Keystone Ridge Post Acute Nursing And Rehabilitati
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 7501 Keystone Drive, Omaha, Nebraska 68134
- CMS Provider Number
- 285238
- Inspections on file
- 24
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Keystone Ridge Post Acute Nursing And Rehabilitati during CMS and state inspections, most recent first.
Surveyors found black buildup on both ovens, food debris on the kitchen mixer, and missing grout with food debris between floor tiles, indicating that cleaning procedures were not followed as required by facility policy and the Nebraska Food Code. These unsanitary conditions had the potential to affect all residents receiving food from the kitchen.
The facility's QAPI program did not effectively identify or address ongoing issues with environmental cleanliness, kitchen sanitation, dental appointment follow-up, and infection control, resulting in repeated deficiencies. Despite regular committee meetings and some performance improvement efforts, problems such as unclean resident rooms, lack of dental follow-up, unsanitary kitchen conditions, and improper infection control practices persisted, affecting all residents.
Surveyors identified multiple environmental deficiencies in 17 resident rooms, including cracked caulking, damaged walls and doors, broken fixtures, strong urine odors, soiled floors, and non-functioning lights. The Maintenance Director confirmed these issues had not been previously identified or addressed, and no work orders were in place for repairs.
Two residents did not receive necessary assistance from staff to obtain dental services, including a missed and unrescheduled dental appointment for one resident and failure to replace a lost dental partial for another. Despite facility policy requiring prompt referral and support for dental care, these actions were not completed or documented.
Staff failed to store a urinary catheter drainage bag properly for a resident with severe cognitive impairment and other medical conditions, with the bag observed on the floor and inside a trash can. Additionally, an LPN did not use the required disinfectant for a glucometer after a blood glucose check, as confirmed by the DON.
A resident with multiple health conditions had blood pressure readings significantly below the established parameters on two occasions. Despite this, the facility failed to notify the medical provider as required. The Director of Nursing confirmed that the physician should have been informed of these critical readings.
A resident with epilepsy and left-side paralysis suffered a burn from spilled coffee, resulting in redness and blisters. The facility did not report or investigate the incident as required by policy, as it was not deemed significant by the Administrator.
A facility failed to complete INR monitoring tests for a resident on Coumadin, leading to missed doses and a significant medication error. The resident, with a history of atrial fibrillation and other conditions, required regular PT/INR testing to ensure therapeutic dosing. However, the facility did not consistently perform these tests or follow up with the prescriber for orders, resulting in lapses in therapy.
Two residents in a LTC facility experienced significant medication errors due to the facility's failure to administer medications as per physician orders. One resident, with a history of heart conditions, missed multiple doses of Coumadin and PT/INR tests. Another resident, with chronic pain and opioid dependence, did not receive prescribed Fentanyl patches and Oxycodone, leading to increased agitation and a hospital visit. Staff interviews revealed a lack of awareness and procedural errors in medication reordering.
A resident with a history of falls and agitation was not properly evaluated after sustaining a black eye and other injuries. Despite staff observations and reports, no incident report or neurological checks were conducted, and the injuries were not reported to the DON. The facility's policy on incidents and accidents was not followed.
Three residents in a LTC facility experienced falls due to the facility's failure to implement assessed interventions. A resident with cognitive impairment fell while transferring without assistance, another resident intentionally slid out of a wheelchair, and a third resident rolled out of bed, sustaining a nasal fracture. Observations revealed deficiencies such as call lights out of reach, beds in incorrect positions, and missing fall mats, indicating lapses in care plan implementation.
The facility failed to ensure an RN was present for at least 8 consecutive hours on two specific dates, as confirmed by staffing records and the Administrator. The facility census was 73 residents.
The facility failed to prepare and serve food that is palatable, attractive, and at a safe and appetizing temperature. Observations revealed improper hand hygiene, unmeasured ingredients, and inadequate food temperatures. A test tray showed food temperatures significantly below the required 135 degrees, posing a risk of food-borne illnesses to the residents.
The facility failed to maintain sanitary conditions in the kitchen and during meal service, leading to potential food-borne illness risks. Observations included dirty equipment, improper food labeling, and inadequate hand hygiene practices by staff.
The facility failed to document the offering, education, and current vaccination status of the COVID-19 vaccine for a CNA. The facility's policy requires staff to be educated on vaccine risks and benefits, offered the vaccines, and that vaccination data be reported to relevant agencies. Interviews with the DON confirmed the lack of documentation.
The facility failed to maintain the cleanliness and condition of various areas, including resident rooms and common areas, affecting 23 of 43 occupied rooms and several common areas. Issues included cracked caulking, scrapes in drywall, stained areas, cracked ceiling tiles, pulled-away baseboards, dusty ventilation covers, broken fixtures, strong odors, and missing closet doors. The Maintenance Director confirmed these issues had not been previously identified or addressed.
The facility failed to ensure that ventilation systems were operational in six resident bathrooms. An observation with the Maintenance Director revealed that the ventilation system in these rooms was not functional and could not draw a 1-ply square of toilet paper to the surface of the ventilation cover. The Maintenance Director confirmed the system had not been operational and there was no documentation of the last check.
The facility failed to treat residents with dignity and respect during meal services, leading to visible distress and embarrassment. Staff were observed serving food in a random order, causing delays, and speaking to residents in loud, raised voices. Residents expressed frustration and embarrassment over these actions.
A facility failed to honor a resident's right to make choices regarding life-sustaining measures. The resident, who was cognitively intact, had conflicting code status information in their medical records. Despite the resident's clear verbal confirmation that they wanted CPR, the facility had accepted a DNR form signed by a relative who was not the activated DPOA. The facility's process for handling advance directives was found to be inconsistent, leading to a discrepancy that was only corrected after the surveyor's findings.
The facility failed to ensure full visual privacy in three dual occupancy rooms (511, 513, and 529) as there were no privacy curtains present to surround the beds. This affected three residents who could be visibly seen from the hallway or by their roommates. The Maintenance Director confirmed the absence of privacy curtains.
The facility failed to submit an abuse investigation to the state agency within 5 working days for two residents. One resident with a fractured hip fell and was sent to the hospital, but the state agency was not notified. Another resident with multiple diagnoses fell and sustained a subdural hematoma, but the incident was not reported to APS.
The facility failed to notify a resident and their family representative in writing of the resident's transfer to the hospital. The resident, who was cognitively intact and had multiple diagnoses, was transferred on 11/27/2023. The facility could not produce any written notice of the transfer/discharge, as confirmed by the Administrator.
The facility failed to provide bathing per a resident's preference, resulting in a nine-day lapse between showers. The resident, who had an intact cognitive status and was dependent on staff for bathing, did not receive showers twice a week as preferred. This deficiency was confirmed by the DON and observed through the resident's unkempt appearance and electronic records.
Unsanitary Kitchen Equipment and Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain the dual ovens, kitchen stand mixer, and kitchen floor in a clean and sanitary condition, as required by professional standards and the Nebraska Food Code. Specifically, there was black buildup on the bottom of both ovens, food debris accumulation on the arm and stand of the kitchen mixer, and missing grout between two rows of tiles near the stove top and ovens, with food debris present in the unfilled space. These findings were confirmed during observations with both the Certified Dietary Manager (CDM) and the Registered Dietitian (RD), who acknowledged the presence of buildup and missing grout. Interviews with the CDM and RD confirmed that the facility had a cleaning checklist in place, which required weekly cleaning of the ovens and cleaning of the mixer after each use. The facility's policy outlined that the CDM was responsible for oversight and that kitchen staff were assigned daily, weekly, and monthly cleaning tasks. Despite these policies, the observed conditions indicated that cleaning procedures were not being followed as required, resulting in unsanitary kitchen equipment and surfaces that could potentially affect all 69 residents who consumed food prepared in the facility kitchen.
QAPI Program Fails to Address Repeat Deficiencies in Environment, Kitchen, and Infection Control
Penalty
Summary
The facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified and addressed concerns related to deficient practices found during the annual survey, as well as repeat deficiencies from previous surveys. Specifically, the QAPI program did not maintain correction for issues such as environmental cleanliness and maintenance (F 584), dental appointment follow-up (F 791), kitchen sanitation (F 812), and infection control practices (F 880). The QAPI committee was responsible for reviewing survey results, internal audits, infection control data, grievances, accidents, clinical outcomes, dietary performance, and performance improvement plans (PIPs), but failed to implement effective interventions for recurring issues. The facility's policy required regular meetings and data-driven interventions, but these were not successful in preventing repeat citations. During the most recent survey, deficiencies included failure to protect residents' property and maintain cleanliness in resident rooms, lack of follow-up on dental appointments, inadequate maintenance of kitchen appliances and floors, and improper infection control practices such as not disinfecting glucometers between uses and improper handling of catheter bags. These deficiencies had the potential to affect all 69 residents in the facility. Interviews confirmed that environmental and kitchen sanitation issues had been cited in previous years, and while a PIP was initiated for the kitchen, it was not effective in maintaining correction, and no PIP was implemented for environmental concerns.
Widespread Environmental Deficiencies in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents, as required by regulation. During an environmental tour with the Maintenance Director and Housekeeping Supervisor, multiple deficiencies were identified in 17 out of 41 occupied resident rooms. These included cracked and stained caulking around toilets, scrapes and holes in drywall and doors, cracked and bubbled ceiling tiles, pulled-away baseboards, food and water stains on ceilings, broken or missing fixtures such as nightlight covers, kick plates, toilet paper holders, towel bars, and window blinds. Additionally, there were strong urine odors, soiled and sticky floors, loose or torn fall stop strips, missing light covers, non-functioning lights, broken beds, and missing call light cords. Some rooms also had dried tube feeding solution on fall mats and peeling floor finishes. The Maintenance Director confirmed during the interview that the identified areas required cleaning or repair and acknowledged that there were no existing work orders for these issues. The concerns had not been previously identified by facility staff prior to the surveyors' environmental tour. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency, nor does it indicate any corrective actions taken following the findings.
Failure to Assist Residents in Obtaining Dental Services
Penalty
Summary
The facility failed to assist two cognitively intact residents in obtaining necessary dental services. For one resident, documentation showed a scheduled dental appointment that was not completed, and the Director of Nursing confirmed that the appointment was not rescheduled. This resident had previously returned from an oral surgery appointment and had a follow-up scheduled, but there was no evidence that the follow-up occurred or was rescheduled after being missed. For another resident, the facility lost the resident's dental partial during a room move and did not replace it. The resident reported the missing partial to the Administrator in Training, and a missing item form was completed. Although a dental appointment was scheduled, it was canceled by the dental provider, and there was no documentation of a rescheduled appointment or further action taken by the facility to address the resident's dental needs. The facility's own policy requires prompt referral and assistance for dental services, including documentation of actions taken if delays occur, but these steps were not followed.
Infection Control Lapses in Catheter Bag Storage and Glucometer Disinfection
Penalty
Summary
Facility staff failed to properly store a urinary catheter drainage bag for a resident with multiple complex medical conditions, including severe cognitive impairment, pressure ulcer, and sepsis. Observations revealed that the resident's catheter drainage bag was repeatedly found either inside a red trash can or directly on the floor while the resident was in a wheelchair or in their room. A nurse aide confirmed that the catheter bag should not be placed on the floor or inside a trash can, indicating a lapse in infection prevention and control practices. Additionally, a licensed practical nurse performed a blood glucose check on another resident and, after completing the procedure, wiped the glucometer with an alcohol wipe instead of the required Sani-Cloth Germicidal Wipes. The Director of Nursing confirmed that the correct disinfection procedure was not followed. These actions demonstrate failures in adhering to established infection control protocols during resident care activities.
Failure to Notify Medical Provider of Critical Blood Pressure Readings
Penalty
Summary
The facility failed to notify the medical provider of blood pressures outside of established parameters for one resident. Resident 6, who was admitted to the facility with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, essential hypertension, and dependence on renal dialysis, had specific medication orders and vital sign parameters that required medical provider notification if certain thresholds were exceeded. These included notifying the medical provider if the systolic blood pressure was greater than 180 or less than 80, among other vital sign parameters. On two occasions, Resident 6's blood pressure readings were significantly below the established threshold, recorded at 74/57 and 77/58. Despite these readings, there was no documentation indicating that the resident's medical provider was notified of these critical blood pressure levels. This oversight was confirmed in an interview with the Director of Nursing, who acknowledged that the physician should have been informed of the blood pressure readings that were outside the set parameters.
Failure to Report and Investigate Resident Burn Incident
Penalty
Summary
The facility failed to report and investigate a potential neglect incident involving a resident who suffered a burn injury. The resident, who had a medical history of epilepsy and left-side paralysis following a stroke, reported spilling hot coffee on themselves in the dining room. The incident resulted in a 10 cm by 2 cm area of redness with fluid-filled blisters and a small amount of blood in the groin area. Despite the severity of the injury, the facility did not report the incident to Adult Protective Services or the survey agency, as it was not considered a significant injury by the Administrator. The facility's policy on abuse prevention and prohibition requires all allegations of abuse, neglect, or misappropriation of resident property to be promptly and thoroughly investigated and reported to the appropriate authorities. However, a review of the facility's investigation records from the relevant period did not include an investigation of the resident's burn. Interviews with the Administrator confirmed that interviews were conducted regarding the burn, but the incident was not reported externally. This oversight indicates a failure to adhere to the facility's policy and regulatory requirements for reporting and investigating potential neglect incidents.
Failure to Monitor INR and Administer Coumadin
Penalty
Summary
The facility failed to complete INR monitoring tests to ensure therapeutic dosing of Coumadin for a resident with a history of atrial fibrillation, coronary artery disease, cerebrovascular accident, seizure disorder, and a heart valve replacement. The resident was taking an anticoagulant to prevent blood clots, which required regular PT/INR testing to monitor the effectiveness of the medication. However, the facility did not consistently perform these tests or follow up with the prescriber for Coumadin orders, leading to missed doses and a significant medication error. The record review revealed multiple instances where PT/INR tests were either not completed or not communicated to the prescriber in a timely manner. For example, on several occasions, the PT/INR was completed, but the results were not called to the prescriber until days later, resulting in a lapse in Coumadin therapy. Additionally, there were no orders for Coumadin dosing on certain days, and the facility failed to obtain new orders promptly, further contributing to the medication error. Interviews with the Director of Nursing confirmed that the missed doses of Coumadin were a significant medication error and that nursing staff should have called the prescriber with PT/INR results on the day the tests were taken. The facility's policy on medication errors and adverse reactions emphasized the importance of administering medications in accordance with prescriber's orders, which was not adhered to in this case.
Removal Plan
- The DNS or designee will identify all other residents on routine narcotics to complete full audit of eMAR documented administration and verification of medication availability.
- The DNS or designee will educate nurses and CMAs currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR blood draw, as well as expectation of time deadlines to notify PCP or coumadin clinic, manually entering telephone orders for next INR and coumadin dose.
- The DNS or designated clinical manager will complete all INR draws and notification, while completing follow up education and verification of understanding with nurses.
- The ED or designee will audit staff education completion of the above areas every shift. The DNS or designee will audit eMAR for omissions of missed narcotic prior to end of shift or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification or until substantial compliance is determined. The above audits will submitted to QAPI monthly until substantial compliance is determined.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents, resulting in significant medication errors. Resident 1, who had a history of atrial fibrillation, coronary artery disease, cerebrovascular accident, seizure disorder, and a heart valve replacement, was prescribed anticoagulants to prevent blood clots. However, there were multiple instances where Coumadin was not administered as ordered, and PT/INR tests were not conducted as required. These omissions were confirmed by the Director of Nursing as significant medication errors. Resident 4, diagnosed with Pick's disease, opioid dependence, and chronic pain syndrome, experienced missed doses of prescribed pain medications, including Fentanyl patches and Oxycodone tablets. The facility's failure to reorder these medications correctly resulted in the resident experiencing increased agitation and confusion, leading to an emergency hospital visit. Interviews with staff revealed a lack of awareness regarding the missing medications and the proper procedure for reordering controlled substances. The facility's policies on medication errors and adverse reactions were not followed, contributing to the deficiencies. The report highlights the failure to administer medications as per the prescriber's orders and the lack of timely communication with the pharmacy and healthcare providers, which led to significant medication errors for both residents.
Removal Plan
- The DNS or designee will identify all other residents on routine narcotics to complete a full audit of eMAR documented administration and verification of medication availability.
- The DNS or designee will educate nurses and CMAs currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR blood draw, as well as expectation of time deadlines to notify PCP or coumadin clinic, manually entering telephone orders for next INR and coumadin dose.
- The DNS or designated clinical manager will complete all INR draws and notification, while completing follow up education and verification of understanding with nurses.
- The ED or designee will audit staff education completion of the above areas every shift. The DNS or designee will audit eMAR for omissions of missed narcotic prior to end of shift or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification or until substantial compliance is determined. The above audits will be submitted to QAPI monthly until substantial compliance is determined.
Failure to Evaluate Resident Injury
Penalty
Summary
The facility failed to evaluate a resident following the identification of an injury from unknown sources. Resident 4, who was admitted with diagnoses including Pick's disease, opioid dependence, and chronic pain syndrome, was identified as being at risk for falls. The care plan for Resident 4 included several interventions to prevent falls and injuries, such as offering extra pillows, placing a fall mat, and ensuring the call light was within reach. Despite these measures, a weekly skin evaluation noted swelling on Resident 4's left eye, which was not further evaluated. On the day of the incident, Resident 4 exhibited increased agitation and confusion, scooting on the floor and engaging in jerking movements that resulted in new bruises. The resident was eventually sent to the hospital for evaluation and treatment. However, there was no documentation of an evaluation of the resident's left eye, despite multiple staff members observing a black eye and other injuries. These observations were reported to various nursing staff, but no incident report was completed, and no neurological checks were initiated. Interviews with staff revealed that the black eye and other injuries were not reported to the Director of Nursing. The facility's policy on incidents and accidents required immediate assistance, assessment by a licensed nurse, and notification of the medical provider, which were not followed in this case. The Director of Nursing confirmed that the necessary procedures, such as neuro checks and incident reporting, were not conducted as required.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement assessed interventions to prevent potential injuries for three residents, leading to deficiencies in care. Resident 1, who was moderately cognitively impaired and at high risk for falls, was found on the floor after attempting to transfer from a chair to a bed without assistance. The resident's care plan included interventions such as frequent checks, offering assistance after smoking, and ensuring the call light was within reach. However, observations revealed that the call light was out of reach, contributing to the resident's fall and subsequent injuries. Resident 4, who was cognitively intact but at high risk for falls due to mobility deficits and behavioral issues, was found on the floor after intentionally sliding out of a wheelchair. The care plan included interventions like using a non-skid mat and placing the bed in a low position. Despite these measures, the resident's bed was observed in a high position, and the bed control could not be locked as required. Additionally, a nursing assistant was unaware of how to access care plan interventions, indicating a lack of staff training or communication. Resident 5, who was at medium risk for falls, sustained a nasal fracture after rolling out of bed. The care plan included using a floor mat to prevent injury, but observations showed the mat was missing, reportedly taken for another resident. This oversight in implementing the care plan interventions contributed to the resident's injury. The facility's policy on fall management emphasizes providing an environment free of accident hazards and ensuring adequate supervision, but these incidents highlight failures in adhering to these standards.
Failure to Ensure RN Presence for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 03-31-2024 and 04-28-2024. This deficiency was identified through a review of the facility's Daily Nursing Daily Deployment sheets and Nurse Staffing Hours postings, which confirmed the absence of an RN for the required duration on the specified dates. The facility census at the time was 73 residents. The Administrator confirmed in an interview on 05-02-2024 that there was no RN working for 8 consecutive hours on the mentioned dates.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to prepare and serve food that is palatable, attractive, and at a safe and appetizing temperature. Observations revealed that Cook-E did not follow proper hand hygiene protocols and did not measure spices or butter when preparing meals. Additionally, Cook-E handled food with soiled gloves and did not maintain appropriate food temperatures. The ham, potatoes, and corn were not kept at the required temperatures, posing a risk of food-borne illnesses to the residents. Cook-E also struggled with portion sizes and ingredient measurements due to the recipe being for a larger number of servings than needed for the facility's census of 73 residents. Further observations showed that Cook-F also failed to adhere to proper hand hygiene and glove use protocols while serving meals. Cook-F touched both clean and dirty surfaces with the same gloves and did not wash hands between glove changes. A test tray revealed that the food temperatures were significantly below the required 135 degrees, with ham at 102 degrees, ground ham at 104.1 degrees, diced potatoes at 98.4 degrees, and corn at 106 degrees. The Certified Dietary Manager confirmed that the food did not reach the necessary temperatures and acknowledged the issues with the preparation and serving processes.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food service safety. During an initial tour of the kitchen, surveyors observed a buildup of grease, dirt, and food crumbs in various areas, including the dish room and around the oven. Additionally, small bowls and plates were stored in a manner that allowed water to splash onto them, and several trays and dishes were found with dried food debris. The meat slicer and other cooking equipment were visibly dirty, and personal items were stored alongside food items, further compromising sanitation. The facility also failed to properly label and date food items, with several instances of expired or undated food being found in storage areas, including the walk-in freezer and dry storage room. The freezer door was not functioning properly, leading to ice buildup and potential contamination of stored food items. Cleaning logs indicated that essential cleaning tasks were not performed regularly, and interviews with staff confirmed issues with the kitchen floor drains, which had only recently been addressed. During meal service, a dietary aide was observed failing to follow proper hand hygiene and gloving procedures, leading to cross-contamination. The aide touched resident plates with bare hands, used soiled gloves to handle food, and did not perform adequate hand hygiene between tasks. This was confirmed by the Certified Dietary Manager, who acknowledged the concerns with hand hygiene and cross-contamination in the dining room. A resident reported that their food was served cold and that the eggs were consistently of poor quality. The facility's hand hygiene policy and the CDC guidelines for hand hygiene were not followed, contributing to the risk of food-borne illnesses among residents.
Failure to Document COVID-19 Vaccine Offer and Education for Staff
Penalty
Summary
The facility failed to maintain proper documentation regarding the offering, education, and current vaccination status of the COVID-19 vaccine for its staff. Specifically, the personnel record of a CNA lacked any record of the facility offering the COVID-19 vaccine, providing education on the vaccine, or documenting the current vaccination status. The facility's policy mandates that staff be educated on the risks and benefits of specific vaccines, offered the vaccines, and that vaccination data be reported to the CDC National Healthcare Safety Network and/or state/local agencies as required. Interviews with the Director of Nursing confirmed the absence of such documentation for the staff member in question.
Facility Fails to Maintain Cleanliness and Condition of Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain the cleanliness and condition of various areas, including walls, floors, curtains, fixtures, ceiling tiles, ventilation covers, baseboards, doors, and nightlights in 23 of 43 occupied resident rooms, as well as common areas such as the bathhouse, activity room, and hallways. Specific issues included cracked and broken caulking around toilets, scrapes in drywall, stained areas around toilets, cracked or missing ceiling tiles, pulled-away baseboards, unpainted patched ceiling areas, scraped bathroom and room doors, dusty ventilation covers, holes in walls from doorknobs, broken nightlights, unsecured wall plates, missing or broken toilet paper holders and towel bars, broken window curtains, broken plastic glove holders, strong urine odors, soiled and sticky floors, and doors that would not close properly. Additionally, there were no closet doors in 19 occupied resident rooms on the garden level, which was confirmed by the Maintenance Director (MD) as not being homelike. The MD confirmed during an interview that the identified areas needed cleaning and repair and acknowledged that there were no existing work orders for these issues. The MD also confirmed that these concerns had not been identified prior to the environmental tour of the facility. The facility census at the time was 73 residents, indicating that a significant portion of the resident rooms and common areas were affected by these deficiencies, compromising the residents' right to a safe, clean, comfortable, and homelike environment.
Non-Functional Ventilation Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that ventilation systems were operational in resident bathrooms in six rooms (5116, 5119, 5121, 5124, 5126, and 5128) out of 43 occupied rooms. During an observation conducted on 5/2/24 between 08:00 AM and 9:15 AM with the Maintenance Director, it was revealed that the ventilation system in these rooms was not functional and could not draw a 1-ply square of toilet paper to the surface of the ventilation cover. An interview with the Maintenance Director confirmed that the ventilation system had not been operational and there was no documentation of when the system was last checked to ensure it was functional. The facility census was 73 at the time of the observation.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two sampled residents with dignity, respect, and care that promotes the maintenance and enhancement of their quality of life. During meal service observations, it was noted that food was served in a random order, causing some residents to wait up to 30 minutes while others at the same table were already eating. This led to visible distress in one resident who expressed frustration over the delay. Additionally, staff members were observed speaking to residents in loud, raised voices, which was perceived as disrespectful and embarrassing by the residents. One resident was particularly upset when a staff member loudly questioned another staff member about a meal in front of the residents, and another resident expressed that this kind of treatment was a regular occurrence. Further observations revealed that a dietary assistant did not refer to individual meal tickets and instead loudly asked residents what they wanted for breakfast from a distance of approximately 40 feet. This behavior was noted by a resident who commented on the staff's habit of yelling. Another incident involved a resident spilling coffee while trying to pour it into a bottle, and the Certified Dietary Manager loudly reprimanded the resident, causing embarrassment. Interviews with the residents confirmed that they were bothered by the way staff spoke to them, although one resident mentioned trying not to let it affect them. The report references CMS guidelines that emphasize the right of residents to be treated with dignity and respect.
Failure to Honor Resident's Code Status Preferences
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding life-sustaining measures. Resident #25, who was cognitively intact with a BIMS score of 15, had conflicting code status information in their medical records. The Point Click Care (PCC) EMR dashboard indicated a No Code status, while a signed DNR form dated earlier indicated a Full Code. Despite the resident's clear verbal confirmation that they wanted CPR if their heart stopped, the facility had accepted a DNR form signed by a relative who was not the activated Durable Power of Attorney (DPOA). Interviews with staff revealed that the resident's code status was inconsistently documented and communicated, leading to confusion about the resident's true wishes. Further investigation showed that the facility's process for handling advance directives involved multiple steps, including entering the code status into the computer, obtaining the Medical Director's electronic signature, and updating the resident's status in the PCC. However, the facility failed to ensure that the resident's current wishes were accurately reflected in their records. The Social Service Director (SSD) confirmed that the resident's DPOA was not enacted, meaning the resident was capable of making their own decisions. Despite this, the facility had initially relied on the relative's signed DNR form, leading to a discrepancy that was only corrected after the surveyor's findings.
Lack of Privacy Curtains in Dual Occupancy Rooms
Penalty
Summary
The facility failed to ensure full visual privacy in three dual occupancy rooms (511, 513, and 529) out of 49, as there were no privacy curtains present to surround the beds. This deficiency was observed on 04/29/24 between 3:00 PM and 3:15 PM in the Garden level of the facility. The lack of privacy curtains affected three residents (Residents 8, 38, and 63) who resided in those rooms, potentially exposing them to being visibly seen from the hallway or by their roommates. The Maintenance Director confirmed during an interview on 05/02/24 that the privacy curtains were indeed missing, which compromised the residents' visual privacy.
Failure to Report Abuse Investigation Timely
Penalty
Summary
The facility failed to submit an abuse investigation to the state agency within 5 working days for two residents. Resident 80, who had a diagnosis of fractured hip, dementia, and high blood pressure, fell and was sent to the hospital for an x-ray. The facility's investigation of the fall did not list the state agency as notified. An interview with the Administrator confirmed that the facility did not follow up and send the investigation to the state agency. Resident 61, who had multiple diagnoses including encephalopathy, epilepsy, and hemiplegia, fell and sustained a subdural hematoma and other injuries. The facility's incident report did not indicate that the fall was reported to Adult Protective Services (APS). An interview with the Facility Administrator confirmed that there was no record of the fall incident being reported to APS. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the state survey agency and APS within specified timeframes.
Failure to Notify Resident and Family of Hospital Transfer
Penalty
Summary
The facility failed to notify Resident 43 and the resident's family representative in writing of the resident's transfer to the hospital. Resident 43, who was cognitively intact with a BIMS score of 15, had multiple diagnoses including Neuroleptic induced Parkinsonism, Schizoaffective Disorder, and Anxiety Disorder. A review of the resident's Clinical Census Sheet showed that the transfer occurred on 11/27/2023. However, the facility could not produce any written notice of the transfer/discharge in the resident's electronic health record. This deficiency was confirmed during an interview with the facility Administrator on 05/01/2024.
Failure to Provide Bathing Per Resident Preference
Penalty
Summary
The facility failed to provide bathing per resident preference for one of the sampled residents. Resident 4, who had an intact cognitive status as indicated by a BIMS score of 15, was dependent on staff for bathing and personal hygiene. The resident's care plan specified a preference for showers with the assistance of one staff member. However, the resident did not receive a shower for nine days between 4/22 and 5/1, despite the facility's policy requiring showers, bed baths, or sponge baths to be provided according to the resident's schedule or preferences. This lapse was confirmed by the Director of Nursing (DON) during an interview on 05/01/24, who acknowledged that Resident 4 had not received showers twice a week as preferred by the resident. Observation of Resident 4 on 4/29/24 revealed that the resident's hair was uncombed and greasy, further indicating a lack of proper hygiene care. During an interview on the same day, Resident 4 stated that they had not had a shower in two weeks. The facility's electronic records corroborated this, showing that the resident received showers on 4/5, 4/9, 4/13, 4/21, and 4/22, but not between 4/22 and 5/1. This failure to adhere to the resident's bathing schedule and preferences constitutes a deficiency in providing the necessary care and assistance for activities of daily living, as required by the facility's policy and the resident's care plan.
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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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