Holmes Lake Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 6101 Normal Blvd, Lincoln, Nebraska 68506
- CMS Provider Number
- 285164
- Inspections on file
- 25
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holmes Lake Rehabilitation & Care Center during CMS and state inspections, most recent first.
The facility did not notify DHHS within the required 5 working days after a change in the DON position, with notification sent significantly late. The DON confirmed the delay and acknowledged errors in the recorded service dates. This issue had the potential to impact all residents in the facility.
Multiple residents with significant medical and mobility needs experienced frequent and prolonged delays in staff response to call lights, with some waiting up to two hours for assistance. Device Activity Reports and direct observations confirmed that staff often failed to respond within the facility's expected timeframe, and staff members were seen walking past rooms with active call lights without checking on residents.
A resident with multiple medical conditions and no cognitive impairment was the subject of an abuse allegation. The facility did not submit the required 5-day written investigation report to DHHS within the mandated timeframe, instead sending it two days late. The DON confirmed the delay in submission.
The facility failed to have a nursing services representative present during care plan conferences for several residents, contrary to its policy. The policy requires the presence of the DON or an RN designee at these conferences. Documentation showed that nursing services were absent for multiple residents on several occasions, and the facility Administrator confirmed the DON's expected attendance.
A resident with Type 2 Diabetes Mellitus received an incorrect insulin dose due to a nurse's failure to prime the insulin pen and dial the prescribed dose before injection. The facility's policy requires these steps to ensure accurate dosing, but the nurse did not follow them, as confirmed by interviews with the nurse and facility staff.
A facility failed to follow infection control procedures during peri care for a resident with a cerebral infarct. A Nurse Aide removed the resident's clothing and soiled brief without gloves, then applied gloves but did not change them or perform hand hygiene before wiping the peri/rectal area. This breach was confirmed by the facility's Regional Nurse Consultant and the Nurse Aide.
The facility failed to ensure proper infection control practices, with staff observed not wearing N-95 masks correctly and not following hand hygiene protocols. A resident in a COVID-positive room was attended by an RN wearing a surgical mask instead of an N-95 mask, who also mishandled a COVID sample and neglected handwashing between glove changes. These actions were contrary to the facility's infection prevention policies.
The facility failed to maintain kitchen cleanliness and proper temperature control of fluids, posing a risk for food-borne illness to all 47 residents. Observations revealed environmental concerns such as a ceiling exhaust fan and light panels coated with a dark substance, food debris in storage areas, and improper fluid temperatures during lunch service. The Dietary Manager confirmed the fluids were not within safe temperature limits, violating the facility's food safety policy.
The facility failed to handle laundry properly, leading to potential cross-contamination, and did not implement Enhanced Barrier Precautions for residents with catheters. Additionally, a resident's PAP device was missing a filter, and another resident's CPAP mask was improperly stored, increasing infection risks.
The facility did not ensure that its nurse aides completed the required 12 hours of continuing education annually. A review of the facility's policy indicated that it must provide at least 12 hours of in-service training each year. However, an interview confirmed that four staff members had not completed the required education hours, with only abuse and neglect training completed in the past year. This deficiency could potentially affect all 47 residents.
The facility failed to provide adequate bathing services for several residents, with documented gaps in bathing over extended periods. A resident with dementia did not receive a bath for 25 days, while another with severe cognitive impairment went without for 40 days. Additionally, a resident's indwelling catheter was not changed monthly as ordered, due to unavailability of latex-free catheters. The DON confirmed these deficiencies in care.
The facility failed to notify the representatives of two residents after falls, as required by their policy. One resident, severely cognitively impaired, had multiple falls, including one from a recliner, without family notification. Another resident with moderate cognitive impairment also experienced falls without representative notification. Staff interviews confirmed the oversight.
A resident with severe cognitive impairment and a history of falls experienced multiple falls from a power recliner due to the facility's failure to update the care plan with new interventions. Despite the facility's policy requiring assessment and intervention adjustments after falls, these were not completed. Observations showed the recliner remote was often out of reach, contributing to the falls. The facility also failed to conduct new Recliner Chair Assessments and did not adequately inform the resident's family about the risks or notify them of all fall incidents.
A facility failed to provide a valid rationale for a resident's PRN Lorazepam prescription, which was not re-evaluated or discontinued as required. Despite the resident's cognitive awareness and absence of anxiety in their MDS, Lorazepam was prescribed for anxiety without a stop date. The facility's pharmacy recommended discontinuation or a clinical rationale, but this was not addressed, leading to a deficiency.
A resident with multiple diagnoses and a high risk for falls experienced numerous falls without new interventions being implemented. Despite being cognitively intact, the resident's falls resulted in injuries, and the facility's safety monitoring sheets showed inconsistent completion. Staff interviews confirmed the lack of new interventions and consistent monitoring.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the Department of Health and Human Services (DHHS) within 5 working days regarding a change in the Director of Nursing (DON) position, as required by licensure regulations. Record review showed that the previous DON's service ended on 2/2/2024 and the new DON began on 2/3/2024, but DHHS did not receive notification of this change until 3/31/2025. Interviews with the DON confirmed that the notification was not sent within the required timeframe and that the service dates should have been recorded as 2025. This lapse had the potential to affect all residents in the facility, which had a census of 50 at the time.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for four residents, resulting in significant delays in meeting resident needs. Observations, interviews, and record reviews revealed that residents frequently experienced extended wait times for staff to respond to their call lights, with some instances exceeding one hour and, in one case, up to two hours. Device Activity Reports confirmed numerous occurrences where call lights were not answered within the expected timeframe, with many responses taking between 22 and 168 minutes. The DON confirmed that call lights should be answered in less than 20 minutes, but this standard was not met. One resident with a history of cerebral infarction, hemiplegia, diabetes, and other complex medical needs reported waiting up to two hours for assistance, particularly during evening shifts. Another resident with moderate cognitive impairment and multiple health conditions described waiting up to 1.5 hours for call light responses. A third resident, dependent on staff for most activities of daily living and with a history of falls and skin issues, was observed by the surveyor to have their call light ignored by multiple staff members over a period of more than 30 minutes, despite visible indicators that the call light was active. A fourth resident with hemiplegia, cerebrovascular disease, and other chronic conditions also reported frequent delays, sometimes waiting up to two hours for staff response. The documented delays in call light response were corroborated by both resident interviews and electronic call system records, which showed repeated and prolonged response times well beyond the facility's stated expectation. Staff members, including nurse aides and other personnel, were observed walking past rooms with active call lights without checking on the residents' needs, further contributing to the deficiency.
Failure to Timely Submit 5-Day Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a 5-day written investigation report to the Department of Health and Human Services (DHHS) following an allegation of abuse involving a resident. According to the facility's own investigation form, such reports must be faxed to Health Facility Investigations within 5 working days from the date of the allegation or incident. However, for an incident involving a resident with multiple medical conditions, including hemiplegia, hemiparesis, cerebrovascular disease, atrial fibrillation, diabetes, anxiety, and a history of falls, the required report was not sent within the mandated timeframe. Record review showed that the resident, who had no cognitive impairment as indicated by a BIMS score of 15, was the subject of an abuse allegation on 3/18/25. The investigation report related to this allegation was submitted to DHHS on day 7, exceeding the 5-day requirement. The Director of Nursing confirmed in an interview that the report was sent late, acknowledging the failure to meet the regulatory deadline.
Absence of Nursing Services in Care Plan Conferences
Penalty
Summary
The facility failed to have a nursing services representative present during care plan conferences for four sampled residents, despite the facility's policy requiring such attendance. The policy, dated September 2019, mandates that care plan conferences should include the resident, their family or legal representative, the Clinical Reimbursement Manager/MDS Coordinator, and the Director of Nursing Services (DON) or a Registered Nurse (RN) designee. The absence of nursing services was documented in the care plan conference notes for three residents on multiple occasions. An interview with the facility Administrator confirmed that the DON was expected to attend these conferences but did not for the residents in question.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. During an observation, a registered nurse (RN) administered insulin to a resident without priming the insulin pen or dialing the prescribed dose before injection. This action was confirmed by the RN during an interview, acknowledging that the pen should have been primed and the correct dose dialed to ensure accurate administration. The resident involved had an active diagnosis of Type 2 Diabetes Mellitus and was on a prescribed regimen of Insulin Glargine, with specific dosages ordered by the physician. The facility's policy on using the Flexpen Insulin Competency requires priming the pen to remove air bubbles and ensure the full dose of insulin is administered. The failure to follow this procedure was observed and confirmed by both the RN and the facility's administrator. Additionally, the Regional Nurse Consultant confirmed that there were 13 residents in the facility requiring injectable insulin, indicating a broader potential for similar errors if procedures are not consistently followed.
Infection Control Breach During Peri Care
Penalty
Summary
The facility failed to ensure proper infection control procedures during peri care for Resident 11, who was admitted with a primary diagnosis of cerebral infarct. During an observation, Nurse Aide (NA)-F was seen assisting Resident 11 to the bathroom and removing the resident's pants and soiled brief without wearing gloves. After performing hand hygiene and applying gloves, NA-F removed the resident's shoes, pants, and soiled brief, then applied a clean brief. However, NA-F did not change gloves or perform hand hygiene before wiping the resident's peri/rectal area. This was confirmed by both the facility's Regional Nurse Consultant and NA-F during interviews, acknowledging that gloves should have been changed before providing perineal care.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple observations of staff not wearing N-95 masks correctly and not adhering to hand hygiene protocols. Nurse Aide-A, the Social Service Director, and a Maintenance worker were observed wearing N-95 masks without securing both straps over their heads, which was confirmed through interviews. Additionally, a Registered Nurse (RN) entered a COVID-positive resident's room wearing a surgical mask instead of an N-95 mask, and failed to follow proper procedures for handling a COVID sample, including placing it on a clean barrier and washing hands between glove changes. The facility's infection prevention and control program policy, as well as the hand hygiene protocol, were not followed, leading to potential cross-contamination risks. The RN was observed placing a COVID sample directly on a treatment cart without a barrier, and not washing hands after removing gloves, which was acknowledged during an interview. The Director of Nursing confirmed that staff should wear N-95 masks correctly and adhere to hand hygiene practices. The facility's policies emphasize the importance of hand hygiene as a primary means to prevent infection spread, yet these were not adhered to during the observed incidents.
Kitchen Cleanliness and Temperature Control Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen, which posed a potential risk for food-borne illness affecting all 47 residents who consumed food prepared in the facility's kitchen. During an observation, several environmental concerns were noted, including a ceiling exhaust fan coated with a fuzzy dark gray/black substance located above the food preparation area, ceiling light panels with multiple specks of a dark gray/black substance, and exhaust fans in the dry storage room similarly coated. Additionally, food debris was found on the bottom shelf of the freezer, and two white bins in the dry storage room contained food debris and were coated with a dark gray, thick, and shiny substance. A storage rack near the dry storage room door had staff personal items and visible food debris, and a wheeled cart with an attached can opener was coated with food debris and a brown, thick, shiny substance. The floor in the dishwashing area was also coated with a dark gray substance. The facility also failed to ensure that fluids were maintained within the required temperature range, as observed during a lunch service. A test tray prepared for residents eating in their rooms revealed that the temperatures of the fluids were not within safe limits. The white milk was at 60 degrees, tomato juice at 62 degrees, and iced tea at 61 degrees, all of which were concerning to the Dietary Manager (DM), who refused to taste test them. The DM confirmed that the temperatures were not cold enough and should not have been served to the residents, indicating a failure to adhere to the facility's food safety policy, which defines the danger zone for temperatures as above 41 degrees Fahrenheit and below 135 degrees Fahrenheit.
Deficiencies in Infection Control and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper handling of contaminated and clean laundry, leading to potential cross-contamination. Observations revealed that staff members, including nursing assistants and housekeeping aides, were carrying linens and laundry in a manner that allowed them to come into contact with their clothing. This was contrary to the facility's policies, which required that soiled linens be handled in a way that prevents contamination and that clean linens be transported on covered carts. The Director of Nursing confirmed that the staff should not allow laundry to touch their clothing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters. Observations showed that there was no EBP signage or personal protective equipment (PPE) available outside the rooms of residents with catheters, despite the facility's policy requiring such measures. Interviews with staff confirmed that these precautions were not in place, which could increase the risk of infection transmission. Additionally, the facility did not ensure that a resident's Positive Airway Pressure (PAP) device was properly maintained. The device was missing a filter, which should have been replaced according to the manufacturer's recommendations. Another resident's CPAP mask was not stored correctly, as it was found lying uncovered on the floor and draped over furniture, contrary to the facility's policy that required masks to be stored in labeled plastic bags. These oversights in equipment maintenance and storage could contribute to the spread of infections.
Failure to Ensure Required Continuing Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that its nurse aides completed the required 12 hours of continuing education annually, as mandated by state and federal regulations. A review of the facility's policy on training and continuing education for nurse aides revealed that the facility is responsible for providing at least 12 hours of in-service training each year, based on the employment date. However, an interview with the facility's Corporate Nurse Consultant confirmed that four staff members, hired on various dates, had not completed the required continuing education hours. The only training these staff members had completed in the past year was related to abuse and neglect. This deficiency had the potential to affect all 47 residents in the facility.
Deficiencies in Bathing Services and Catheter Management
Penalty
Summary
The facility failed to provide adequate bathing services for several residents, as evidenced by the lack of documented baths or refusals over extended periods. Resident 2, with a diagnosis of dementia and moderately impaired cognition, did not receive a bath or have a refusal documented for two separate periods totaling 25 days. Similarly, Resident 35, who had severe cognitive impairment, went without a documented bath or refusal for a total of 40 days. Resident 38, with moderately impaired cognition, also experienced gaps in bathing services, with no baths or refusals documented for 20 days. Interviews with staff confirmed the absence of a specific bath aide and reliance on a posted list for daily bathing assignments. Resident 31 reported receiving only one shower in the previous four weeks, despite being scheduled for showers twice weekly. This resident, who preferred to be clean-shaven, had visible facial hair growth, indicating a lack of personal hygiene care. The facility's documentation confirmed that Resident 31 had not received a shower in 39 days, and the care plan lacked any mention of bathing preferences. The Director of Nursing acknowledged the expectation for weekly baths and confirmed the deficiency in providing personal hygiene services. Additionally, the facility failed to change Resident 31's indwelling catheter monthly as per the physician's order. The resident, with a diagnosis of neurogenic bladder and moderately impaired cognition, had not had their catheter changed since July, despite orders for monthly changes. Progress notes indicated that the catheter was not changed due to the unavailability of latex-free catheters, and the Director of Nursing confirmed the oversight. This failure to adhere to physician orders further highlights the facility's deficiencies in providing necessary care.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify the representatives of two residents following their falls, as required by their Fall Management policy. Resident 23, who was severely cognitively impaired, experienced multiple falls, including one on 10/02/2024, from a power lift recliner. Despite the policy stating that the family and physician should be notified and the incident documented, the family was not informed of this fall. The family member/POA only learned of the incident by accident during a visit to the facility, and the Clinical Nurse Consultant confirmed the oversight. Similarly, Resident 38, who had a moderate cognitive impairment, experienced falls on 9/18/2024 and 9/24/2024. The facility's records showed that the resident's representative was not notified of these incidents, contrary to the facility's expectations. Interviews with the facility's staff, including the Administrator and Corporate Nurse, confirmed that the representative should have been informed. The facility's process was to notify the physician and family as soon as possible, but this was not adhered to in these cases.
Failure to Implement Fall Prevention Interventions for a Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for Resident 23, who was identified as being at high risk for falls due to multiple medical conditions, including muscle weakness, a history of falling, Alzheimer's disease, and difficulty walking. The resident was severely cognitively impaired, requiring substantial assistance for daily activities and transfers. Despite the resident's history of falls, the facility did not update the care plan with new interventions following falls on 09/24/2024 and 10/02/2024, which involved the resident sliding out of a power recliner. The facility's Fall Management policy required assessment and intervention adjustments after a fall, but these were not completed for Resident 23. The resident had multiple falls from the power recliner, yet the care plan lacked new interventions to address these incidents. Observations revealed that the power recliner remote was often out of reach or improperly secured, contributing to the resident's falls. Interviews with nursing assistants confirmed a lack of awareness of specific care plan interventions to prevent further falls from the recliner. Additionally, the facility did not conduct new Recliner Chair Assessments following each fall, as confirmed by the Clinical Nurse Consultant. The resident's family was not adequately informed about the risks associated with the power recliner or notified of all fall incidents, leading to concerns about the resident's safety. The facility's failure to update the care plan and conduct necessary assessments contributed to the ongoing risk of falls for Resident 23.
Failure to Provide Rationale for PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that a valid rationale was provided and the provider's order was followed for a resident's PRN Lorazepam prescription. The resident, who was admitted with diagnoses of restlessness, agitation, depression, and psychotic disorder, was cognitively aware with a BIMS score of 15 out of 15. Despite the absence of anxiety in the resident's MDS for mood disorders, the resident was prescribed Lorazepam for anxiety. The facility's Medication Regimen Review policy requires that any irregularities be reported and acted upon, and PRN orders for psychotropic drugs are limited to 14 days unless extended with documented rationale. The facility's pharmacy recommended discontinuing the Lorazepam or providing a clinical rationale and reassessment date, but there was no evidence of the physician addressing this recommendation. The resident's order for Lorazepam, which started without a stop date, was not re-evaluated in 30 days as ordered. Interviews with the Clinical Nurse Consultant confirmed that the rationale for continuing the PRN Lorazepam was not provided, and the medication was not stopped or re-evaluated as required.
Failure to Implement and Re-evaluate Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement and re-evaluate interventions to prevent ongoing falls for a resident identified as high risk for falls. The resident had multiple diagnoses, including Wernick's Encephalopathy, amputation, depression, alcohol abuse, generalized anxiety disorder, hypertension, repeated falls, encephalopathy, hypotension, muscle weakness, and a history of falling. Despite being cognitively intact, the resident experienced numerous falls, some resulting in injuries such as a fractured nose, multiple bruises, and a laceration to the face. The facility's Comprehensive Care Plan (CCP) did not indicate any new interventions following these falls, and the Morse Fall Scale assessments consistently identified the resident as high risk for falling. The facility's Fall Investigation Reports revealed that the root cause of the falls was the resident self-transferring. However, the initial interventions to prevent falls were to continue current safety measures without implementing new strategies. This pattern continued despite the resident experiencing multiple falls over several months. Additionally, the facility's Safety Monitoring sheets, which required staff to complete hourly safety checks, showed numerous instances where staff did not initial the checks, indicating a lack of consistent monitoring. Interviews with facility staff, including a Certified Medication Assistant (CMA), a Nursing Assistant (NA), and the Director of Nursing (DON), confirmed that the resident was a high fall risk and that the safety monitoring sheets were not consistently completed. The DON acknowledged that the safety monitoring was the primary intervention in place for months and admitted that no new interventions were implemented with each fall to prevent future incidents. This failure to update and communicate fall prevention interventions contributed to the ongoing risk of falls for the resident.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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