Indian Hills Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ogallala, Nebraska.
- Location
- 1720 North Spruce, Ogallala, Nebraska 69153
- CMS Provider Number
- 285091
- Inspections on file
- 21
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Indian Hills Manor during CMS and state inspections, most recent first.
The facility failed to meet regulatory and policy timeframes for reporting an incident of resident-to-resident abuse and submitting the investigation results. An incident of abuse occurred between two residents, one with dementia, weight loss, unsteadiness, and type 2 DM, and another with COPD, pneumonia, bladder dysfunction, and heart failure. The DON and ADM were notified by phone the day of the incident, but the ADM did not notify the State Agency until days later, beyond the required 24 hours, and the written investigation report was also submitted after the 5-working-day deadline.
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training for the year, potentially affecting all residents. Record reviews showed that MA-D, NA-A, MA-G, and MA-F did not meet the training requirements, with some completing duplicate courses. The Administrator confirmed these deficiencies.
The facility failed to implement a water management program to prevent legionella, with zero chlorine levels found in tested areas despite flushing. Additionally, an LPN did not follow hand hygiene protocols during wound care for a resident, failing to sanitize hands between glove changes.
The facility did not ensure that five employees, including a cook, a dietary aide, the DON, and two nurse aides, completed their initial orientation training within two weeks of hire. This training was supposed to cover resident rights and emergency procedures, as required by regulations. The lack of training was confirmed through record reviews and an interview with the Administrator, potentially affecting all 27 residents in the facility.
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training, including dementia management and abuse prevention. Record reviews showed that staff had incomplete or duplicate training hours, potentially affecting all residents. The Administrator confirmed the shortfall in training hours.
A facility failed to protect the private health information of three residents during medication administration. An RN was observed leaving a computer screen open with residents' private health information visible while administering medications in the dining room. This action violated the facility's privacy policies, which emphasize the protection and confidentiality of personal and medical records.
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. Residents admitted with conditions such as palliative care needs, diabetes type 2, and dementia with a femur fracture did not have timely care plans. The facility's process did not include a separate baseline care plan, leading to delays in care plan initiation.
The facility failed to document and monitor three residents during acute illnesses, including influenza A and pneumonia. Resident 18 was transferred to the hospital without proper documentation of their condition or assessment. Resident 3 and Resident 8, both diagnosed with influenza A, were not consistently monitored every shift as required. The DON confirmed these deficiencies in care and documentation.
A facility failed to accurately update a resident's MDS, listing resolved fractures as active diagnoses. Despite the resident's fractures having resolved over a year ago, the MDS assessments continued to reflect them as active, contrary to the facility's policy and federal guidelines. The ADON and MDS Nurse confirmed the inaccuracies in the assessments.
A resident with severe cognitive impairment and dependent on staff for bathing did not receive necessary bathing services while in isolation for Influenza A. Staff were instructed not to give baths to isolated residents, but bed baths were not offered or documented, leading to a two-week period without bathing, contrary to the resident's care plan.
The facility failed to implement and revise nutritional interventions for residents experiencing significant weight loss. A resident with dementia and COPD lost 9.8% of their weight over five months due to inadequate meal assistance and documentation. Another resident with a cerebral infarction lost 5.9% of their weight in less than a month, with inconsistent meal monitoring and assistance. A third resident with dementia and Parkinson's disease lost 16.81% of their weight over six months, with frequent interruptions in feeding assistance and poor documentation of meal intakes.
The facility failed to resolve ongoing grievances and ensure residents could voice concerns without fear of retaliation. Issues included inaccessible call lights, unmade beds, and staff unavailability due to smoke breaks. Residents reported threats of room changes if they complained. Grievances were repeatedly documented but remained unresolved, indicating ineffective communication and follow-up between departments.
The facility failed to ensure the Dietary Manager had the necessary credentialing as required by the job description, which included completing a Dietary Manager certification course. The President of Operations and the facility Administrator confirmed the current DM did not meet these qualifications, potentially affecting all residents consuming food from the kitchen.
The facility staff failed to follow proper handwashing, gloving, and food storage practices, leading to potential cross-contamination risks. Observations revealed outdated and undated food items, disorganized kitchen utensils, and non-cleanable cooking equipment. A dietary cook was seen handling food without washing hands or using gloves, further compromising food safety.
The facility's QAPI program was found deficient as the QAA committee did not include the Infection Preventionist due to their night shift, and no performance improvement projects were conducted. The committee, which met monthly, failed to address significant issues like resident weight loss, potentially affecting all 34 residents.
A LTC facility failed to use required PPE for a resident on Enhanced Barrier Precautions, did not perform proper hand hygiene and gloving during a blood glucose test, and lacked measures to prevent Legionella growth. A resident with a pressure ulcer was not provided with proper signage for precautions, and a blood glucose test was conducted without hygiene protocols. The facility also did not conduct a water risk assessment for Legionella prevention.
The facility did not ensure that four NAs completed the required 12 hours of continuing education in 2023, including training in Dementia care and infection control. NA-M had only 0.5 hours of education, lacking both Dementia and infection control training. NA-N completed 4.25 hours without Dementia training, while NA-O and NA-P had 7.10 and 5.15 hours, respectively. The Administrator confirmed the deficiency, and the facility's policy mandates compliance with education requirements, which was not met.
A facility failed to provide timely assistance with activities of daily living (ADLs) for residents requiring help. One resident with dementia was left without repositioning or toileting for hours, resulting in saturated clothing and dried feces. Another resident with cerebral infarction was left unattended during meals, leading to uneaten food. A third resident with severe cognitive impairment was not toileted for extended periods. Staff interviews confirmed these deficiencies.
The facility failed to provide adequate staffing, resulting in insufficient feeding assistance, repositioning, and incontinence care for residents. A resident with dementia was left unable to reach their meal and went without repositioning or incontinence care for hours, while another resident requiring partial assistance with eating was left unattended with uneaten meals. Staffing shortages were confirmed by staff and the DON, with only one nurse aide available during meal times.
The facility failed to ensure call devices were within reach for two residents, both with cognitive impairments and mobility issues. Observations revealed that the call devices were not accessible, leading to distress for one resident. A nurse aide confirmed that call devices should be within reach, indicating a lapse in policy adherence.
A facility failed to accurately assess a resident's medication usage during the Admission MDS process. The resident, with Type 2 Diabetes Mellitus, had orders for glipizide, metformin, and Victoza, but the MDS inaccurately documented insulin usage. The MAR confirmed no insulin orders, and the resident, cognitively intact, reported taking Victoza for years. The facility's MDS policy was not followed, leading to this documentation error.
A resident with dementia was diagnosed and treated for a UTI, but the facility failed to update the care plan to reflect this change. Despite receiving antibiotics, the care plan did not include new interventions for the UTI, contrary to the facility's policy. The DON confirmed the care plan should have been revised.
A resident with paraplegia and a stage 4 pressure ulcer was not repositioned as required by their care plan and facility policy. Observations showed the resident remained in the same position for extended periods, both in bed and in a wheelchair. The air mattress was set incorrectly, and the head of the bed was elevated beyond recommended levels. The DON confirmed these discrepancies, leading to a deficiency in pressure ulcer care.
A facility failed to ensure physician review of Medication Regimen Reviews for a resident with multiple diagnoses, including Dementia and Parkinson's disease. Despite the pharmacist's concerns about medications like citalopram and risperidone, there was no documentation of physician review or response. The facility's policy requires adherence to CMS guidelines, which was not followed.
A facility failed to limit PRN orders for antipsychotic drugs to 14 days or document a stop date, as required by policy. A resident was prescribed Seroquel for insomnia without a stop date or re-evaluation, which the facility did not consider appropriate. The resident had a history of heart failure, insomnia, and moderate cognitive impairment.
Failure to Timely Report Resident-to-Resident Abuse and Investigation Results
Penalty
Summary
The facility failed to timely report an incident of resident-to-resident abuse to the State Agency and failed to submit the required investigation report within the regulatory timeframe. An untitled facility document showed that an incident of abuse between Resident 1 and Resident 2 occurred on 2/28/26 at 12:45 PM, and the Administrator was notified that same day at 1:15 PM. Resident 1 had unspecified dementia, weight loss, unsteadiness on feet, and type 2 diabetes mellitus, while Resident 2 had chronic obstructive pulmonary disease, pneumonia, bladder dysfunction, and heart failure. Despite the facility’s abuse prevention plan policy stating that alleged violations of abuse or neglect are to be reported to the Administrator and the State Agency immediately, the State Agency was not notified until 3/2/26 at 1:00 PM. Record review and interviews confirmed that the Director of Nursing was notified by telephone on 2/28/26 that an incident of abuse had occurred between the two residents and that the Director of Nursing then notified the Administrator by telephone the same day. The Administrator stated that the incident was reviewed on the next working day, 3/2/26, and only then reported to the State Agency, which was beyond the 24-hour requirement in regulation and facility policy. The same untitled document and the Administrator’s interview further confirmed that the results of the investigation were submitted to the State Agency on 3/6/26, which exceeded the required 5 working days for submission of the investigative report.
Deficiency in Staff Training Hours
Penalty
Summary
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training for the year, as mandated by the licensure reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and interviews, which revealed that the lack of training had the potential to affect all residents within the facility, which had a census of 27. The Facility Assessment Tool indicated that all training should be completed at least upon orientation, annually, and as needed, covering topics such as dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. Specific findings showed that MA-D had only 0.5 hours of ongoing training and no training on dementia or abuse/neglect. NA-A had completed 4.95 hours of training, with some courses being duplicates, resulting in a total of 4.7 hours. MA-G had completed 9 hours of training, while MA-F had 15.7 hours, but with 4 hours being duplicates, resulting in 11.7 hours of valid training. An interview with the Administrator confirmed these findings, acknowledging that the employees had not met the required training hours for the year.
Deficiencies in Water Management and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement a comprehensive water management program to monitor and prevent the potential for legionella and other waterborne pathogens, which could affect all residents. The facility's policy required the maintenance director to maintain documentation describing the water system and apply control measures at each control point. However, the facility did not have a description of its water systems, and chlorine levels in tested eyewash stations and selected resident rooms were consistently found to be zero on multiple dates, despite documentation indicating that these areas were flushed. This was confirmed by the Nursing Home Administrator, who acknowledged the lack of additional dates for these tasks. Additionally, the facility failed to adhere to proper hand hygiene protocols during wound care for a resident. The resident had a physician's order for daily wound care on the right gluteal fold. During an observation, an LPN removed a soiled dressing, changed gloves without performing hand hygiene, and applied a new dressing. The facility's policy required hand hygiene after removing gloves and before putting on new gloves, which was not followed. The LPN confirmed the failure to perform hand hygiene during an interview.
Failure to Complete Initial Orientation Training for Staff
Penalty
Summary
The facility failed to ensure that five sampled employees completed their initial orientation training within two weeks of beginning employment, as required by the licensure reference 175 NAC 12-006.04(B)(i). This training was supposed to include essential topics such as resident rights and emergency procedures. The deficiency was identified through record reviews and interviews, which revealed that none of the five employees had evidence of completing the required orientation training. The employees in question included a cook, a dietary aide, the Director of Nursing (DON), and two nurse aides. The facility's Facility Assessment Tool, dated February 26, 2025, indicated that training should be completed at orientation, annually, and as needed, covering topics like effective communication, resident rights, abuse/neglect, infection control, and culture change. However, personnel file reviews showed no evidence of initial orientation training for the cook and dietary aide, and no evidence of training on resident rights and emergency procedures for the DON and the two nurse aides. An interview with the Administrator confirmed the lack of initial orientation training for these employees, which had the potential to affect all residents in the facility, which had a census of 27.
Deficiency in Staff Training Hours
Penalty
Summary
The facility failed to ensure that four out of five sampled employees completed the required 12 hours of ongoing training within the year, which included essential topics such as dementia management and resident abuse prevention. This deficiency was identified through record reviews and interviews, revealing that the training shortfall had the potential to affect all residents in the facility, which had a census of 27. The facility's Facility Assessment Tool, dated February 26, 2025, stipulated that all training should be completed at least upon orientation, annually, and as needed, with a minimum of 12 hours per year covering various critical topics. Specific deficiencies were noted in the training records of the staff. Medication Aide (MA) D, hired in 2010, had only 0.5 hours of ongoing training and none in dementia or abuse/neglect. Nurse Aide (NA) A, hired in 2022, completed 4.95 hours of training, with some courses duplicated, resulting in only 4.7 hours of valid training. MA G, hired in 2013, completed 9 hours of training, while MA F, hired in 2022, completed 15.7 hours, but with 4 hours of duplicate courses, resulting in 11.7 hours of valid training. An interview with the Administrator confirmed these findings, acknowledging the failure to meet the required training hours for the year.
Failure to Protect Resident Health Information During Medication Administration
Penalty
Summary
The facility failed to protect the private health information of three residents during medication administration. A Registered Nurse (RN-J) was observed administering medications in the dining room using a laptop computer mounted on a mobile medication cart. During the process, RN-J left the computer screen open with the private health information of Residents 9, 23, and 32 visible to anyone in the vicinity while they walked to the residents' tables to administer medications. This occurred for each of the three residents, and RN-J confirmed this was their usual routine. The facility's policies, as reviewed, emphasize the importance of protecting the privacy of individual health information and ensuring confidentiality of personal and medical records. However, the actions observed during the medication administration process were in direct violation of these policies. RN-J acknowledged the oversight and confirmed that the private health information was left visible, which should not have happened according to the facility's privacy policies and procedures.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for three residents. The Baseline Care Plan Policy, dated 4/23/2019, requires that a baseline care plan be developed within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. However, for Resident 35, who was admitted for palliative care with diagnoses including atrial fibrillation, osteomyelitis, and neuralgia, the care plan was not initiated until several days after admission. The Social Services Director and Director of Nursing confirmed that the facility did not utilize a separate baseline care plan, and the nursing portion of the care plan was delayed due to late or incomplete admission assessments. Similarly, Resident 23, admitted with a primary diagnosis of diabetes type 2, did not have a baseline care plan developed within the required timeframe. The earliest entry in the care plan was made several days after admission. The Registered Nurse Clinical Coordinator and Director of Nursing confirmed the absence of a baseline care plan. For Resident 27, admitted with dementia and a femur fracture, the care plan was also not initiated within the required timeframe. The Director of Nursing confirmed the lack of a baseline care plan for this resident as well. These deficiencies indicate a systemic issue in the facility's process for developing timely baseline care plans.
Failure to Document and Monitor Residents During Acute Illnesses
Penalty
Summary
The facility failed to ensure proper documentation and monitoring during the course of acute illnesses for three residents, leading to deficiencies in care. Resident 18, who had a history of unspecified dementia, ventricular tachycardia, and cardiomyopathy, was admitted to the hospital with pneumonia after a recent diagnosis of influenza A. However, there was no documented evidence of Resident 18's transfer to the hospital or any nursing assessment prior to the transfer. The Director of Nursing (DON) confirmed that there should have been documentation of Resident 18's condition, assessment results, and subsequent transfer to the hospital. Resident 3, diagnosed with dementia and chronic obstructive pulmonary disease, tested positive for influenza A. Despite the care plan interventions to monitor for signs of dehydration and other symptoms, there was a lack of consistent documentation and assessment between specific dates. The DON confirmed that Resident 3 had not been monitored every shift during their acute illness, which was against the facility's expectations for monitoring during such conditions. Resident 8, with a history of congestive heart failure, diabetes, and vascular dementia, also tested positive for influenza A. Similar to Resident 3, there was insufficient documentation and assessment during the course of the illness. The DON acknowledged that Resident 8 had not been monitored every shift as required during acute illnesses. These lapses in documentation and monitoring reflect a failure to adhere to the facility's policies and procedures for managing changes in residents' conditions.
Inaccurate MDS Assessment for Resident's Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated comprehensive assessment tool. The deficiency was identified during a review of records and interviews, where it was found that the MDS did not accurately reflect the active diagnoses for one resident. Specifically, the resident had been admitted with a diagnosis of dementia and had a history of fractures, including a trochanteric fracture of the femur and fractures of the sixth and seventh cervical vertebrae. These fractures were incorrectly listed as active diagnoses in the resident's MDS assessments conducted on multiple occasions, despite having resolved over a year ago. The facility's policy, which was intended to ensure the timeliness and accuracy of all MDS assessments, was not followed. The Assistant Director of Nursing confirmed that the resident's fractures had resolved, and the MDS Nurse acknowledged that the MDS assessments were incorrectly coded. The incorrect coding persisted across several assessments, indicating a failure to update the resident's medical status accurately. This oversight resulted in the inclusion of resolved conditions as active diagnoses, contrary to the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.
Failure to Provide Bathing Services During Isolation
Penalty
Summary
The facility failed to provide adequate bathing services to a resident during isolation precautions. The resident, who was admitted with a diagnosis of dementia and had severe cognitive impairment, was dependent on staff for bathing assistance. The resident was placed in isolation after testing positive for Influenza A, and during this period, the facility did not provide the necessary bathing services as per the resident's care plan. The care plan indicated that the resident required extensive assistance with bathing, yet the records show that no baths were given from February 5, 2025, to February 19, 2025, while the resident was in isolation. Interviews with staff revealed that they were instructed not to give baths to residents in isolation to prevent the spread of influenza. However, it was noted that bed baths could have been offered and documented, which was not done in this case. The Assistant Director of Nursing confirmed that the resident did not receive a bath for two weeks while in isolation, which was against the facility's policy and the resident's care plan requirements. This oversight led to a deficiency in providing necessary care and assistance for activities of daily living, specifically bathing, to the resident during their isolation period.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility failed to implement, evaluate, and revise nutritional interventions for residents experiencing significant weight loss. Resident 4, diagnosed with chronic conditions such as dementia and COPD, experienced a 9.8% weight loss over five months. Despite having a care plan that included nutritional supplements and monitoring, the facility did not document weights consistently or provide adequate assistance during meals. Observations showed Resident 4 was unable to reach their meal due to improper wheelchair positioning, and staff assistance was insufficient, leading to minimal food intake. Resident 27, admitted with a cerebral infarction, also experienced a significant weight loss of 5.9% in less than a month. The resident's care plan required monitoring of meal intake and weight, but documentation was inconsistent, and the resident was often left unattended during meals. Observations revealed the resident frequently had their eyes closed during meal times, with food left uneaten and no staff intervention to assist or encourage eating. Resident 14, with a history of dementia and Parkinson's disease, showed a 16.81% weight loss over six months. The resident required assistance with feeding due to tremors and loose-fitting dentures, but staff frequently interrupted feeding assistance, resulting in the resident consuming less than 25% of meals. The facility failed to document meal intakes consistently, and the DON confirmed that aides were expected to assist with feeding according to the care plan, which was not adhered to.
Unresolved Grievances and Retaliation Concerns
Penalty
Summary
The facility failed to resolve ongoing grievance concerns and did not ensure that residents could voice concerns without fear of retaliation. The facility's grievance policy, revised in March 2019, was not effectively implemented. The policy required grievances reported during resident or family council meetings to be documented and investigated within 72 hours, but this process was not followed. Multiple unresolved issues were documented in Resident Council meetings from October 2023 to March 2024, including call lights not being answered promptly, staff not knocking before entering rooms, and beds not being made or stripped on bath days. Specific grievances included staff leaving call lights inaccessible, not changing bed linens regularly, and failing to provide snacks and fresh ice water. Residents also reported that staff threatened to move them if they complained too often and that staff were unavailable due to frequent smoke breaks. These issues were repeatedly brought up in Resident Council meetings but remained unresolved, indicating a lack of effective communication and follow-up between the Social Services Director, nursing department, and other responsible parties. Interviews with residents and staff confirmed these ongoing issues. Resident 26 reported that staff often left the call light clipped to the fitted sheet, making it inaccessible for Resident 25, who also experienced delays in receiving assistance. The Social Services Director and Director of Nursing acknowledged that grievance forms were not always returned with resolutions, and the nursing department was not consistently informed of unresolved concerns. This lack of resolution and communication contributed to the ongoing grievances and dissatisfaction among residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary credentialing to meet the requirements for the position, as outlined in the facility's job description for the role of Dietary Service Director dated 7/1/2018. The job description specified that the DM should have completed a Dietary Manager certification course. During an interview, the President of Operations and the facility Administrator confirmed that the current DM did not have the required training to fulfill the qualifications for the position. This deficiency had the potential to affect all residents consuming food from the kitchen, with the facility census being 34 and a total sample size of 19.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility staff failed to adhere to proper handwashing and gloving techniques, as well as appropriate food storage, preparation, and serving practices, which could potentially lead to cross-contamination and foodborne illnesses affecting all residents served meals from the kitchen. The facility's policy on date marking for food safety was not followed, as evidenced by the presence of outdated and undated food items in the walk-in refrigerator and freezer. Observations revealed pork chops, broccoli, egg salad, ham cubes, and mandarin oranges in the refrigerator, along with unlabeled and undated chicken products and French fries in the freezer. During a kitchen sanitation tour, several issues were identified, including a heavy layer of dust and grease on the stove hood, disorganized kitchen drawers with utensils stored in a manner that could contaminate food contact surfaces, and undated food items such as flour tortilla shells, cornstarch, and honey. Additionally, frying pans and cookie sheets were found with heavy carbon buildup, making them non-cleanable, and an ice machine was observed with makeshift containers to catch leaks. Personal items, such as a cell phone and charger, were improperly stored on the steam table, posing a contamination risk. A dietary cook was observed handling food without washing hands, using gloves, or employing tongs, directly touching prepared cheese and bacon sandwiches with bare hands. This action was confirmed by the facility's Administrator, Dietary Manager, and President of Operations, who acknowledged that kitchen staff were responsible for ensuring food items were labeled, dated, and discarded if outdated. They also confirmed that utensils should be stored to prevent contamination, the ice machine required maintenance, and personal items should not be stored in food service areas.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as required by their policy. The policy outlined that the Quality Assurance and Assessment (QAA) committee should include the Director of Nursing (DON), Medical Director (MD), Infection Preventionist (IP), and three other staff members, and that the committee should meet at least quarterly to address quality deficiencies. However, the facility's QAA committee did not include the IP due to their night shift schedule, and the facility had not conducted any performance improvement projects (PIPs) as mandated by their policy. Additionally, the committee had not addressed significant issues such as resident weight loss during their meetings. An interview with the Administrator revealed that the QAA committee met monthly, but the IP was not involved in these meetings. The Administrator stated that the DON was informed about infection control topics, and the committee occasionally discussed issues like infection surveillance, antibiotic stewardship, abuse, gradual dose reductions (GDRs), and medication regime reviews (MRR). Despite these discussions, the facility did not implement any PIPs, which are essential for addressing high-risk or problem-prone areas, as required by their QAPI policy. This lack of action had the potential to affect all 34 residents residing in the facility.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to utilize the required Personal Protective Equipment (PPE) when performing wound care for a resident on Enhanced Barrier Precautions. The resident, who was admitted with diagnoses including dementia, a history of Transient Ischemic Attack, hemiplegia, and an unstageable pressure ulcer, was observed without proper signage indicating the need for enhanced precautions. A Registered Nurse (RN) did not wear a gown, gloves, or mask while performing a dressing change, despite the presence of PPE outside the resident's room. The RN was unaware of the need for additional PPE, and it was later confirmed that the facility should have had signs posted to inform staff of the precautions. The facility also failed to complete hand hygiene and proper gloving during a blood glucose test for another resident. A Medication Aide (MA) did not use a barrier for the blood glucose monitor and supplies, did not perform hand hygiene, and did not wear gloves during the procedure. The MA also failed to clean and disinfect the blood glucose monitor before returning it to storage. These actions were confirmed as incorrect by the Vice President of Operations, who noted the lack of adherence to the facility's policies on hand hygiene and glove use. Additionally, the facility did not implement measures to prevent the growth of Legionella and other waterborne pathogens. The Administrator confirmed that no water risk assessment had been conducted, and there was no documented plan to prevent pathogen growth in the facility's water systems. The facility's policy on Legionella prevention was not followed, as there was no full-scale environmental investigation or decontamination of potential sources.
Deficiency in Nursing Assistant Continuing Education
Penalty
Summary
The facility failed to ensure that four Nursing Assistants (NAs) received the required 12 hours of continuing education in 2023, which includes training in Dementia care and infection control. A review of staff education records showed that NA-M had only 0.5 hours of continuing education and lacked both Dementia and infection control training. NA-N completed 4.25 hours of continuing education but did not receive Dementia training. NA-O had 7.10 hours, and NA-P had 5.15 hours of the required 12 hours of continuing education. An interview with the Administrator confirmed the deficiency in staff education. The facility's policy, effective October 2022, mandates compliance with State and Federal regulations for continuing education, including training in Dementia, infection control, and abuse/neglect. However, the facility did not adhere to these requirements, as evidenced by the incomplete training records of the nursing assistants.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide timely repositioning, feeding assistance, and toileting/incontinence management for several residents who required assistance with activities of daily living (ADLs). Resident 4, who had diagnoses including dementia and chronic obstructive pulmonary disease, required extensive assistance with various ADLs. Observations revealed that Resident 4 was left in a wheelchair for extended periods without repositioning or toileting assistance, resulting in the resident being found with saturated clothing and dried feces on their skin. The resident was also not provided adequate assistance during meal times, consuming only a few bites of food. Resident 27, admitted with a primary diagnosis of cerebral infarction, required partial assistance with eating. However, observations showed that the resident was left unattended with uneaten food in front of them for extended periods. Despite attempts to wake the resident, staff did not provide consistent assistance, resulting in the resident not consuming their meals. The Director of Nursing acknowledged that staff should have assisted the resident more, especially given the resident's recent stomach bug and decreased appetite. Resident 15, with severe cognitive impairment and frequent incontinence, required maximum assistance with toileting and personal hygiene. Observations indicated that the resident was not assisted with toileting for several hours, both before and after breakfast. Interviews with staff confirmed that the resident had not been toileted since before breakfast, highlighting a failure to provide necessary assistance in a timely manner.
Inadequate Staffing Leads to Insufficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, resulting in inadequate feeding assistance, repositioning, and incontinence care for several residents. Resident 4, who had multiple diagnoses including dementia and required extensive assistance with activities of daily living, was observed in a tilt-n-space wheelchair unable to reach their meal. Despite attempts to assist, the resident consumed only a few bites of food and was left without proper repositioning or incontinence care for extended periods, leading to saturated clothing and dried feces on the skin. Similarly, Resident 27, who required partial assistance with eating, was left unattended with uneaten meals in front of them. The resident was observed with eyes closed and food untouched for long durations, indicating a lack of staff intervention to ensure adequate nutrition. Despite being cued to eat, the resident's food intake was minimal, and they were often left without assistance, highlighting the facility's staffing inadequacies. Interviews with staff and the Director of Nursing confirmed the staffing shortages, with only one nurse aide available during meal times and insufficient staff to provide necessary care. The facility's staffing assignments revealed gaps in coverage, contributing to the inability to meet residents' needs for timely assistance with meals, repositioning, and incontinence management.
Failure to Ensure Call Device Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call devices were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident 14, who had severe cognitive impairment and required maximum assistance for toileting, hygiene, and dressing, was observed on two separate occasions with the call device hanging on the wall at the foot of the bed, out of reach. During one observation, Resident 14 was found lying in bed, whimpering and crying out for help, indicating distress and an inability to access assistance. Similarly, Resident 23, who had a self-care deficit related to dementia, impaired balance, and limited mobility, was observed twice without a call device within reach or viewable sight. The care plan for Resident 23 included an intervention to encourage the use of the call device for assistance, which was not adhered to. An interview with a nurse aide confirmed that call devices should be within reach for all residents, highlighting a lapse in the facility's adherence to its policy on call light accessibility.
Inaccurate Assessment of Resident's Medication Usage
Penalty
Summary
The facility failed to accurately assess a resident's medication usage during the completion of their Admission Minimum Data Set (MDS). The resident, who was admitted with a diagnosis of Type 2 Diabetes Mellitus, had physician's orders for glipizide, metformin, and Victoza, all intended to manage their diabetes. However, the Admission MDS inaccurately documented that the resident had received insulin injections during the lookback period, despite the Medication Administration Record (MAR) showing no orders for insulin and confirming the resident took their oral hypoglycemic medications as prescribed. An interview with the resident revealed that they had been taking Victoza, a noninsulin injectable medication, for 5 to 6 years. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. The facility's policy on MDS, which aims to ensure the timeliness and accuracy of assessments, was not adhered to, resulting in the inaccurate documentation of the resident's medication usage.
Failure to Update Care Plan for UTI Treatment
Penalty
Summary
The facility failed to update the care plan for a resident who was diagnosed and treated for a urinary tract infection (UTI). The resident, who was admitted with a primary diagnosis of unspecified dementia with psychotic disturbance, showed symptoms of a UTI, including blood in the urine and painful urination. A urinalysis was conducted, and the resident was treated with antibiotics Bactrim DS and Keflex for the UTI. Despite these developments, the resident's care plan was not updated to reflect the new diagnosis and treatment. The facility's policy requires care plans to be updated to reflect current care needs as changes occur. However, a review of the resident's care plan revealed no updates regarding the UTI or the antibiotics prescribed. The Director of Nursing confirmed that the care plan should have been revised to include new interventions following the diagnosis and treatment of the UTI.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement interventions per their policy and the resident's care plan for a resident with a stage 4 pressure ulcer. The resident, who was admitted with complete paraplegia and fecal incontinence, had a primary diagnosis of a stage 4 pressure ulcer on the right ischium. The facility's policy required repositioning every two hours for residents in bed and every hour for those in a wheelchair, but these measures were not consistently followed. Observations revealed that the resident was often left in the same position for extended periods, both in bed and in a wheelchair, contrary to the care plan's requirements. The resident's air mattress was incorrectly set at 250 pounds, despite the resident weighing 109 pounds, which was confirmed by the Director of Nursing (DON) as inappropriate. The resident was observed lying on their back or at a slight angle with the head of the bed elevated beyond the recommended degree, and repositioning was not done as frequently as required. Interviews with the DON confirmed that the resident was not repositioned as per the care plan and facility policy. The DON acknowledged that the air mattress setting was incorrect and that the head of the bed was elevated more than the policy allowed. These failures in following the care plan and facility policy contributed to the deficiency in providing appropriate pressure ulcer care and prevention for the resident.
Failure to Document Physician Review of Medication Regimen
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews were reviewed by the physician and that a rationale was provided when no action was taken for one of the sampled residents. Resident 14, who was admitted to the facility with multiple diagnoses including Dementia, Parkinson's disease, delusional disorder, Major Depressive Disorder, anxiety, heart failure, and Chronic Obstructive Pulmonary Disease, did not have documentation showing that the physician had completed the required monthly medication review. Specifically, a Consultation Report dated 9/24/2023 indicated that the pharmacist conducted a comprehensive medication review, but there was no documentation of a physician review. Further, a Consultation Report dated 11/15/2023 revealed that the pharmacist had concerns regarding Resident 14's use of citalopram and risperidone, yet there was no documentation that the physician reviewed or responded to these concerns. An interview with the President of Operations confirmed the lack of documentation for the physician's review of the Medication Regimen Reviews for the specified dates. Additionally, a Consultation Report with a recommendation date of 5/24/2023 showed a recommendation to trial discontinuation of melatonin, which the physician declined with a rationale of no change. The facility's policy, last revised on 8/17/2023, mandates adherence to CMS guidelines for pharmaceutical care, which was not followed in this instance.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days or had a stop date or duration documented by the prescriber. Specifically, for one resident, there was an order for Seroquel, an antipsychotic medication, to be administered as needed for insomnia, without a stop date, duration, or re-evaluation date. The facility's policy required that PRN orders for antipsychotic medications be limited to 14 days and not renewed unless the physician evaluated the resident for the appropriateness of the medication. The resident involved had a history of heart failure, insomnia, atrial fibrillation, osteoarthritis, and a recent urinary tract infection. The resident's cognition was moderately impaired, and they exhibited verbal behaviors directed at others, impacting their care. The Director of Nursing confirmed that the only diagnosis for the PRN Seroquel was insomnia, which the facility did not consider appropriate for the use of an antipsychotic medication. This oversight in medication management led to the deficiency noted in the report.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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