Linden Court
Inspection history, citations, penalties and survey trends for this long-term care facility in North Platte, Nebraska.
- Location
- 4000 West Philip Avenue, North Platte, Nebraska 69101
- CMS Provider Number
- 285083
- Inspections on file
- 18
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Linden Court during CMS and state inspections, most recent first.
A resident's wedding ring was reported missing by a family member, prompting an incomplete investigation by facility staff. The search included the resident's room and interviews with some staff and a roommate's family member, but did not include all staff with access or a documented timeline of the ring's disappearance. Required documentation of interviews and a thorough investigation, as outlined in facility policy, were not completed.
The facility did not consistently implement its elopement prevention protocols, resulting in incomplete Elopement Risk Manuals, unsecured entrance doors without adequate supervision, and insufficient staff education on elopement procedures. Several high-risk residents were not properly documented in the required manuals, and some staff were unaware of which residents were at risk or how to access relevant information.
Surveyors identified that several residents' MDS assessments were inaccurately coded, including incorrect documentation of medication use and incomplete care area assessment (CAA) summaries. For example, medications were listed as administered when they were not, and required rationales for care planning decisions regarding cognitive impairment and urinary incontinence were left blank or not addressed. MDS coordinators confirmed these errors and omissions during interviews.
A resident's care plan was not updated to remove anticoagulant and antidepressant medications that were no longer being administered, as confirmed by the MAR and MDS review. Facility policy requires care plans to be revised after each MDS assessment and as needed, but this was not done in this case.
The facility failed to ensure proper hand hygiene and hair restraint use in the kitchen, potentially affecting all residents. Culinary Lead-B did not perform hand hygiene after handling raw meat, and Culinary Assistant-C was observed without a hair restraint. The facility relied on the 2017 Nebraska Food Code for guidance but lacked a specific policy for hair restraints.
The facility failed to follow infection control practices during environmental cleaning and PPE application. A housekeeping staff member was observed not changing gloves between rooms, and a Nurses Assistant improperly applied a gown before entering an Enhanced Barrier Precautions room. These actions were confirmed to be against facility policy by the Infection Preventionist nurse.
The facility failed to include specific medical needs in the care plans of two residents. One resident on anticoagulant therapy did not have this treatment reflected in their care plan, while another resident undergoing hemodialysis lacked a focus area for dialysis in their care plan. These omissions were confirmed by facility staff.
A resident experienced significant weight loss, but the facility failed to update the care plan to reflect this change. Despite the resident's dietary needs changing to a mechanical soft diet, the care plan still indicated a regular diet. Interviews with staff revealed a lack of communication and follow-through in updating the care plan, with the MDS Nurse and RD not ensuring the care plan reflected the resident's current needs.
A resident was discharged without a complete discharge summary, missing key information such as a recapitulation of stay, assistance needs, continence status, skin condition, and medication reconciliation. The LPN responsible was unaware of the requirements, and the facility lacked a specific discharge policy, relying instead on an incomplete checklist.
The facility failed to administer medications correctly, resulting in a 9.38% error rate. A resident received rivaroxaban without food, another was given potassium chloride without food, and a third received an incorrect dosage of MiraLAX. These errors highlight non-compliance with medication protocols.
Failure to Thoroughly Investigate Missing Resident Property
Penalty
Summary
The facility failed to conduct and document a thorough investigation into the misappropriation of a resident's property, specifically a wedding ring belonging to a resident who had been admitted in July 2022. The resident's personal inventory included several rings of value, and the missing wedding ring was reported by a family member after noticing its absence during a visit. The family member had last seen the ring during a previous visit and, upon discovering it missing, reported it to the nurse on duty. The facility's investigation, as documented, included searching the resident's room and the unit, and interviewing the roommate's daughter, but did not include interviews with all staff who had access to the resident or the resident's belongings. Further, the investigation did not document interviews with all potentially involved staff, nor did it establish a clear timeline for when the ring was last seen. Interviews were conducted with the nurse and aide on duty at the time of the report and the ADON, but the findings from these interviews were not documented. The facility also did not rule out the possibility that misappropriation had occurred, and interviews with other residents were not completed due to their impaired cognition. These actions and omissions are contrary to the facility's own policy, which requires all allegations of abuse or neglect to be thoroughly investigated and documented.
Failure to Maintain Elopement Prevention Protocols and Supervision
Penalty
Summary
The facility failed to provide a safe environment for residents identified as being at risk for elopement, as evidenced by multiple lapses in the implementation of its elopement prevention policy. Observations revealed that the front entrance doors were accessible by sensor and were not consistently monitored or secured, with front desk staffing not covering all hours when the doors were unlocked. Staff members assigned to the front desk were not always aware of their responsibilities regarding monitoring the entrance or the procedures for elopement prevention. Additionally, there was no wander guard system in place to prevent residents from exiting through the front door. Record reviews showed that the Elopement Risk Manuals, which were supposed to contain up-to-date Missing Resident Identification Forms for all residents at risk, were incomplete or missing forms for several high-risk residents across multiple units. Staff interviews indicated a lack of awareness among some nursing assistants regarding which residents were at risk for elopement and where to locate the Elopement Risk Manuals. Furthermore, the process for updating these manuals was not consistently followed, and some staff members responsible for updates were unclear about the procedures. Education and preparedness for elopement prevention were also insufficient. Not all staff had received required training on elopement prevention, and attendance at in-service education events was incomplete. After an actual elopement incident involving a resident, no additional education was provided to staff. Elopement drills were conducted with limited staff participation, and there was a lack of follow-up education after incidents. These deficiencies affected a significant number of residents identified as high risk for elopement.
Inaccurate Coding and Incomplete Documentation in Resident Assessments
Penalty
Summary
The facility failed to accurately code and complete comprehensive assessments for several residents, as evidenced by discrepancies between the Minimum Data Set (MDS) documentation and supporting medical records. For one resident, the MDS indicated the use of anticoagulant and antidepressant medications during the observation period, but the medication administration record showed that these medications were not in use during that time. Interviews with MDS coordinators confirmed that these medications should not have been coded on the MDS. Another resident was coded on the MDS as having received anticonvulsant medication during the look-back period, but a review of physician orders and the electronic medication administration record revealed no such medication was prescribed or administered. The MDS coordinator confirmed the error in coding. Additionally, the care area assessment (CAA) summaries for two residents were incomplete or incorrectly documented. For one resident, cognitive impairment and urinary incontinence were identified as issues, but the rationale for not addressing these in the care plan was left blank, and the decision not to address them was not explained. The MDS coordinator acknowledged these areas should have been marked to be addressed and properly documented. For another resident, the CAA for urinary incontinence was marked to be addressed in the care plan, but the section requiring a description of the impact and rationale for the care plan decision was left blank. The MDS coordinator confirmed this documentation was incomplete. These findings demonstrate failures in the accurate coding of assessments and completion of care area assessment summaries for multiple residents.
Care Plan Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to update the care plan for one resident to accurately reflect current care needs. Record review showed that the resident's care plan, last updated on 04/30/2025, listed anticoagulant and antidepressant medications as active, even though the medication administration record indicated that neither medication was in use during the Minimum Data Set (MDS) observation period. The most recent quarterly MDS assessment was completed on 04/23/2025. Facility policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive or quarterly MDS assessment, and as needed. Interviews with the MDS Coordinator RN and LPN confirmed that the care plan should not have included the anticoagulant and antidepressant medications, as the resident was no longer taking them during the relevant period.
Failure in Hand Hygiene and Hair Restraint Compliance in Kitchen
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols and hair restraint requirements in the kitchen, potentially affecting all 104 residents. During an observation, Culinary Lead-B (CL-B) was seen preparing meatloaf and did not perform hand hygiene after handling uncooked ground beef. CL-B removed gloves after handling the meat, discarded them, and continued to handle other food items and containers with bare hands before completing hand hygiene only at the end of the preparation process. Interviews with CL-B and the Culinary Director confirmed the failure to perform hand hygiene as required after handling raw meat. Additionally, the facility did not enforce the use of hair restraints in the kitchen as per the 2017 Nebraska Food Code, which the facility used for guidance. An observation revealed Culinary Assistant-C (CA-C) walking through the food preparation area without a hair restraint. The Culinary Director, who was present during the observation, confirmed that CA-C should have been wearing a hair restraint. The facility lacked a specific policy for hair restraints, relying instead on the state food code.
Infection Control Lapses in PPE and Environmental Cleaning
Penalty
Summary
The facility failed to adhere to infection control practices during environmental cleaning and the application of Personal Protection Equipment (PPE). Observations on the 100 Hall revealed a housekeeping staff member exiting a resident's room with gloves on, then replenishing supplies at the housekeeping cart and entering another room without changing gloves. This practice was repeated in three resident rooms. Additionally, a Nurses Assistant was observed improperly applying a gown by not tying it at the neck before entering an Enhanced Barrier Precautions room. Interviews confirmed that these actions were not in line with the facility's policies, as the housekeeping staff should have removed gloves and performed hand hygiene between rooms, and the Nurses Assistant should have properly secured the gown before entering the room. The Infection Preventionist nurse confirmed that the observed practices were against the facility's infection control policies, emphasizing the need for hand hygiene and proper PPE application. The facility's census at the time was 104 residents, indicating the potential for widespread impact due to these lapses in infection control.
Deficiencies in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which resulted in deficiencies in addressing their specific medical needs. Resident 99, who was admitted with a diagnosis of cardiac arrhythmia and a history of blood clots, was on long-term anticoagulant therapy. However, the care plan for Resident 99 did not include a focus area for anticoagulant use, which was confirmed by the MDS nurse during an interview. This oversight meant that the care plan did not reflect the necessary monitoring and interventions required for the resident's anticoagulant therapy. Similarly, Resident 97, who was on hemodialysis due to end-stage renal disease, did not have dialysis included as a focus area in their care plan. Despite being scheduled for dialysis three times a week since admission, the care plan lacked any mention of dialysis-related interventions or monitoring. This was confirmed by both the MDS nurse and the Director of Nursing, who acknowledged the omission and the importance of including dialysis in the care plan due to its potential side effects and complications.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as Resident 94, was reviewed and revised to reflect significant weight loss. The resident, who was admitted with diagnoses including pneumonia, altered mental status, and functional diarrhea, experienced a 7% weight loss over 30 days. Despite this, the care plan was not updated to include new interventions or strategies to address the weight loss. The resident's care plan, dated several months after admission, still reflected a regular diet, even though the resident had been changed to a mechanical soft diet due to difficulty chewing. Interviews with facility staff revealed a lack of communication and follow-through in updating the care plan. The MDS Nurse, responsible for overseeing the care plan, indicated that each department was responsible for entering their own data and interventions, but the care plan was not revised to reflect the resident's current needs. The Registered Dietician believed the existing care plan was sufficient, despite acknowledging the resident's dietary changes. The Director of Nursing confirmed that the care plan should have been updated to include the resident's weight loss under the core focus area, indicating a lapse in the facility's care planning process.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, identified as Resident 102, who was discharged on 10/31/2024. The discharge summary lacked critical information such as a recapitulation of the resident's stay, details on physical functioning and assistance level needs, continence status, skin condition, and a reconciliation of medications. The resident had a history of a right femur fracture with surgical correction and high blood pressure, and was on a high-risk anticoagulant medication. The Minimum Data Set (MDS) indicated that the resident required supervision with bathing, setup assistance with eating, and was independent with other activities of daily living, was occasionally incontinent of urine, and had no skin conditions. Interviews with the LPN responsible for completing the discharge summary and the Director of Nursing revealed that the necessary sections of the discharge summary were left incomplete due to a lack of awareness of the requirements. The facility did not have a specific policy regarding discharges but used a checklist to ensure all steps were completed. However, the checklist failed to ensure the inclusion of all necessary information in the discharge summary, leading to the deficiency identified by the surveyors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications correctly to three residents, resulting in a medication error rate of 9.38%, which exceeds the acceptable threshold of less than 5%. Resident 99, who has a history of blood clots and is on anticoagulants, was given rivaroxaban without food, contrary to the physician's order that it should be administered with food to ensure efficacy. Similarly, Resident 3, diagnosed with dementia and GERD, received potassium chloride without food, which was against the prescribed order to administer it with or after meals to prevent gastrointestinal irritation. Additionally, Resident 96, who suffers from constipation, was given an incorrect dosage of MiraLAX. The RN measured the MiraLAX powder using a medication cup instead of the bottle's lid, leading to an incorrect dosage. The RN was unaware of the proper conversion from cubic centimeters to grams, resulting in a failure to administer the correct 17 grams as prescribed. These errors highlight a lack of adherence to medication administration protocols, contributing to the facility's high medication error rate.
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.
