weight gain had no care plan interventions for nutrition or education. Staff interviews confirmed that care plans were not consistently updated to reflect residents' current needs or preferences.
The facility did not provide or document risk versus benefit information for psychotropic medications to two residents and their representatives. Despite multiple medication changes and the use of high-risk drugs, there was no evidence that risks, benefits, options, or alternatives were discussed or acknowledged. Staff confirmed that the facility did not have a process for reviewing or documenting this information.
A resident was discharged without the required notification to the state LTC Ombudsman. Review of records and interviews with the Social Services Director revealed that the facility's process only included ombudsman notification for hospital transfers, not discharges, resulting in the omission of the discharge notice for this resident.
A resident with multiple sclerosis and a denuded area on the left buttock did not receive comprehensive wound assessments or have treatment orders in place. Documentation was incomplete and did not follow best practice guidelines or facility policy, and staff confirmed that the wound was not fully assessed or managed according to protocol.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
The facility failed to report incidents of serious bodily injury within the required timeframe for two residents. One resident with a fractured fibula and another with a fractured femur experienced delays in reporting to APS, exceeding the two-hour requirement. The Director of Nursing confirmed these delays during an interview.
The facility failed to properly store oxygen tubing and CPAP mask/tubing for several residents, leading to potential cross-contamination. Observations showed that oxygen and CPAP supplies were not stored in bags as required by facility policy. The Director of Nursing confirmed the expectation for proper storage, but it was not followed, indicating a lapse in infection prevention and control practices.
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by licensure regulations. Interviews revealed a lack of awareness among staff regarding the required hours, and the Director of Nursing confirmed the oversight in monitoring education hours. The absence of a Staff Development Coordinator contributed to the deficiency, with the Payroll Coordinator responsible for auditing and notifying supervisors about incomplete education hours.
A resident with asthma did not have their nebulizer cleaned after each use, contrary to facility policy, leading to potential cross-contamination. Observations showed liquid residue in the nebulizer chamber, and interviews with the resident, an LPN, and the DON confirmed the failure to rinse the nebulizer as required.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the required systems to safeguard residents from these incidents were either not in place or not adequately enforced. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training, inconsistent reporting mechanisms, and a lack of clear protocols for identifying and responding to potential abuse, neglect, or theft events. As a result, residents were left vulnerable due to the absence of comprehensive preventive measures and oversight, as directly evidenced by the survey findings.
Failure to Post Actual Nurse Staffing Hours on Daily Reports
Penalty
Summary
The facility failed to ensure that the required daily posting of nurse staffing information included the actual hours worked for each staff category. Observations on multiple dates revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted in a common area, and while the reports listed the number of RNs, LPNs, and nurse aides assigned to each shift, they did not include the actual hours worked by each staff category as required by facility policy. The posted reports only indicated the number of staff per shift and the resident census, omitting the specific work hours for each staff type. Record review of the facility's policy confirmed that the daily posting should include the actual time worked during each shift for every category and type of nursing staff. During an interview, the Director of Nursing acknowledged that the posted reports did not contain the required information regarding actual hours worked. No information was provided about any residents' medical history or condition in relation to this deficiency.
Multiple Infection Control Failures in Staff Screening, Hand Hygiene, and Equipment Storage
Penalty
Summary
The facility failed to ensure that pre-employment health screenings were completed for a newly re-hired nurse aide. Although the facility's policy required all new hires to complete a health screening and tuberculosis test during general orientation, the personnel and medical files for the nurse aide did not contain documentation of a health screening for the current hire date. The business office and infection preventionist confirmed that the health screen was not repeated upon re-hire, despite a gap in employment. Dietary staff were observed not adhering to hand hygiene and personal grooming standards during meal service. A dietary aide with long artificial nails, which is prohibited by facility policy, was seen serving food and drinks to residents without performing hand hygiene between tasks or wearing gloves. The dietary manager was aware of the artificial nails but did not consider them a concern, and the infection preventionist confirmed that artificial nails should not be worn in the dietary department. The aide's competency review indicated requirements for short, unpolished, and clean nails, as well as proper handwashing, which were not followed during the observed meal service. The facility also failed to maintain sanitary storage and documentation for oxygen delivery devices and nebulizer equipment for two residents. Observations revealed that oxygen tubing was stored on the floor or in bags with outdated or missing labels, and there were no clear directions in the administration records for changing the equipment as required by policy. Additionally, enhanced barrier precautions (EBP) were not properly implemented for residents with wounds or at risk for multidrug-resistant organisms. PPE was not available near or outside resident rooms as required, and staff were not consistently aware of EBP protocols. These failures affected multiple residents, including those with chronic wounds, respiratory conditions, and those requiring supplemental oxygen.
Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that all Minimum Data Set (MDS) assessments for residents were submitted to the State within the required 14-day period after completion. This deficiency affected all seven residents sampled, as their MDS data was either finalized but not transmitted or submitted but not reviewed and accepted within the mandated timeframe. The facility's policy requires timely and accurate completion and submission of MDS assessments in compliance with federal and state regulations, with oversight by the MDS Coordinator and the interdisciplinary team. However, due to the MDS Coordinator's frequent absences and being the sole individual responsible for MDS data, the submission process was delayed, and no other staff monitored or managed the workload in the Coordinator's absence. Record reviews confirmed that for each of the seven residents sampled, the MDS data was either finalized but not sent or was in a production batch that had not been reviewed and accepted within the required period. Interviews with the MDS Coordinator corroborated that the assessments were not submitted on time, and there was no backup process in place to ensure timely submission during the Coordinator's absence. The facility census at the time was 73 residents, and the deficiency was identified through both record review and staff interviews.
Failure to Develop and Implement Individualized, Measurable Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, individualized care plans were developed and implemented for several residents, as required by both federal and state regulations. Specifically, care plans lacked person-centered goals, measurable objectives, and appropriate interventions for conditions such as respiratory infections, diabetes, nutrition, urinary tract infections, fluid restrictions, and resident choices. For example, one resident with a complex medical history including pneumonia, heart failure, and chronic kidney disease experienced multiple medication changes and ongoing respiratory symptoms, yet the care plan only addressed antibiotic use and oxygen therapy, omitting other relevant interventions for respiratory status and chronic cough. Another resident with diabetes, bilateral lower extremity amputations, and significant weight gain had a care plan that did not address nutritional choices, diabetic education, or set measurable weight goals, despite the resident keeping high-sugar snacks at the bedside and expressing knowledge of the risks. Similarly, a resident with a history of recurrent urinary tract and yeast infections had a care plan that only addressed a single episode of UTI and did not reflect the resident's infection history or all relevant interventions. Observations and interviews confirmed that care plans were not updated to reflect ongoing or recurrent issues, and that interventions were not tailored to the residents' individual needs and preferences. Additionally, a resident with chronic kidney disease and a physician-ordered fluid restriction was known by staff and family to be noncompliant with the restriction, but this was not reflected in the care plan. Interviews with staff, including the MDS Coordinator and DON, confirmed that care plans were often not personalized, and that acute issues were removed from care plans once resolved, without maintaining a history of significant conditions. The facility's own policy required individualized, comprehensive care plans, but in practice, care plans were not consistently updated or detailed to guide staff in providing individualized care.
Failure to Inform Residents and Representatives of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents and their representatives were fully informed about the risks, benefits, options, and alternatives of psychotropic medications prior to starting or changing such medications. For two of five sampled residents, documentation and interviews revealed that no risk versus benefit information was provided or discussed in plain language, and there was no evidence that residents or their representatives signed or received any such information. Instead, the facility only documented that family members were notified of medication changes in the progress notes, without specifying the content of those discussions. One resident, who was cognitively intact and had multiple complex diagnoses including breast cancer, diabetes, hypertension, and coronary artery disease, received several psychotropic medications for anxiety and depression. The medical record showed multiple medication changes, including new orders for Buspar, Ativan, and Hydroxyzine, but there was no documentation of any risk and benefit discussion or signed acknowledgment by the resident or representative. The MDS Coordinator and DON both confirmed that the facility did not have a process for reviewing or documenting the risks and benefits of psychotropic medications with residents or their representatives. Another resident, with diagnoses including Alzheimer's disease, insomnia, nightmare disorder, depression, unspecified dementia with agitation, and convulsions, was prescribed multiple high-risk medications such as antipsychotics, antidepressants, anticonvulsants, and diuretics. The care plan included non-pharmacological interventions and monitoring for side effects, but there was no available documentation of risk versus benefit information being provided to the resident or representative. The DON confirmed that the facility had never reviewed or documented such information with residents or their representatives.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman of a resident's discharge, as required by both facility policy and regulatory requirements. Record review showed that a resident was admitted and subsequently discharged, but there was no documentation in the medical record indicating that a discharge notice was provided to the ombudsman. The facility's policy specifies that a copy of all discharge notices must be sent to the ombudsman and relevant state agencies, with documentation of the date this was completed in the resident's record. Interviews with the Social Services Director (SSD) revealed that the SSD was unaware of the requirement to notify the ombudsman of resident discharges, and only notified the ombudsman of hospital transfers. Review of the facility's monthly notification email and the Emergency Transfers From Facility form confirmed that the resident's discharge was not included in the ombudsman notification. The SSD confirmed that the omission was due to a lack of awareness of the requirement.
Failure to Routinely Assess and Obtain Treatment Orders for Resident Wound
Penalty
Summary
The facility failed to ensure that wounds were comprehensively assessed on a routine basis and did not obtain treatment orders for a wound for one resident. The resident, who had multiple sclerosis and was admitted with a denuded area on the left buttock, was identified as having a potential for skin breakdown. The care plan included weekly skin assessments but did not list any treatment interventions for the wound. Documentation in the resident's records showed inconsistent and incomplete wound assessments, with missing details such as anatomical location, wound characteristics, and pain or symptom reporting. Progress notes and skin condition records indicated the presence of an open area on the left buttock, but assessments lacked comprehensive information as outlined in best practice guidelines and facility policy. Despite ongoing documentation of the wound, there were no physician orders for wound care in the resident's medical record during the review period. Interviews with nursing staff and the DON confirmed that the wound was not fully assessed or documented on a routine or weekly basis, and that no treatment orders were obtained for the area. This failure to follow established protocols and obtain necessary physician orders resulted in a deficiency related to the comprehensive assessment and management of wounds.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Delayed Reporting of Serious Bodily Injuries
Penalty
Summary
The facility failed to report incidents resulting in serious bodily injury within the required timeframe for two residents. Resident 2, who had a history of a fractured right fibula, dizziness, type 2 diabetes mellitus, and dementia, experienced a fall on 10/19/2024. Initially, the resident denied injury, but later notes indicated bruising and pain to the right ankle, which was eventually diagnosed as a fracture on 10/21/2024. The incident was reported to Adult Protective Services (APS) on 10/22/2024, more than two hours after the suspicion of serious bodily injury was formed, and the investigative report was submitted to the state agency after more than five calendar days. Resident 6, with diagnoses including a fractured right femur, irregular heartbeat, heart failure, dementia, high blood pressure, and a history of a heart attack, was found on the floor on 08/16/2024 with pain and inability to move the right leg. The resident was transported to the emergency room and diagnosed with a right femur fracture. The incident was reported to APS on 08/19/2024, again exceeding the two-hour reporting requirement. The Director of Nursing confirmed these reporting delays during an interview on 12/16/2024.
Improper Storage of Oxygen and CPAP Supplies
Penalty
Summary
The facility failed to properly store oxygen tubing and CPAP mask/tubing to prevent potential cross-contamination for several residents. Observations revealed that Resident 7's oxygen tubing was not stored in the attached bag on the concentrator when not in use, despite the facility policy requiring such storage. Similarly, Resident 23's CPAP mask and tubing were found draped over the CPAP machine without a storage bag, and the oxygen tubing was also improperly stored. The Director of Nursing confirmed that the facility's expectation was to store these supplies in a bag to prevent cross-contamination, but this was not adhered to. Resident 59's oxygen tubing was observed to be under the handle of the concentrator and not stored in a bag, as required by the facility's policy. The Director of Nursing acknowledged that the staff had been educated on the proper storage practices, yet the tubing was still not stored according to policy. Additionally, Resident 53's oxygen tubing was found coiled and tucked under the concentrator handle without being stored in a bag, and the nasal prongs were not properly positioned in the resident's nostrils during use. Resident 42's oxygen tubing was observed to be improperly stored, with the nasal cannula touching the wheelchair tire and the tubing wrapped around the flow meter of a portable oxygen tank. The facility's policy did not address the storage of oxygen tubing with portable tanks, and the Director of Nursing confirmed that the expectation was for the tubing to be stored in a bag when not in use. These observations indicate a failure to adhere to infection prevention and control practices, as outlined in the facility's policy.
Deficiency in Nursing Assistant Continuing Education Compliance
Penalty
Summary
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by the licensure reference number 175 NAC 12.006.4(B)(ii)(1). Specifically, NA-A, NA-C, and NA-D did not meet the continuing education requirements, with NA-A completing zero hours, NA-C completing 11.75 hours, and NA-D completing 9.25 hours within their respective annual periods. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adequately monitor or enforce the completion of these education hours. Interviews with nursing assistants NA-F and NA-G indicated a lack of awareness regarding the exact number of required continuing education hours, with incorrect estimates of 72 and 40 hours, respectively. The Director of Nursing confirmed the oversight in monitoring the education hours and acknowledged that staff continued to work without completing the required training. Additionally, the Business Office Manager confirmed the absence of a Staff Development Coordinator, with the Payroll Coordinator responsible for auditing education hours and notifying supervisors. However, the facility's policy of withholding annual pay increases until education hours are completed was not sufficient to ensure compliance with the training requirements.
Failure to Clean Nebulizer After Use
Penalty
Summary
The facility failed to ensure proper cleaning of a Metered Dose Inhaler (Nebulizer) after each use, which is necessary to prevent potential cross-contamination. This deficiency was identified for one resident, who was diagnosed with asthma and had a prescribed order for Ipratropium-Albuterol solution to be administered via nebulization three times a day. The facility's policy on administering medications through a nebulizer requires that the equipment be rinsed in warm water after each use to ensure safe administration of inhaled medications. Observations and interviews revealed that the nebulizer used by the resident was not being rinsed after treatments. On two separate occasions, a clear liquid was observed in the nebulizer chamber, indicating it had not been cleaned. Interviews with the resident and a Licensed Practical Nurse (LPN) confirmed that the nebulizer was not rinsed after each use. The Director of Nursing also confirmed that the facility's expectation, as per policy, was for staff to rinse the nebulizer after medication administration, which was not being followed in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
