Mitchell Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mitchell, Nebraska.
- Location
- 1723 23rd Street, Mitchell, Nebraska 69357
- CMS Provider Number
- 285287
- Inspections on file
- 21
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Mitchell Care Center during CMS and state inspections, most recent first.
The facility did not ensure that two nurse aides completed the required 12 hours of annual training, and five nurse aides did not complete the mandated 4 hours of Alzheimer's and dementia care education. The DON confirmed these training deficiencies, which had the potential to affect all residents.
Two residents experienced multiple episodes of constipation without appropriate assessment or intervention, despite facility policy and physician orders requiring action. One resident, taking medications associated with constipation, went several days without a bowel movement and did not receive required GI assessments or bowel medications. Another resident had similar periods without a bowel movement, with no evidence of PRN medication administration or documented assessment, even though a bowel management protocol was in place.
Required Nurse Aide Registry checks were not completed for an LPN and a Maintenance Assistant, both of whom could have unsupervised access to residents. Facility policy required verification of board registrations and certifications, but this step was missed for these two employees, as confirmed by the Administrator.
The facility did not implement or document procedures to protect residents from further abuse during an investigation involving an LPN and two residents. The abuse policy lacked required procedures, and there was no evidence that the LPN was suspended or that protective measures were taken while the investigation was ongoing.
The facility did not suspend or restrict an LPN accused of abuse during an investigation, allowing the LPN continued access to residents. The DON, who is related to the LPN, handled the investigation without removing the LPN from duty, and initial documentation of the investigation was lacking. The LPN's absence from work following the incident was due to the original schedule, not as a protective measure.
The facility did not report an allegation of abuse involving an LPN and two residents to the State Agency as required by policy. The DON, who is related to the LPN, conducted an internal investigation but did not document or report the findings, believing no abuse had occurred. The NHA confirmed the lack of reporting and documentation, acknowledging the deficiency.
The facility failed to properly label and date-mark food items, risking potential food-borne illnesses. Observations revealed unlabeled bins and bags of food, and expired items used in meal preparation. Interviews confirmed these deficiencies, affecting all 43 residents served by the kitchen.
The facility failed to maintain operational ventilation systems in the bathrooms of the 100, 200, and 300 wings, affecting all 43 residents. A strong odor was detected, and inspections showed that the ventilation systems in several rooms were not functional. The Administrator and Maintenance Personnel confirmed the issue.
The facility failed to implement proper infection control measures, including the use of enhanced barrier precautions and hand hygiene. A resident with a stage 4 pressure ulcer did not receive care with the required PPE, and staff did not follow hand hygiene protocols during catheter care and medication administration, leading to contamination risks.
A resident on hypertension medication did not have their blood pressure monitored weekly as required by the facility's protocol. Despite being on Amlodipine Besylate and Lisinopril, there was no order for weekly monitoring, leading to significant gaps in blood pressure readings. The DON confirmed the oversight, which resulted in the resident experiencing critical blood pressure fluctuations, including a hospital admission.
A facility failed to ensure a pharmacist identified irregularities during monthly medication regimen reviews for a resident with severe cognitive impairment. The resident had an order for PRN Ativan without a stop date, which was not flagged as an irregularity from March to August. The pharmacist later confirmed this oversight.
A facility failed to ensure a PRN Ativan order for a resident with severe cognitive impairment had a stop date, as required by their policy. The policy states that PRN psychotropic medications should be used for a limited duration unless extended with documented rationale. This deficiency was confirmed by the DON during an interview.
Failure to Ensure Required Nurse Aide Training and Dementia Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual training hours and specific education in Alzheimer's and dementia care. Record reviews showed that two nurse aides did not complete the mandated 12 hours of ongoing training within the annual period, with one aide completing only 8 hours and another just 1 hour. The Director of Nursing confirmed these deficiencies during an interview. Additionally, five nurse aides did not complete the required 4 hours of annual training in Alzheimer's care and dementia care. Documentation for each of these aides indicated no evidence of such training during the specified timeframes. The Director of Nursing also confirmed that these nurse aides had not fulfilled the annual dementia care training requirement. These failures had the potential to affect all residents in the facility, which had a census of 42 at the time.
Failure to Implement Bowel Management Program for Two Residents
Penalty
Summary
The facility failed to implement its bowel management program as outlined in its policy and procedure, resulting in inadequate prevention and management of constipation for two residents. For one resident, who was always incontinent of bowels and taking medications known to cause constipation, there were multiple documented periods of three to five days without a bowel movement. During these periods, there was no evidence of gastrointestinal assessments, progress notes, or administration of bowel medications as required by the facility's protocol. The Medication Administration Record showed only a single administration of a bowel medication, with no further interventions or documentation of effectiveness, and the Director of Nursing confirmed that the protocol was not followed. For another resident, documentation showed several episodes of three to four days without a bowel movement. Although there was a physician's order for a PRN bowel medication, there was no evidence in the Medication Administration Record or progress notes that the medication was administered during these episodes. Additionally, there were no assessments or interventions documented in response to the lack of bowel movements, despite the resident being under a fluid restriction and having a care plan that addressed bowel continence. Interviews with nursing staff confirmed the lack of documentation and intervention according to the facility's bowel management protocol.
Failure to Complete Required Nurse Aide Registry Checks for Staff
Penalty
Summary
The facility failed to complete required Nurse Aide Registry checks for two of five sampled employees, specifically an LPN and a Maintenance Assistant, both of whom had the potential for unsupervised access to all residents. Record reviews showed that neither employee had documentation of a completed Nurse Aide Registry check in their personnel files. The facility's policy required verification of board registrations and certifications for prospective employees, but this process was not followed for these two staff members. The Administrator confirmed during an interview that the checks had not been completed for these employees.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to implement and document effective policies and procedures to prevent further abuse during the investigation of abuse allegations. A review of the facility's abuse policy revealed it did not include procedures for protecting residents while abuse allegations were being investigated, nor did it document how residents would be protected in reports to the State Agency. Additionally, an investigative summary regarding an incident involving an LPN and two residents did not contain evidence of measures taken to protect residents during the investigation. The summary only described interviews conducted by the DON and education provided to the LPN, without specifying any protective actions. Interviews with staff and administration confirmed that the alleged employee was not suspended or formally removed from duty during the investigation. The DON stated that the LPN was not suspended because they believed nothing had happened, and the NHA confirmed there was no documentation of suspension or protective measures. Staff statements and investigation documentation were either missing or only obtained after the fact, and there was no evidence that residents were protected from potential further abuse during the investigative process.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to protect residents from further potential abuse during the investigation of an alleged abuse incident involving a nurse and a resident. According to the facility's abuse policy, there should be evidence that all investigative components are thoroughly investigated and that further abuse, neglect, exploitation, or mistreatment is prevented while the investigation is ongoing. However, the Director of Nursing (DON) confirmed that the alleged employee, an LPN, was not suspended or otherwise restricted from resident care during the investigation, as the DON believed nothing had happened. The LPN in question had access to all residents in the building while on shift, despite being formally assigned to half the building. The DON, who is a sibling of the LPN, stated that all disciplinary actions regarding the LPN were handled by the former Nursing Home Administrator (FNHA). The DON was made aware of the incident several days after it occurred and conducted interviews, but did not suspend the LPN during the process. The Nursing Home Administrator (NHA) later confirmed that there was no documentation of the initial investigation and only provided employee statements and an investigation summary after re-obtaining statements from staff. The facility's records showed that the LPN was not scheduled to work for several days following the incident, but this was due to the original schedule and not as a result of any suspension or protective measure.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by regulatory guidelines. According to the facility's own Abuse Policy, any reportable incident or allegation must be reported immediately or within 24 hours, with a follow-up investigation submitted within 5 working days. A review of an investigative summary revealed that the Director of Nursing (DON) was notified of an incident involving an LPN and two residents, where the LPN was observed speaking firmly and using a curse word in response to a resident. Staff interviews provided conflicting accounts, with one staff member recalling loud talking and another denying verbal abuse. The DON conducted interviews and documented findings but did not report the allegations to the State Agency, stating that nothing had happened. Further interviews revealed that the DON was aware of the incident and had a personal relationship with the LPN involved, which influenced the handling of disciplinary actions. The DON confirmed that the incident was not reported because they believed no abuse had occurred. The Nursing Home Administrator (NHA) also confirmed that there was no documentation of the investigation and acknowledged that the incident should have been reported to the State Agency. The failure to report the allegation had the potential to affect all residents in the facility.
Deficiencies in Food Labeling and Date-Marking
Penalty
Summary
The facility failed to ensure proper labeling and date-marking of food items, which is a requirement to prevent potential food-borne illnesses. During an initial kitchen tour, it was observed that large plastic bins containing thick-it, cornstarch, flour, and sugar were not dated with an open and use-by date. Additionally, four sealed plastic bags containing a red liquid were only marked with a received-by date and lacked any identification of the contents. Interviews with the Certified Dietary Manager (CDM) and Cook-B confirmed these labeling deficiencies. Further observations in the walk-in freezer revealed clear plastic bags of unidentified meat products and breaded food items, which were only labeled with received-by dates and lacked any additional identification. The facility also failed to adhere to the 7-day consumption or disposal requirement for ready-to-eat, time/temperature-controlled foods. During an observation, Cook-B was seen preparing a salad using lettuce, onion, shredded cheese, and pickles that were dated beyond the 7-day limit. Interviews with Cook-B and the CDM confirmed that these items were more than seven days old and should have been removed from the mobile salad station. These deficiencies in food labeling and date-marking had the potential to affect all 43 residents served by the facility's kitchen.
Non-Functional Ventilation System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in the bathrooms of the 100, 200, and 300 wings, potentially affecting all 43 residents residing within the facility. A review of the facility's maintenance policy, last revised in December 2009, indicated that maintenance personnel are responsible for maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. During an observation on August 8, 2024, a strong odor of bowel movement was detected in the 100 wing. Further inspection revealed that the ventilation systems in rooms 101, 104, 111, 200, 300, and 301 were not functional, as they failed to draw a 1-ply square of toilet paper to the surface of the ventilation cover. An interview with the Administrator and Maintenance Personnel confirmed the non-functionality of the ventilation systems in these wings, affecting all residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of enhanced barrier precautions (EBP) and personal protective equipment (PPE). In the case of Resident 3, who had a stage 4 pressure ulcer and a suprapubic urinary catheter, the facility's policy required staff to wear gloves and gowns during high-contact care activities. However, during an observation, a nurse aide assisted with wound care and repositioning without wearing a gown, despite being aware of the EBP requirements. This oversight was confirmed during an interview with the nurse aide. Additionally, the facility's staff did not follow proper hand hygiene protocols during urinary catheter care for Resident 40 and medication administration for Resident 12. A nurse aide failed to perform hand hygiene between glove changes and contaminated their clothing due to improper gown use during catheter care. Similarly, a registered nurse administered insulin to Resident 12 without changing gloves after touching potentially contaminated surfaces. These actions were confirmed through interviews with the involved staff members.
Failure to Monitor Blood Pressure in Resident on Hypertension Medication
Penalty
Summary
The facility failed to adequately monitor the blood pressure of a resident who was taking medications for hypertension. According to the facility's Admission Check Off List, staff were required to put an order in for weekly vital signs for residents on blood pressure medication. However, a review of Resident 2's records revealed that there was no order for weekly blood pressure monitoring, despite the resident being on Amlodipine Besylate and Lisinopril for blood pressure management. The resident's blood pressure was not consistently checked on a weekly basis, as evidenced by gaps in the recorded blood pressure readings over several months. The deficiency was confirmed through interviews with the Director of Nursing (DON), who acknowledged that the facility did not have an order for weekly blood pressure monitoring for Resident 2, contrary to the facility's protocol. The resident experienced significant fluctuations in blood pressure, including a critically low reading that led to hospital admission. Despite these fluctuations, the facility did not implement the required weekly monitoring, which was a clear deviation from the established care protocol for residents on hypertension medication.
Pharmacist Fails to Identify Medication Irregularity
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified irregularities during the monthly medication regimen review (MRR) for a resident. The deficiency was identified for one resident out of a sample of five, in a facility with a census of 43. The facility's policy on Medication Regimen Reviews, last revised in April 2007, lacked information on identifying irregularities in accordance with regulatory requirements. The resident in question was admitted with diagnoses of dementia, Alzheimer's disease, and Major Depressive Disorder, and had a severe cognitive impairment as indicated by a Brief Interview for Mental Status score of 4/15. The resident had an order for PRN Ativan starting in February 2024, which did not include a stop date. Despite this, the pharmacist's monthly reviews from March to August 2024 did not identify any irregularities. An interview with the pharmacist confirmed that the absence of a stop date for Ativan should have been recognized as an irregularity. This oversight indicates a failure in the medication review process, as the pharmacist did not identify the irregularity in the resident's medication order during the specified period.
PRN Psychotropic Medication Lacked Stop Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, specifically Ativan, prescribed to a resident had a stop date, which is a requirement according to their policy. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If an extension is needed, the attending physician must document the rationale and indicate the duration in the resident's medical record. However, in this case, the PRN Ativan order for the resident, who was admitted with dementia, Alzheimer's disease, and Major Depressive Disorder, did not have a stop date. The deficiency was identified during a record review and confirmed through an interview with the Director of Nursing, who acknowledged that the PRN Ativan order lacked a stop date. The resident in question had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 4/15 on their quarterly Minimum Data Set assessment. The absence of a stop date for the PRN Ativan order was a clear deviation from the facility's policy, which requires such orders to have a specified duration or stop date.
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.
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