Imperial Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Imperial, Nebraska.
- Location
- 933 Grant Street, Imperial, Nebraska 69033
- CMS Provider Number
- 285252
- Inspections on file
- 23
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Imperial Manor Nursing Home during CMS and state inspections, most recent first.
The facility failed to adhere to proper food storage and handling practices, as observed in the walk-in refrigerator and freezer. Boxes of lettuce and other food items were stored on the floor, and chicken was thawing above ready-to-eat lettuce. Interviews with dietary staff revealed that food deliveries had not been properly stored due to time constraints, and some items had been on the floor for over five days.
A survey found deficiencies in food safety and sanitation at a facility, including outdated food items, improper hand hygiene, and lack of sanitizer testing. Staff failed to use pasteurized eggs and did not follow food preparation directions, affecting 32 residents.
The facility failed to ensure nurse aides completed the required 12 hours of continuing education, including dementia and abuse training. Four nurse aides did not meet the training requirements, potentially affecting all 32 residents. Record reviews showed deficiencies in training hours, confirmed by the Administrator.
The facility failed to prevent elopement for a resident with dementia, as no new interventions were implemented after elopement incidents. Additionally, two residents at risk for falls did not have necessary interventions in place, such as keeping a walker and call light within reach. Another resident with severe cognitive impairment had their call light consistently out of reach, contrary to facility policy.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies. One resident with COPD had their nasal cannula tubing improperly stored and oxygen concentrator set at an incorrect rate. Another resident with multiple diagnoses, including COPD, was found with an unplugged CPAP device and incorrect oxygen settings. Staff interviews confirmed these issues, highlighting a failure to adhere to the facility's oxygen administration policy.
A resident was prescribed Doxycycline for a chronic knee infection without a stop date, contrary to the facility's Antibiotic Stewardship Program policy. The Infection Preventionist confirmed no attempts were made to discontinue the antibiotic, highlighting a deficiency in medication management.
A resident with moderate cognitive impairment and dysphagia was improperly administered Metoprolol Succinate extended-release in a crushed form, contrary to manufacturer instructions. The RN confirmed the error, and the DON acknowledged the practice of crushing medications for residents who refuse whole pills, despite lacking documentation to support this decision.
A facility failed to report a resident's elopement to the State Agency within the required 5 working days. The policy required reporting to the administrator and State Survey Agency but lacked a specific timeframe. A resident eloped after breakfast and was redirected by staff, attempting to leave again an hour later. The Administrator confirmed the report was not completed on time.
A facility failed to complete a significant change in status MDS assessment within the required 14-day timeframe for a resident admitted to hospice care. The assessment was delayed beyond the mandated period, as confirmed by the MDS Coordinator, despite the facility's adherence to the RAI Manual's guidelines.
A facility failed to complete an accurate PASRR for a resident with schizoaffective disorder. The PASRR form incorrectly indicated no suspected mental illness, despite the resident's diagnosis and use of psychotropic medications. The Social Service Director confirmed the facility's responsibility to complete the PASRR for residents admitted from home and acknowledged the need for a level two PASRR.
A facility failed to develop a comprehensive baseline care plan for a resident admitted with COPD and dementia. The care plan lacked essential components such as physician's orders, dietary orders, and social services, as confirmed by the MDS Coordinator. This omission was contrary to the facility's policy requiring such information in baseline care plans.
A facility failed to follow infection control protocols for a resident with a urinary catheter and MRSA. Staff did not don gowns during care and neglected hand hygiene between glove changes, contrary to the facility's policies.
The facility did not submit the required PBJ data for the third quarter of 2024, as mandated by CMS. The policy required submission by August 14th, but the data for April 1 to June 30, 2024, was not submitted. The Administrator confirmed the business manager's failure to report on time, potentially affecting all 32 residents.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a survey. In the walk-in refrigerator, two boxes of lettuce were stored on the floor, and a non-drip container of chicken was thawing on a shelf above a box of ready-to-consume lettuce. Additionally, a bowl of ground meat was stored above a bowl of potato salad. The walk-in freezer door was left open into the refrigeration area, and several boxes of food, including desserts, ice cream, fine ground beef, potato triangles, and dinner roll dough, were stored on the floor. A plastic bag of sliced apples and a large container of ice cream were also found on the floor, along with two non-drip containers of frozen produce holding sliced apples. The black plastic floor mats in the freezer area had small bits of yellow and brown debris. Interviews with the dietary staff revealed that the delivery truck had arrived, and the food in the freezer was to be put away by the end of the shift. However, due to meal preparation, there was no time to do so immediately. The Dietary Supervisor confirmed that food deliveries occur on Mondays, Thursdays, and Fridays, and no deliveries had been made since the previous Friday. It was confirmed that food had been stored on the floor for over five days, indicating a failure to adhere to the facility's policy and procedure for food receiving and storage, which mandates that food be stored in a manner that complies with safe food handling practices.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food safety and sanitation during a survey. Observations revealed that the kitchen had outdated food items, including undated and expired products such as baking soda, granola, and cottage cheese. The kitchen surfaces, including shelves and carts, were covered with dust, grime, and food particles, posing a risk of contamination. Additionally, the facility failed to use pasteurized eggs when serving over-easy eggs, increasing the risk of foodborne illness among residents. The survey also identified issues with hand hygiene and sanitization practices. Staff members were observed not performing proper hand hygiene between tasks, such as changing gloves without washing hands. The sanitizer solution used for cleaning surfaces was not tested for effectiveness, as the facility had run out of test strips. This lack of testing and improper hand hygiene practices could lead to cross-contamination and the spread of foodborne illnesses. Furthermore, the facility did not follow package directions when preparing food, such as stuffing, which resulted in improperly cooked meals. The dietary staff was uncertain about the sanitization process of the dishwasher, and the chemicals used were not tested due to a lack of test strips. These deficiencies in food preparation and sanitation practices had the potential to affect all 32 residents served by the kitchen, compromising their health and safety.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of continuing education, including training in dementia care and abuse prevention, as mandated by Licensure Reference 175 NAC 12-00604(B)(ii). This deficiency was identified through record reviews and interviews, affecting four out of five sampled nurse aides. Specifically, Nurse Aide G, F, D, and H did not meet the continuing education requirements, which had the potential to impact all 32 residents residing in the facility. The record review revealed that Nurse Aide G had not completed any training hours for the year, including dementia or abuse training. Nurse Aide F had completed only 9.05 hours, Nurse Aide D had completed 11.3 hours, and Nurse Aide H had completed 11.55 hours of training for the year. An interview with the Administrator confirmed these findings, indicating that the facility did not comply with the required training hours for these nurse aides.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to implement necessary interventions to prevent elopement for Resident 26, who was admitted with dementia, agitation, and anxiety. Despite being identified as an elopement risk with a history of wandering into unsafe spaces, Resident 26 managed to elope through the front door and later through a rear door on the same day. The care plan included interventions such as documenting wandering behavior, providing structured activities, and using a Wander Guard. However, no new interventions were implemented after the elopement incidents, as confirmed by RN-E. The facility also failed to ensure fall prevention interventions were in place for Resident 3 and Resident 22. Resident 3, who had severe cognitive impairment and a history of falls, was observed without their walker within reach on multiple occasions, contrary to their care plan. NA-D was unaware of the intervention to keep the walker within reach. Similarly, Resident 22, with severe cognitive impairment and at risk for falls, was observed with their call light inaccessible, despite the care plan intervention to remind them to use it when needing to transfer. NA-C confirmed the call light was not within reach. Additionally, the facility did not ensure a call light was within reach for Resident 15, who had severe cognitive impairment. Observations revealed the call light was consistently across the room, not within reach, and Resident 15 confirmed they had to walk to the wall to use it. NA-J and the MDS Coordinator confirmed that Resident 15 did not have a pendant and should have had the call light within reach. The DON confirmed the expectation for call lights to be near residents, but this was not adhered to for Resident 15.
Deficiencies in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to maintain sanitary conditions and adhere to prescribed oxygen settings for two residents, leading to deficiencies in respiratory care. Resident 30, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had an order for oxygen at 2 Liters Per Minute (LPM) at bedtime and as needed. However, observations revealed that the nasal cannula tubing was improperly stored on the floor, and the oxygen concentrator was set at 4 LPM instead of the prescribed 2 LPM. Interviews with nursing staff confirmed these discrepancies, indicating a failure to follow the facility's policy on oxygen administration, which requires oxygen delivery devices to be kept in plastic bags when not in use and administered under a physician's orders. Resident 8, with diagnoses including COPD, Essential Hypertension, and Chronic Systolic Heart Failure, had a physician's order for oxygen at 2 LPM to maintain oxygen saturation levels above 90%. During an observation, it was found that the resident's CPAP device was unplugged, resulting in the resident not receiving oxygen. After the device was plugged in, the oxygen concentrator was set at 0.5 LPM, contrary to the prescribed 2 LPM. An interview with a registered nurse revealed that the staff responsible for the medication cart should have been monitoring the oxygen machine and saturation levels, but this was not done, leading to the deficiency.
Antibiotic Prescription Lacks Stop Date
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of antibiotics. A review of the facility's Antibiotic Stewardship Program policy, last revised on 10/8/2024, indicated that all antibiotic prescriptions should specify the dose, duration, and indication for use. However, upon admission on 8/1/2023, a resident was prescribed Doxycycline for a chronic knee infection without a specified stop date. This oversight was confirmed during an interview with the Infection Preventionist on 10/9/2024, who acknowledged that no attempts had been made to discontinue the antibiotic, resulting in a deficiency in the facility's medication management practices.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that a resident received an extended-release medication according to the manufacturer's directions, resulting in a significant medication error. The resident, identified as having moderate cognitive impairment and diagnosed with non-Alzheimer's dementia and dysphagia, was administered Metoprolol Succinate extended-release in a crushed form, contrary to the manufacturer's instructions. The medication administration was observed when a registered nurse (RN) prepared and crushed all oral medications, including the extended-release Metoprolol, and mixed them with applesauce for the resident to consume. The RN confirmed that Metoprolol ER should not be crushed and acknowledged the absence of any special order or instructions permitting this action. The Director of Nursing (DON) stated that while some medications should not be crushed, they continue to do so for residents who refuse to swallow whole pills, with the Medical Director's agreement. However, there was no documentation in the resident's medical record to support the decision to crush the medication. This oversight led to the improper administration of the medication, violating the manufacturer's guidelines.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the State Agency within the required timeframe of 5 working days. The facility's policy on reporting alleged violations, dated February 22, 2023, mandates that such incidents be reported to the administrator and the State Survey Agency, but it does not specify a timeframe for reporting. On January 27, 2024, a registered nurse documented in the progress notes that a resident had eloped out the front door after breakfast and was subsequently redirected by staff. The resident attempted to leave the facility again about an hour later. An interview with the Administrator on October 10, 2024, confirmed that the report to the State Agency regarding this elopement had not been completed within the required timeframe.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. According to the Long-Term Care Facility Resident Assessment Instrument Manual, a significant change of status assessment is required when a terminally ill resident enrolls in a hospice program, and the Assessment Reference Date (ARD) must be no later than the 14th calendar day after the determination of the significant change. However, the MDS assessment for the resident was completed beyond this required timeframe. The resident in question was admitted to the facility and later had an active physician's order dated June 5, 2024, to admit them to hospice services. The MDS assessment, which was supposed to reflect this significant change, was dated July 4, 2024, indicating a delay in compliance with the mandated assessment period. An interview with the MDS Coordinator confirmed that the assessment was not completed within the required timeframe, despite the facility's adherence to the RAI Manual's guidelines for completing and submitting MDS assessments.
Failure to Complete Accurate PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed prior to the admission of a resident diagnosed with schizoaffective disorder. Upon reviewing the resident's records, it was found that the PASRR form, dated the day of admission, incorrectly indicated that the resident did not have a suspected mental illness, despite the diagnosis of schizoaffective disorder. Additionally, the form failed to acknowledge other diagnoses such as psychotic disturbance and mood disturbance, as well as the use of psychotropic medications. The Social Service Director confirmed that the facility was responsible for completing the PASRR for residents admitted from home and acknowledged that the diagnosis should have triggered a level two PASRR.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident, identified as Resident 30, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and dementia. The baseline care plan, which is a written strategy for how nursing home staff will help a resident receive the care they need, was missing essential components such as physician's orders, dietary orders, and social services. This deficiency was confirmed during an interview with the Minimum Data Set (MDS) Coordinator, who acknowledged that the required information was not included in the baseline care plan for Resident 30. The facility's policy, implemented on 10/7/2022, mandates that baseline care plans must include initial goals, physician's orders, dietary orders, therapy services, and social services, but these were not present in the interim care plan dated 3/29/2024.
Infection Control Deficiency: PPE and Hand Hygiene Lapses
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during the care of a resident with a urinary catheter and a history of Methicillin-resistant Staphylococcus aureus (MRSA) infection. Specifically, the facility did not ensure that staff donned appropriate Personal Protective Equipment (PPE), such as gowns, during high-contact care activities. This was observed when a nurse aide began providing care to a resident without wearing a gown, despite the resident's care plan indicating the necessity of wearing gowns and gloves during physical contact due to the resident's medical condition. Additionally, the facility did not comply with hand hygiene protocols between glove changes. Observations revealed that two nurse aides changed gloves without performing hand hygiene before applying new gloves. Interviews with the nurse aides confirmed that they did not perform hand hygiene between glove changes, acknowledging that they should have done so. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene before donning gloves and immediately after removing them.
Failure to Submit PBJ Data for Q3 2024
Penalty
Summary
The facility failed to submit the required Payroll Based Journal (PBJ) data for the third quarter of 2024, which is a mandatory requirement for all long-term care facilities as per the Centers for Medicare and Medicaid Services (CMS). The facility's policy, last reviewed on August 31, 2024, mandates that this data be submitted no later than the specified deadline for each quarter, with the deadline for the third quarter being August 14th. A review of the PBJ report from CMS confirmed that the facility did not submit the data for the period of April 1 to June 30, 2024. During an interview, the Administrator acknowledged that the business manager did not report the third quarter PBJ on time, as required. This oversight had the potential to affect all 32 residents residing within the facility.
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 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 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 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 multiple open wounds, a PICC line, and an active MRSA infection was not managed under the facility’s Enhanced Barrier Precautions (EBP) policy, which requires gown and glove use and door signage for residents with wounds, indwelling devices, or MDROs during high-contact care. Observations showed no EBP signage or gowns available at the room, and an LPN performed wound care using only gloves without a gown, later confirming that EBP should have been used but was not.
Surveyors found that medications were not stored securely as required by facility policy and regulations. A container of Gavilyte-G solution labeled for a resident was left on a bathroom sink, and a clear plastic bag containing multiple medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, was found on a dresser in another resident’s room. The second resident was cognitively intact per BIMS, required extensive assistance with ADLs, was at risk for pressure ulcers, and had two venous ulcers. An LPN and the Wound and Infection Nurse confirmed these medications should not have been stored in these unsecured locations and should have been kept locked.
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.
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.
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 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.
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 Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy during care of a resident with multiple wounds, an indwelling device, and an active MDRO infection. The facility’s EBP policy dated 01-2024 states that residents with wounds or indwelling medical devices, regardless of MDRO status, and residents known to be infected or colonized with an MDRO, are to be placed on EBP with signage on the door and targeted gown and glove use during high-contact activities, including wound care. EBP is required for activities such as dressing, bathing, hygiene, changing linens and briefs, toileting assistance, device care, and any wound care requiring a dressing. Record review showed that the resident was cognitively intact, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had multiple wounds including venous ulcers, open wounds on both buttocks, a left BKA incision, several unstageable pressure ulcers on the right lower extremity, a PICC line in the right upper arm, and an active MRSA infection. Observations on separate days revealed there was no EBP signage on the resident’s door and no gowns available inside or outside the room. During observed wound care, an LPN used gloves but did not wear a gown, and later confirmed that EBP had not been utilized and should have been during the wound care encounter.
Medications Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were stored safely and securely in accordance with its policy and regulatory requirements. The facility’s policy on centralized medication storage, revised 8/2024, stated that medications are to be stored safely, securely, and properly, accessible only to authorized personnel. During an observation on 3/17/26 at 8:14 AM, surveyors found a container of Gavilyte-G solution, labeled by the pharmacy for Resident 3, sitting on the bathroom sink in Resident 3’s bathroom with approximately one inch of solution remaining. In an interview on 3/16/26 at 10:47 AM, the Wound and Infection Nurse confirmed that the Gavilyte-G container should not have been stored on the resident’s bathroom sink. The facility also failed to secure multiple medications in the room of Resident 2. Resident 2’s MDS dated 01-04-2026 showed the resident was admitted on a prior date, had a BIMS score of 13 indicating cognitive intactness, required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers, was at risk of developing a pressure ulcer, and had two venous ulcers. On 03-16-2026, an observation revealed a clear plastic bag containing medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, sitting on the dresser in Resident 2’s room. In an interview on the same date, LPN D confirmed that these medications were on the dresser and acknowledged that medications are supposed to be kept locked up.
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.
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