Life Care Center Of Omaha
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 6032 Ville De Sante Drive, Omaha, Nebraska 68104
- CMS Provider Number
- 285137
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Life Care Center Of Omaha during CMS and state inspections, most recent first.
The facility failed to complete and document a discharge plan for a cognitively intact resident with multiple comorbidities, including generalized muscle weakness, gait difficulty, cognitive communication deficit, type 2 DM, morbid obesity, HTN, and CHF. Despite facility policy requiring early identification of discharge goals, incorporation into the care plan, and confirmation that the discharge destination met health, safety, and preference needs, the resident’s care plan contained no discharge plan. The resident independently applied for an independent living apartment and arranged A&D waiver services, while documentation showed a care plan conference noting no discharge plans and non-attendance by the resident. An MDS LPN later confirmed via email that the resident had been approved for independent living with a caregiver, and the SSD documented that the resident discharged to independent living, refused SSD assistance, and that the SSD could not confirm the transition or produce any discharge planning documentation.
A resident with a pressure ulcer did not receive timely wound care or recommended nutritional support after hospital readmission. Wound treatment orders were delayed, and the prescribed supplement for wound healing was not provided, resulting in the development of additional wounds and worsening of existing pressure ulcers, as confirmed by staff interviews and record review.
Staff failed to ensure continuous tube feeding for a resident as ordered, with the feeding pump found idle and not restarted as required. Additionally, another resident did not receive feeding tube site care per physician orders, as Vaseline gauze was omitted and the dressing caused discomfort and bleeding, with the LPN confirming the lapse.
Two residents were emergently transferred to the hospital without the facility providing required reports on their care needs to the receiving institution. One resident, with complex care needs including dialysis and an infectious disease, and another resident, who was unresponsive and required total assistance, were both sent to the hospital without staff communicating their clinical information. Both an LPN and the DON confirmed that the expected transfer reports were not provided.
Licensed staff provided care to a resident who was required to wear an external cardiac defibrillator (Life Vest) without having received prior training on the device. Multiple LPNs confirmed they had not been trained and had no access to training materials, and the DON verified that no training had occurred before care was provided.
Staff did not follow required contact and enhanced barrier precautions for infection control, including not wearing gowns during high-contact care for a resident with C. difficile and two residents with indwelling devices or MDROs, despite facility policy and posted signage.
A resident with severe cognitive impairment and protein calorie malnutrition received a tube feeding formula (Isosource) that did not match the physician's order for Nepro, and water flushes were administered without a physician's order. The feeding bags were not properly labeled or dated, and staff confirmed the discrepancies between the orders and care provided.
Surveyors observed that the facility's medication error rate exceeded 5%, with three errors out of 29 administrations. Two residents were affected: one did not receive prescribed eye drops due to unavailability, and another missed an allergy medication and received an eye medication late. These errors were confirmed by nursing staff and were not in accordance with the facility's medication administration policy.
Surveyors observed that 10 insulin pens in use for three residents were not labeled with the date they were opened, contrary to facility policy requiring all insulin pens to be dated upon initial use. A RN confirmed the absence of opened dates, which is necessary to ensure insulin is not used beyond its 28-day expiration period.
Facility staff failed to include a resident and their family in the quarterly care planning process, as required. A family member reported not being invited or aware of the process, and the Social Services Director confirmed the absence of documentation for the care planning. This indicates a failure to involve residents and families in person-centered care plans.
The facility failed to implement fall prevention interventions for three residents, as outlined in their care plans. A resident did not have a fall mat in place, another was observed sitting on a sling without a fall mat, and a third resident also lacked a fall mat, despite these being required interventions. These deficiencies were confirmed by facility staff.
The facility reported a medication error rate of 11.76%, affecting three residents. Errors included late administration of Atorvastatin and missed Metamucil for a resident, unavailability of Diltiazem for another, and early administration of Calcium Carbonate for a third resident. Staff confirmed these errors during interviews.
A facility failed to complete a PASARR Level II for a resident with Bipolar Disorder, a serious mental illness, which was not identified during the initial PASARR Level I screening. The resident's medical records and MDS assessment confirmed the diagnosis, but the facility did not make the required referral for a Level II evaluation. The Social Services Director acknowledged the oversight, which was contrary to the facility's PASARR policy.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident's electronic medical record showed no care plan was created, which was confirmed by the ADON. This omission violated the facility's policy on person-centered care planning, which aims to ensure continuity of care and resident safety.
A facility failed to complete a Comprehensive Care Plan (CCP) for a resident after a comprehensive assessment. The resident required assistance with various activities, but the CCP only addressed Advanced Directives and lacked necessary care information. An interview with the ADON confirmed the CCP was incomplete, violating the facility's policy on person-centered care planning.
A resident with dysphagia and anoxic brain damage was not provided with activities that met their needs and interests. Despite a care plan goal for participation in activities, the resident was often observed in bed without activities, and minimal participation was documented. The Activity Director noted potential discrepancies in recorded visits, but the resident's preferences for music and group activities were not adequately addressed.
A resident with a history of falls and medical conditions was not provided with adequate fall prevention measures as outlined in their care plan. Despite having interventions such as a fall mat and bed positioning, the resident was found in unsafe positions, and staff confirmed that necessary equipment like wedges was not consistently used.
A resident with dysphagia and anoxic brain damage received enteral feeding not in accordance with physician orders. The nurse administered an extra feeding earlier than scheduled and did not follow the prescribed water flush protocol, as confirmed by the ADON.
A resident with severe cognitive impairment and a history of attempting to leave the facility unattended was identified as at risk for elopement and equipped with a Wanderguard bracelet. Despite orders to check the bracelet's placement and function every shift, there were multiple instances where the resident attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented the resident being found outside the building on two occasions, with the Wanderguard not functioning properly. Documentation revealed a lack of consistent monitoring and documentation of the bracelet's function, highlighting gaps in the facility's elopement prevention measures.
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. Despite being identified as an elopement risk and having a care plan in place, the resident was found outside the facility on two separate occasions. The Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds.
The facility failed to ensure that two nurse aides completed the required 12 hours of yearly in-service training. One nurse aide completed only 1.95 hours of continuing education without any training on abuse prevention or dementia, while another completed only 1.03 hours. The DON confirmed these deficiencies.
The facility failed to ensure the posting of daily nursing staffing information. Observations revealed that the daily nursing staffing posting was outdated, and the Administrator confirmed the issue, noting that a new scheduler had just been hired.
Failure to Complete and Document Discharge Planning for Cognitively Intact Resident
Penalty
Summary
The facility failed to complete and document discharge planning for one cognitively intact resident. Facility policy required that discharge planning begin upon or shortly after admission, be incorporated into the baseline and comprehensive care plans, address the resident’s discharge goals and treatment preferences, identify the discharge destination, and ensure it met the resident’s health and safety needs and preferences. Record review showed that this resident, who had generalized muscle weakness, difficulty walking, a cognitive communication deficit, type 2 diabetes, morbid obesity, hypertension, and congestive heart failure, had no discharge plan initiated on the care plan. The resident’s Discharge MDS showed a BIMS score of 15, indicating intact cognition, and staff interviews confirmed the resident was able to make needs known. Documentation revealed the resident independently completed a rental application for an independent living apartment and later had a care plan conference record indicating no discharge plans and that the resident did not attend the conference. An email from the MDS LPN to the SSD, Administrator, DON, and Business Office Manager confirmed that the MDS LPN had received confirmation the resident was approved for independent living with a caregiver and was working with the Office on Aging to set up caregiver services. A progress note by the SSD on the discharge date stated the resident discharged to an independent living facility and refused assistance from SSD, and SSD was unable to confirm the transition. In interview, SSD stated there was no established discharge plan, that the resident had arranged the discharge and A&D waiver services independently, that SSD did not learn of the discharge plans until the day of discharge, and that the part‑time social services assistant had been collaborating with the resident. SSD was unable to provide any documentation of a discharge plan and confirmed they could not prove that discharge planning documentation had been completed.
Failure to Timely Implement Pressure Ulcer Treatment and Nutritional Interventions
Penalty
Summary
The facility failed to implement timely and appropriate treatment and interventions to promote healing and prevent new pressure ulcers for a resident who was identified as having a pressure ulcer upon readmission from the hospital. Upon return, the resident was noted to have an open wound to the coccyx, but there was no clear documentation of the unit of measurement, and no wound treatment order was in place until five days after the wound was identified. During this period, the resident did not receive wound care as per facility policy, and the recommended nutritional supplement for wound healing, Prosource, was not ordered or administered despite a registered dietician's recommendation. Subsequent wound assessments documented a decline in the resident's skin condition, with the development of additional wounds and progression of an existing wound from stage 2 to stage 3. The treatment administration records and medication administration records showed inconsistencies and delays in implementing wound care orders and nutritional interventions. There was also a lack of documentation for wound assessments on certain dates, and new treatment orders were not consistently reflected in the resident's records. Direct observation and interviews confirmed the presence of multiple pressure ulcers at different stages and locations, and staff acknowledged the delay in initiating wound care and the failure to implement the recommended nutritional support. The resident's wounds increased in number and severity during this period, indicating a lack of adherence to the facility's skin integrity and pressure ulcer prevention policy and failure to follow professional standards for wound management.
Failure to Provide Continuous Tube Feeding and Proper Site Care
Penalty
Summary
Facility staff failed to ensure continuous tube feeding for one resident who was assessed as requiring total assistance for all activities of daily living and had a physician's order for Jevity 1.5 at 40 ml per hour, 24 hours a day. Observations revealed that the resident's tube feeding pump was not running and had been idle for at least 10 minutes on two separate occasions. The nurse responsible confirmed that the tube feeding was not running as ordered and had not been restarted within the last hour. Additionally, staff did not provide feeding tube site care according to the practitioner's orders for another resident with moderate cognitive impairment and total care needs. The treatment order specified cleansing the site and applying Vaseline gauze followed by split gauze twice daily. During observation, the old dressing was found to lack Vaseline gauze, and bright red blood was present at the insertion site. The LPN confirmed the absence of Vaseline gauze and that the old dressing had adhered to the resident's skin, causing discomfort.
Failure to Provide Required Transfer Reports to Receiving Hospitals
Penalty
Summary
The facility failed to provide required reports to the receiving healthcare institution following emergent transfers for two of four sampled residents. For one resident, who was alert, oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions, the facility did not document or communicate the resident's care needs to the hospital after the resident and spouse requested hospital transfer due to body pain. The nurse responsible for the transfer confirmed that no report was given to the hospital. For another resident, who was rarely understood, required total assistance with all activities of daily living, and had a urinary catheter, the facility also failed to document or communicate the resident's care needs to the hospital after the resident was found unresponsive and sent to the hospital via 911. The Director of Nursing confirmed that staff are expected to call the hospital and provide a report, but this was not done in this case.
Lack of Staff Training on External Cardiac Defibrillator
Penalty
Summary
Facility staff failed to ensure that licensed nurses had received training on the use of an external cardiac defibrillator (Life Vest) prior to providing care for a resident who was required to wear the device at all times following hospital discharge. Record review showed that the resident was alert and oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions. Multiple LPNs who provided care to the resident confirmed in interviews that they had not received any training on the Life Vest, nor were there training materials available for staff reference. The Director of Nursing also confirmed that no training on the Life Vest had occurred prior to the resident's admission and care.
Failure to Follow Contact and Enhanced Barrier Precautions for Infection Control
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents requiring contact precautions and enhanced barrier precautions (EBP). For one resident with an active C. difficile infection, staff did not follow posted contact precaution protocols. Specifically, a housekeeper was observed mopping the resident's room without wearing a gown, despite signage and facility policy requiring both gown and gloves for entry and cleaning in such cases. The housekeeper confirmed not wearing the required gown, and the regional nurse consultant verified that this was not in accordance with the resident's isolation status and facility policy. For two other residents, both of whom required EBP due to the presence of indwelling medical devices or multidrug-resistant organisms (MDROs), staff did not wear gowns during high-contact care activities. In one instance, two nursing assistants provided post-shower care, perineal care, and dressing changes to a resident with a urinary catheter and a wound dressing, without wearing gowns. Both staff members stated they were unaware that gowns were required or that the resident was on EBP. In another case, two nursing assistants transferred a resident with an MDRO and a vascular access port for dialysis, and one continued to provide perineal care and a brief change, all without wearing a gown. The staff involved and a registered nurse confirmed they were not aware of the EBP requirement for this resident. Facility policy required the use of gowns and gloves for contact precautions and EBP during high-contact activities for residents with certain infections or indwelling devices. Observations and staff interviews confirmed that these protocols were not followed for the residents in question, despite clear signage and policy directives. The failure to adhere to these precautions was acknowledged by both the staff involved and the regional nurse consultant.
Failure to Administer Enteral Feedings and Water Flushes per Physician Orders
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 3, had a diagnosis of protein calorie malnutrition and required total assistance with all activities of daily living. The resident had a physician's order for Nepro enteral feeding at 45 ml per hour, to be administered continuously over 24 hours. However, observation revealed that the resident was receiving Isosource formula instead of Nepro, and the feeding bag in use was not properly labeled or dated. Additionally, a second feeding bag containing clear liquid (water) was found without a label or date, and the water flushes were being administered at 300 ml every 6 hours without a corresponding physician's order. Interviews with nursing staff confirmed that the tube feeding being administered did not match the physician's order, and that there was no order for the water flushes being provided. The facility's registered dietician also confirmed that Nepro and Isosource formulas are not interchangeable and that Isosource should not have been given to the resident. Review of facility policy indicated that enteral nutrition therapy should be provided in accordance with physician orders and professional standards, which was not followed in this case.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, with an observed error rate of 10.34% during the administration of 29 medications. Specifically, for one resident, a registered nurse did not administer the prescribed Refresh Tears Solution eye drops at the scheduled time because the medication was unavailable. This omission was confirmed by the nurse during an interview. Additionally, another resident did not receive two of their scheduled medications—Certirizine and Timolol Maleate—at the designated administration time. The LPN responsible confirmed that Certirizine was not administered and that Timolol Maleate was given late. These errors were identified through direct observation and staff interviews, and the facility's own medication administration policy requires adherence to physician orders and the correct timing of medication administration.
Insulin Pens Not Dated Upon Opening
Penalty
Summary
During an observation of a medication cart, surveyors found that 10 insulin pens for three residents were not labeled with the date they were opened, as required by facility policy and professional standards. Specifically, three Lantus pens and two lispro pens for one resident, three lispro pens for another resident, and one Lantus pen and one lispro pen for a third resident were all missing opened dates. Facility policy states that all insulin pens should be dated upon opening and that opened Lantus and lispro insulin expire 28 days after being opened. A registered nurse confirmed that the insulin pens in question did not have a date indicating when initial use began.
Failure to Include Resident and Family in Care Planning Process
Penalty
Summary
The facility staff failed to include a resident and their family member in the quarterly care planning process, as required by regulations. This deficiency was identified during a record review and interviews. Resident 2, who was admitted to the facility and later discharged, did not have a documented quarterly care planning process completed as of the review date. The last recorded care planning process for this resident was completed over a year prior. During an interview, a family member of Resident 2 reported not being invited or aware of the quarterly care planning process, despite being involved in planning care for the resident. Additionally, the Social Services Director confirmed that Resident 2's record did not reflect the completion of the care planning process and was unaware of any such process being completed for the resident. This oversight indicates a failure to adhere to the regulatory requirement of involving residents and their families in the development and implementation of person-centered care plans.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement assessed interventions to prevent accidents and falls for three residents. Resident 1's Comprehensive Care Plan (CCP) indicated the need for a fall mat next to the bed, among other interventions, to prevent serious injury. However, observations revealed that Resident 1 did not have a fall mat in place, which was confirmed by an LPN. Similarly, Resident 3's CCP required the removal of a sling after being positioned in a chair and the presence of a fall mat at the bedside. Observations showed that Resident 3 was seated on a sling in a wheelchair and did not have a fall mat next to the bed, as confirmed by both an LPN and an RN. Resident 4's CCP also identified the need for a fall mat at the bedside and a low bed when asleep to prevent serious injury. Observations indicated that Resident 4 did not have a fall mat next to the bed, which was confirmed by an RN. These deficiencies highlight the facility's failure to adhere to the planned interventions outlined in the residents' care plans, potentially compromising the safety and well-being of the residents.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 11.76%. This deficiency affected three out of five sampled residents. For Resident 10, the medication administration record (MAR) indicated that Atorvastatin was to be given at 5:00 PM, but it was administered late at 7:33 PM. Additionally, Metamucil was not given as ordered. Licensed Practical Nurse (LPN) A confirmed these errors during an interview. Resident 11's medication order included Diltiazem to be given at bedtime, but during observation, the medication was not available for administration. Registered Nurse (RN) B confirmed the unavailability of the medication as an error. For Resident 13, the MAR indicated that Calcium Carbonate was to be administered at 10 AM and 3 PM, but it was given early at 7:23 AM. RN D confirmed this early administration as an error during an interview.
Failure to Complete PASARR Level II for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was completed for a resident with a serious mental disorder. The deficiency was identified during a review of records and an interview with the facility's Social Services Director. The resident in question, referred to as Resident 6, was admitted to the facility with a diagnosis of Bipolar Disorder, a serious mental illness. However, this diagnosis was not identified during the initial PASARR Level I screening, which incorrectly indicated no signs of a serious mental illness or intellectual disability. Upon admission, Resident 6's medical records showed a diagnosis of Bipolar Disorder dated shortly after the initial screening. The Minimum Data Set (MDS) assessment for Resident 6 confirmed the presence of Bipolar Disorder, along with other conditions such as anxiety and depression. Despite these findings, the facility did not make a referral for a PASARR Level II evaluation, which is required when a serious mental disorder is identified after admission. The Social Services Director confirmed that a referral should have been made once the omission was recognized. The facility's policy on PASARR, dated 9/25/2023, outlines the procedures for ensuring that potential admissions are screened for serious mental disorders or intellectual disabilities. It specifies that a positive Level I screen necessitates a Level II evaluation by the state-designated authority. The policy also requires the facility to incorporate recommendations from the PASARR Level II determination into the resident's care plan. In this case, the facility did not adhere to these procedures, resulting in a failure to coordinate the necessary assessments and referrals for Resident 6.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy and regulatory standards. The resident, identified as Resident 79, was admitted on a specific date, but a review of their electronic medical record revealed that no baseline care plan was developed or implemented in the Point Click Care system. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the baseline care plan for Resident 79 was blank and lacked necessary information about the resident's physical or medical needs, goals, or interventions. The facility's policy on person-centered care planning mandates that each resident should have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The baseline care plan is intended to ensure continuity of care and communication among staff, increase resident safety, and prevent adverse events immediately after admission. However, in this case, the facility did not adhere to its own procedures, resulting in a deficiency in care planning for Resident 79.
Incomplete Comprehensive Care Plan for a Resident
Penalty
Summary
The facility staff failed to complete a Comprehensive Care Plan (CCP) for a resident, identified as Resident 79, after the completion of a comprehensive assessment. This deficiency was identified during a record review and interview process. Resident 79's Minimum Data Set (MDS) indicated the need for setup or clean-up assistance with oral hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing. Despite these identified needs, the CCP for Resident 79, dated 06/22/2024, only included a focus area related to Advanced Directives and lacked information addressing the resident's care needs. An interview with the Assistant Director of Nursing (ADON) confirmed that Resident 79's CCP had not been completed. The facility's policy on Person-Centered Care Planning, dated 08/22/2023, requires that each resident have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The facility's procedure outlines that the CCP should include measurable goals, timeframes, and interventions to assist the resident in achieving their highest practicable well-being. However, these requirements were not met for Resident 79, as the CCP was incomplete and did not reflect the necessary interventions and goals based on the comprehensive assessment.
Failure to Meet Resident's Activity Needs
Penalty
Summary
The facility failed to provide activities that met the needs and interests of a resident with a diagnosis of dysphagia and anoxic brain damage. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs due to immobility, with a goal of participating in activities at least 1-2 times weekly. However, observations revealed that the resident was often in bed with no activities occurring, and the resident's participation in activities was minimal, with only a few 1-1 visits documented over several months. Interviews with the Activity Director indicated that more 1-1 visits might have been provided than recorded, but the resident was not consistently brought to activities when out of bed. The resident's preferences included listening to music, engaging in group activities, and going outside for fresh air, yet these interests were not adequately addressed. The facility's failure to ensure the resident's participation in activities as per their care plan and preferences led to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for a resident identified as being at risk for falls. The resident, who was admitted with dysphagia and anoxic brain damage, had a care plan that included several interventions to mitigate fall risks, such as keeping the call light within reach, using a fall mat, and ensuring the bed was in a low position when appropriate. Despite these measures, the resident experienced two incidents where they were found on the fall mat next to the bed, indicating that the interventions were not effectively implemented. Observations revealed that the resident was often found in positions that increased the risk of falling, such as having feet off the edge of the bed without wedges in place to prevent this. Interviews with staff confirmed that wedges were not consistently used, and the bed was not always in the low position as required by the care plan. The facility's policy on fall management emphasized assessing residents for fall risks and implementing appropriate interventions, but these were not adequately followed for the resident in question.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that enteral feeding was provided in accordance with the physician's order for a resident with a diagnosis of dysphagia and anoxic brain damage. The resident was receiving more than 51% of their total calories from enteral tube feeding. The physician's orders specified that the resident should receive Jevity 1.5 formula via G-tube with specific water flushes at scheduled times. However, on a particular day, a registered nurse administered an extra feeding of Jevity 1.5 bolus at 9:10 AM, which was not due until 12 PM, and did not follow the prescribed water flush protocol. During the observation, the registered nurse encountered difficulty administering the tube feeding and initially flushed the tube with less water than ordered. The nurse left the room to consult with the nurse practitioner and later realized the error in the timing of the feeding. The Assistant Director of Nursing confirmed that the timing for the administration of the resident's tube feeding was not followed, indicating a failure to adhere to the practitioner's order as outlined in the facility's Enteral Tube Feeding Checklist.
Inconsistent Monitoring of Wanderguard Bracelet for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure monitoring of a Wanderguard bracelet for Resident 1, who was at risk for elopement due to severe cognitive impairment and a history of attempting to leave the facility unattended. Despite being identified as at risk for elopement and having a Wanderguard bracelet in place, there were multiple instances where Resident 1 attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented Resident 1 being found outside the building on two occasions, with the Wanderguard not functioning properly or alarming as intended. Documentation revealed that while there were orders in place to check the Wanderguard bracelet's placement and function every shift, there was a lack of consistent monitoring and documentation of this task. The facility's policy on elopement highlighted the risks associated with residents leaving the premises without supervision and emphasized the need for regular review and revision of care plans for residents at risk of elopement. Interviews with staff members revealed gaps in monitoring Resident 1's Wanderguard bracelet, with no evidence of consistent monitoring between the bracelet being placed and the deficiency being identified. The deficiency in ensuring the proper monitoring of the Wanderguard bracelet for Resident 1 highlights a critical lapse in supervision and safety measures for a resident at high risk of elopement. Despite the facility's policies and procedures in place for elopement prevention, the lack of consistent monitoring and documentation of the bracelet's function put Resident 1 at risk of leaving the facility unsupervised. The repeated instances of Resident 1 attempting to exit the building without the alarm sounding raise concerns about the effectiveness of the facility's elopement prevention measures and the need for improved monitoring protocols to ensure resident safety.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with a BIMS score of 3, indicating severe cognitive impairment. Despite being identified as an elopement risk and having a care plan in place with interventions such as frequent monitoring and a Wanderguard bracelet, the resident was found outside the facility on two separate occasions. On one occasion, the resident was found walking up a hill and was retrieved by staff, and on another occasion, the resident was found walking outside the building by housekeeping staff. In both instances, the resident did not sustain any injuries, and the Wanderguard bracelet was found to be working properly. The facility's policy on missing residents and actual elopement events defines elopement as a resident leaving the premises or a safe area without authorization and necessary supervision. The policy also requires the Executive Director or designee to report such events to all appropriate agencies. However, the Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds. This failure to report and investigate the incidents as required by the facility's policy and state regulations constitutes a deficiency in the facility's compliance with reporting requirements.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that two nurse aides, identified as Nurse Aide C and Nurse Aide D, completed the required 12 hours of yearly in-service training. Specifically, Nurse Aide C, who was hired on 11/28/17, completed only 1.95 hours of continuing education between 11/28/22 and 11/28/23, with no training on abuse prevention or dementia. Similarly, Nurse Aide D, hired on 10/5/18, completed only 1.03 hours of continuing education between 10/5/22 and 10/5/23. The Director of Nursing confirmed these deficiencies during an interview. The facility had a total census of 85 residents at the time of the survey.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posting of daily nursing staffing information. Observations on 4/2/24 at 1:00 PM revealed that the daily nursing staffing posting was dated 3/13/24. A review of the facility staff posting confirmed that the census and staffing hours were from 3/13/24. In an interview on 4/2/24 at 1:11 PM, the Administrator confirmed that the daily nursing staffing posting was not up-to-date and reported that a new scheduler had just been hired.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
