Maple Crest Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 2824 North 66th Avenue, Omaha, Nebraska 68104
- CMS Provider Number
- 285149
- Inspections on file
- 23
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Maple Crest Health Center during CMS and state inspections, most recent first.
A facility failed to secure medications properly, with a bottle of Miconazole 2% powder found unsecured in a resident's room and a medication cart left unlocked. The resident had multiple health issues, including moderate cognitive impairment, and no physician's order for the powder. The facility's policy requires all medications to be secured and carts locked when unattended.
The facility failed to maintain the nutritive value of pureed food for 18 residents. Staff used inappropriate methods, such as adding boiling water and excessive thickener, which could alter the nutritional value and taste. The dietician confirmed these methods were not appropriate, and the taste of the pureed eggs was poor.
The facility failed to offer Pneumococcal vaccinations to four residents, despite having a policy in place. Residents with conditions like congestive heart failure, chronic respiratory failure, and Parkinson's disease were not assessed or offered the vaccine. The Assistant Director of Nursing confirmed the oversight.
A resident with End Stage Renal Disease missed a dialysis appointment due to staffing issues at the dialysis center. The facility failed to notify the resident's physician about the missed session, despite the resident's care plan indicating a need for dialysis. The Director of Nursing confirmed the oversight, which was against the facility's policy requiring immediate notification of significant changes in a resident's condition.
A facility failed to investigate and report an alleged staff-to-resident abuse incident within the required timeframe. A resident with moderate cognitive impairment reported that a caregiver had slammed their feet on the bed. The incident was not documented in the resident's medical records, and no report was sent to DHHS within the mandated period. Interviews confirmed that the facility's policies on abuse investigations and reporting were not followed.
The facility failed to accurately document special treatments for two residents on the MDS. One resident's MDS did not reflect dialysis treatment despite having renal issues, and another resident's MDS failed to indicate hospice care. These inaccuracies were confirmed by the MDS Coordinator.
A facility failed to complete a new PASRR referral for a resident after several new psychiatric diagnoses, including major depressive disorder and PTSD, were identified. Despite policy requirements for re-screens due to changes in condition, no new PASRR screening was conducted since the resident's initial screening in 2017.
A resident's Level I PASARR screen was inaccurately completed, failing to identify diagnoses that should have triggered a Level II screen. The resident had conditions such as vascular dementia, moderate intellectual disabilities, and major depressive disorder, which were not reflected in the initial PASARR assessment. The facility's administrator confirmed the oversight, and no additional PASARR screens were conducted since the initial one.
A resident with Alzheimer's, Lewy body Dementia, Schizophrenia, and Depression did not receive timely incontinence care and position changes as per their care plan. Observations showed no assistance from 8:15 AM to 12:15 PM, and the resident's brief was wet by 2:30 PM. Interviews confirmed the lack of care, highlighting a deficiency in the facility's adherence to the care plan.
The facility failed to implement assessed interventions for two residents, leading to deficiencies in accident prevention. One resident, with severe cognitive impairment, did not consistently have a Rooke boot in place to protect fragile skin, while another resident, at high risk for falls, lacked necessary fall prevention measures such as Dycem in the wheelchair and signage to use the call light. Staff were unaware of these interventions, contributing to the risk of injury.
A resident was not provided timely follow-up dental services after being fitted for dentures, resulting in a delay of several months. The facility failed to maintain communication with the dentist, as required by their policy, leading to the resident not receiving their dentures as expected.
Two residents in a long-term care facility were subject to improper infection control practices. A resident receiving catheter care was handled by staff who failed to change gloves and perform hand hygiene correctly, risking cross-contamination. Another resident, dependent on staff for personal care, was provided perineal care with washcloths potentially contaminated by being placed in a sink. These actions violated the facility's infection control guidelines.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to secure medications properly, resulting in a deficiency. During an observation, a white bottle of Miconazole 2% powder with a worn prescription label was found sitting unsecured in the windowsill of a resident's room. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and moderate cognitive impairment, did not have a physician's order for the Miconazole Powder. The Director of Nursing confirmed that medications should not be kept unsecured in resident rooms and subsequently removed the powder. Additionally, a medication cart on the first floor was found unlocked and unattended. The cart, identified as the East Treatment Cart, was located in a hallway near a resident's room. The Director of Nursing confirmed that all medication and treatment carts should be locked when unattended. The facility's Medication Storage policy mandates that all medications must be secured in a locked storage area, and medication carts should be locked when not in use or unattended by authorized nursing personnel.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to maintain the nutritive value of pureed food, which had the potential to affect 18 residents on a pureed diet. Observations revealed that staff members were using inappropriate methods to prepare pureed foods. For instance, a staff member was observed using a slotted spoon to scoop an indeterminate amount of cooked green beans into a blender, adding two teaspoons of salt, two scoops of liquid butter, and an indeterminate amount of boiling water before blending and adding four ounces of thickener. Similar methods were used for preparing pureed ground beef and turkey breast, where boiling water and thickener were added inappropriately. The dietician confirmed that the use of boiling water in the preparation of pureed foods was not appropriate and noted that the taste of the pureed eggs was not good. The facility's recipe for pureed foods, which follows the International Dysphagia Diet Standardization Initiative (IDDSI) Level 4 guidelines, suggests adding small amounts of gravy, sauce, or other liquids to achieve the desired consistency, but does not recommend the use of boiling water. The improper preparation methods observed could potentially alter the nutritional value and palatability of the pureed foods served to residents.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility staff failed to identify and offer the Pneumococcal immunization to four out of five sampled residents, despite having a policy in place since August 2016 that mandates offering the vaccine to all residents. The policy requires that residents be assessed for eligibility to receive the Pneumococcal vaccine series upon admission and be offered the vaccine within 30 days unless medically contraindicated or previously vaccinated. However, record reviews revealed that Residents 122, 138, and 80 were not identified or offered the vaccine, and Resident 130, who had previously received a PPSV23 vaccine, was not offered any additional Pneumococcal vaccination. The residents involved had various medical conditions that could increase their vulnerability to infections. Resident 122 had conditions such as congestive heart failure and vascular dementia, while Resident 138 suffered from chronic respiratory failure and severe malnutrition. Resident 80 had a history of cerebral infarction and heart disease, and Resident 130 had Parkinson's disease and respiratory failure. Despite these conditions, there was no evidence in their immunization reports that the facility staff had offered the necessary Pneumococcal vaccinations. The Assistant Director of Nursing/Infection Preventionist Nurse confirmed the oversight during an interview.
Failure to Notify Physician of Missed Dialysis Appointment
Penalty
Summary
The facility staff failed to notify the physician of a missed dialysis appointment for a resident who required hemodialysis due to End Stage Renal Disease (ESRD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was dependent on staff for transfers and required substantial assistance with bed mobility and toileting. The resident's care plan indicated a need for dialysis, and the missed appointment was documented in the progress notes. However, the facility did not inform the resident's physician about the missed dialysis session, which was rescheduled due to staffing issues at the dialysis center. During an interview, the Director of Nursing confirmed that the resident's practitioner had not been notified of the missed appointment, which was a requirement according to the facility's policy on changes in a resident's condition. The policy mandates immediate notification to the resident, their representative, and the physician in cases of significant changes in condition or treatment. The failure to notify the physician was a deviation from this policy, as the facility's procedure requires documentation of such notifications and any new orders in the resident's medical record.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough written investigation and report an allegation of staff-to-resident abuse within the required timeframe to the Department of Health and Human Services (DHHS). The incident involved a resident with moderate cognitive impairment, who reported that a male caregiver had slammed their feet on the bed. This allegation was reported to Adult Protective Services (APS) a week after the incident occurred. However, the facility did not document the incident in the resident's medical records or report it to DHHS within the mandated five-day period. Interviews with the facility's social worker and administrator confirmed that no written investigation was completed, and no report was sent to DHHS within the required timeframe. The facility's policies on abuse investigations and reporting were not followed, as the investigation was not documented, and the necessary notifications were not made. The resident involved had a history of adult failure to thrive, diabetes mellitus, Alzheimer's disease, and Parkinson's, and required substantial assistance with daily activities.
Inaccurate MDS Documentation for Special Treatments
Penalty
Summary
The facility failed to accurately identify and document special treatments for two residents on the Minimum Data Set (MDS), a federally mandated assessment tool used for care planning. Resident 54, who was admitted with diagnoses including dependence on renal dialysis, had an MDS that did not reflect dialysis treatment in Section O, Question J 1, despite having renal insufficiency, renal failure, and End Stage Renal Disease (ESRD) marked. The MDS Coordinator confirmed that the MDS should have been coded for dialysis treatment while the resident was in the facility. Similarly, Resident 122, who was readmitted and started on hospice services, had an MDS that failed to mark hospice care in Section O, Question K 1. The MDS Coordinator confirmed that the MDS should have indicated hospice care while the resident was in the facility. These inaccuracies in the MDS documentation were identified through record reviews and interviews with the MDS Coordinator.
Failure to Conduct New PASRR Referral After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new PASRR (Pre-Admission Screening and Resident Review) referral for a resident after several new psychiatric diagnoses were identified. The resident, who was initially screened in 2017 and found not to have a mental illness or intellectual disability, received multiple new psychiatric diagnoses over the years, including adjustment disorder with depressed mood, generalized anxiety disorder, vascular dementia with behavioral disturbance, PTSD, and major depressive disorder. Despite these new diagnoses, the facility did not conduct a new PASRR screening to determine if a Level 2 evaluation was necessary. The facility's policy requires re-screens or status updates of residents due to changes in condition or new diagnoses. However, the facility did not adhere to this policy for the resident in question. The facility administrator confirmed that no new PASRR referral had been made since the resident's initial screening in 2017, despite the resident's significant changes in mental health status.
Inaccurate PASARR Screening for a Resident
Penalty
Summary
The facility failed to accurately complete a Level I PASARR screen for a resident, identified as Resident 23, who was part of a sample of two residents. The PASARR screen, dated May 4, 2018, incorrectly assessed Resident 23 as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). However, a review of the facility's diagnosis report for Resident 23 revealed several admission diagnoses that should have triggered a Level II PASARR screen. These diagnoses included vascular dementia with mood disturbance, moderate intellectual disabilities, major depressive disorder, generalized anxiety disorder, and unspecified psychosis. Further review of Resident 23's medical records and medication administration records from July 2024 confirmed the presence of these conditions, yet no additional PASARR screens had been completed since the initial one in 2018. An interview with the facility's administrator confirmed the inaccuracy of the initial PASARR screen and acknowledged that a Level II PASARR should have been triggered for further review. The facility's policy on admissions and PASRR updates, last reviewed in May 2023, outlines the process for identifying individuals with serious mental illness or intellectual disabilities to ensure they receive necessary specialized services and appropriate placement, which was not adhered to in this case.
Failure to Provide Timely Incontinence and Position Change Care
Penalty
Summary
The facility failed to provide necessary care for Resident 33, who was diagnosed with Alzheimer's Disease, Lewy body Dementia, Schizophrenia, and Depression. The resident was dependent on facility staff for various activities of daily living, including eating, oral hygiene, bathing, dressing, toileting, bed mobility, and transfers. According to the resident's care plan, staff were required to assist with position changes and skin care every two hours and check incontinence briefs every three hours. However, during a continuous observation period from 8:15 AM to 12:15 PM, no assistance with position changes or incontinence care was provided to Resident 33. Further observation at 2:30 PM revealed that the resident's incontinence brief was wet, indicating a lack of timely care. Interviews with Nurse Aids D and E confirmed that Resident 33 had not been repositioned or provided with incontinence care from 8:15 AM until 2:30 PM. Additionally, an interview with LPN D confirmed that the resident's routine care, which included checking for incontinence between breakfast and lunch and transferring to bed after lunch, was not followed. This failure to adhere to the care plan resulted in a deficiency in the care provided to Resident 33.
Failure to Implement Assessed Interventions for Accident Prevention
Penalty
Summary
The facility failed to implement assessed interventions to prevent skin injuries for Resident 105, who had severe cognitive impairment and a history of skin tears. Despite the care plan indicating the use of a Rooke boot to protect the resident's fragile skin during transfers, observations revealed that the boot was frequently not in place. Interviews confirmed that staff removed the boot during transfers due to concerns about slipping, and the boot was often found on the floor rather than on the resident's leg. Additionally, the facility did not implement fall prevention measures for Resident 63, who had moderate cognitive impairment and was at high risk for falls. The care plan included interventions such as using Dycem in the wheelchair, applying blue tape to indicate bed height, and posting signage to remind the resident to use the call light. However, observations showed that these interventions were not in place, and staff were unaware of the need to check for them. The resident was not assisted to the main lounge by the designated time, further indicating a lack of adherence to the care plan. The facility's failure to implement these interventions resulted in deficiencies in accident prevention for both residents. The lack of communication and adherence to care plans contributed to the risk of injury, as evidenced by the absence of necessary protective measures and staff's lack of awareness regarding the interventions.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 55, received follow-up dental services in a timely manner. Resident 55, who had no teeth, was seen and fitted for dentures in April 2024. However, by July 8, 2024, the resident was still waiting for the dentures to be delivered. A review of the resident's medical records showed that there was no evidence of any contact between the facility and the dentist from May 21, 2024, through July 8, 2024, indicating a lack of follow-up on the part of the facility. An interview with the facility's Social Worker on July 9, 2024, confirmed that the facility was unaware of the delay in the delivery of the dentures. The facility's policy on dentures, revised in April 2007, states that the facility is responsible for timely referral for dental services, within three days for an appointment, and that residents will not be charged for repair or replacement of dentures if the loss or damage was incurred by facility staff. The lack of timely follow-up and communication with the dentist led to the deficiency in providing necessary dental care for Resident 55.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control practices, leading to deficiencies in hand hygiene and gloving, which were observed in the care of two residents. Resident 122, who was severely cognitively impaired and required substantial assistance with daily activities, was observed receiving catheter care. During this procedure, a nursing assistant and an LPN failed to change gloves and perform hand hygiene appropriately. The LPN applied hand sanitizer over soiled gloves and continued to assist with personal care, which could lead to cross-contamination. Resident 33, diagnosed with Alzheimer's Disease, Lewy body Dementia, Schizophrenia, and Depression, was also subject to improper infection control practices. The resident was dependent on staff for personal care, including perineal care. During observations, a nurse aide placed washcloths in the bottom of a sink, potentially contaminating them, before using them for perineal care. This practice was confirmed by the nurse aide and an LPN, acknowledging the risk of cross-contamination from the sink. The facility's infection control guidelines and policies were not followed, as evidenced by the improper hand hygiene and use of potentially contaminated washcloths. The guidelines require staff to perform hand hygiene before and after resident contact and to use personal protective equipment to prevent exposure to infectious materials. The failure to adhere to these guidelines resulted in deficiencies in infection prevention and control, as observed by the surveyors.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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