Monument Healthcare And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsbluff, Nebraska.
- Location
- 111 West 36th Street, Scottsbluff, Nebraska 69361
- CMS Provider Number
- 285095
- Inspections on file
- 24
- Latest survey
- August 16, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Monument Healthcare And Nursing Center during CMS and state inspections, most recent first.
A resident who required pain management did not receive safe and appropriate care to address their pain, resulting in a deficiency related to pain management services.
A resident with metabolic encephalopathy experienced an unwitnessed fall resulting in a fractured nasal bone and lacerations requiring hospital treatment. While the State Agency was notified within 2 hours of the injury, the facility did not submit the required follow-up investigative report within 5 business days, as confirmed by the DON.
A resident with multiple medical conditions was administered both antipsychotic and opioid medications without adequate monitoring, documentation, or evaluation of necessity. The medications were given frequently, sometimes together, despite warnings about drug interactions, and there was no evidence of non-pharmacological interventions or timely provider review. The resident experienced cognitive and physical decline, and concerns raised by staff and the resident’s representative were not addressed, resulting in a deficiency related to unnecessary drug use.
A resident with mild cognitive impairment and multiple medical conditions was prescribed a PRN antipsychotic for behavioral symptoms without timely notification to their representative. Facility staff confirmed that notification of such medication changes is expected, but there was no documentation or evidence that the representative was informed, leading to a deficiency.
A resident with dementia, Alzheimer's, and depression exhibited ongoing aggressive and agitated behaviors, including altercations with a roommate and staff. Despite documented incidents and staff concerns about room assignments and behavioral triggers, the care plan contained only generic interventions and was not individualized. Staff reported poor communication from management and uncertainty about behavioral interventions, while the administrator confirmed the care plan was not tailored to the resident.
A resident with a chronic surgical wound did not consistently receive daily wound care as ordered by the physician. Documentation showed that dressing changes were missed on multiple days, and both the resident and an LPN confirmed that dressings were sometimes left unchanged for up to three days. The DON verified that the facility's expectation was for daily dressing changes, but this was not consistently followed.
A resident with dementia and a history of aggression was involved in multiple altercations with others, including a physical incident with a roommate and aggression during meals. Staff concerns about room assignments and behavioral triggers were not addressed by management, and recommendations from healthcare providers were not effectively implemented. The lack of a dedicated unit manager and insufficient oversight contributed to the facility's failure to provide adequate supervision and prevent accidents.
A resident with an open shoulder wound did not receive wound care according to the physician's order. The RN failed to apply the No-Sting barrier film and did not establish a clean field during the procedure. The RN confirmed the omission during an interview.
A facility failed to prevent cross-contamination during wound care for a resident with an open shoulder wound. A nurse did not establish a clean field or perform hand hygiene as required by facility policy. Additionally, the nurse did not follow the physician's order to use a no-sting barrier film, and used non-sterile gloves, compromising the sterile environment.
The facility failed to follow advance directives for CPR/DNR for three residents, leading to discrepancies in code status documentation. A resident listed as DNR in the code listing report had a signed directive for CPR, while two other residents with DNR orders were inaccurately listed as Full Code in the facility's code book. These inconsistencies resulted in an immediate jeopardy finding, later reduced after corrective actions.
The facility's dishwashing machine failed to reach the required temperatures for effective cleaning, posing a risk of foodborne illness to all residents. Observations showed the wash and rinse cycles were below the necessary minimums, and staff interviews revealed a lack of awareness about temperature requirements and the meaning of a blinking light indicating low detergent levels.
The facility failed to review pre-employment health screens for five staff members, risking the transmission of contagious diseases. Multi-use equipment like a Hoyer lift was not sanitized between uses, and the facility lacked a water management plan to prevent Legionella. The Infection Control Coordinator and Maintenance Director confirmed these deficiencies.
The facility failed to provide a clean and homelike environment, with missing baseboard trim, scuffed floors, and rough handrails in the 200 wing. In the 400 wing, a cracked television, stained carpets, peeling wallpaper, and exposed electrical panels were observed. These deficiencies were confirmed by the Maintenance Director, indicating an unsafe environment.
The facility failed to provide and document baseline care plans for four residents within 48 hours of admission, as required. These residents, with various medical conditions such as Hemiplegia, Encephalopathy, and Chronic Respiratory Failure, did not receive the necessary written summaries of their care plans. The Director of Nursing Trainer confirmed the absence of these documents and the lack of evidence that they were provided to the residents or their representatives.
The facility failed to ensure proper blood glucose testing procedures for several residents with diabetes. Staff did not adhere to the protocol of wiping away the first drop of blood before testing, potentially leading to inaccurate readings. Interviews confirmed a lack of awareness or adherence to this procedure among staff.
A long-term care facility failed to maintain a medication error rate below 5%, with observed errors involving insulin and eye drop administration. Errors included incorrect priming of insulin pens and improper application of eye drops, as confirmed by the DON. These procedural lapses contributed to a 16% medication error rate.
The facility failed to ensure staff competency in blood glucose testing and insulin pen use, as observed in three staff members. Staff did not follow procedures for wiping away the first drop of blood during glucose testing, potentially leading to inaccurate readings. Additionally, insulin pens were not primed correctly, risking incorrect insulin doses. The facility lacked adequate training and competency documentation for the staff involved.
A resident with no cognitive impairment repeatedly requested a bed bath instead of a shower, but the facility staff denied this preference, insisting on showers. The resident's care plan lacked documentation of bathing preferences, and despite the facility's policy to accommodate such preferences, the staff did not adhere to it, leading to multiple refusals by the resident.
A resident with severe cognitive impairment and multiple diagnoses experienced several unwitnessed falls due to the facility's failure to implement prescribed fall prevention measures. Despite recommendations for a scoop mattress, observations revealed the use of a regular flat mattress, and staff interviews indicated a lack of awareness about specific interventions. This led to the resident sustaining injuries requiring emergency treatment.
A facility failed to perform monthly medication reviews for a resident with complex medical needs, including diabetes and major depressive disorder, from September 2023 to February 2024. The resident was on multiple medications, and the absence of these reviews could have led to unaddressed medication irregularities. The Infection Control Coordinator confirmed the oversight in the required monthly reviews.
A facility failed to limit PRN antipsychotic medication to 14 days and did not inform a resident or their representative of the medication's risks and benefits. The resident, with multiple diagnoses including dementia, was receiving antipsychotic medications without a gradual dose reduction or psychiatric evaluation, and the PRN order for Haloperidol lacked a discontinuation date.
Medication aides in an LTC facility failed to follow proper insulin administration procedures, leading to significant medication errors for three residents with diabetes. The aides did not prime insulin pens correctly, as they held the pen with the needle tip downward instead of upward, which is necessary to remove air and ensure the correct dose. The Director of Nursing confirmed the facility's procedure was not followed.
The facility failed to maintain a pest-free environment, affecting all 75 residents. Flying insects were observed in the courtyard, where a resident was sitting. A wasp nest was found in a window frame, with multiple wasps present. A nurse confirmed residents use the courtyard but was unaware of insect issues. The Maintenance Director acknowledged the nest's presence for a week and had not exterminated it, despite monthly exterminator visits.
A facility failed to complete required background checks before allowing a Medication Aide to work with residents, violating their policy on abuse prevention. The employee worked several shifts before the Nebraska Central Registry Check was completed, exposing residents to potential risks.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards and addressed their pain appropriately. Specific details about the number of residents sampled or cited, as well as the resident's medical history or condition at the time of the deficiency, are not provided in the report.
Failure to Submit Timely Investigative Report After Resident Injury
Penalty
Summary
The facility failed to submit a required investigative report to the State Agency within 5 working days following a significant injury sustained by a resident. According to the facility's policy, any incident resulting in serious bodily injury must be followed by a detailed investigative report submitted to the state within the specified timeframe. In this case, a resident with a diagnosis of metabolic encephalopathy was admitted to the facility and subsequently experienced an unwitnessed fall, resulting in a fractured nasal bone and lacerations requiring stitches. The incident was documented, and the resident was transported to the hospital for treatment. Although the facility notified the State Agency within 2 hours of becoming aware of the resident's significant injury, there was no evidence that a follow-up investigative report was submitted within 5 business days as required. The Director of Nursing confirmed that the follow-up report was not sent, despite the policy and regulatory requirements. This omission constituted a failure to comply with state regulations regarding timely reporting of incidents involving serious injury.
Failure to Prevent Unnecessary Drug Use and Monitor Medication Interactions
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, as evidenced by the administration of multiple psychotropic and opioid medications without adequate monitoring or documented justification. The resident, who had a history of vertebral fracture, scoliosis, osteoarthritis, and depression, was prescribed risperidone (an antipsychotic) on an as-needed basis for behaviors, as well as multiple opioid medications for pain management. There was no documented stop date or duration for the risperidone, and the order included instructions to follow up with the primary health care provider, but there was no evidence of such follow-up or of regular evaluation of the continued need for the medication. The resident’s medical records showed frequent administration of both antipsychotic and opioid medications, sometimes concurrently, despite a black box warning regarding the risks of combining these drug classes. Documentation was lacking regarding the specific behaviors that prompted the use of the antipsychotic, and there was no evidence of non-pharmacological interventions for pain. Progress notes indicated a decline in the resident’s cognition and physical abilities, with concerns raised by both staff and the resident’s representative. Despite these concerns and requests for medication review, there was no documented evidence that the need for continued use of the antipsychotic or the potential drug interactions were addressed by providers. Interviews with staff and the resident’s representative confirmed that the resident experienced periods of significant cognitive and physical decline, which improved after changes to the medication regimen. The representative was not informed about the initiation of the antipsychotic and expressed concern about the resident’s decline. Staff acknowledged missed opportunities to evaluate for over-medication and potential drug interactions. The facility’s failure to monitor and evaluate the resident’s medication regimen, document the rationale for continued use, and communicate with the resident’s representative contributed to the deficiency.
Failure to Notify Resident Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident and their representative of a newly prescribed medication, specifically an antipsychotic, as required by policy and regulation. Record review showed that a resident with multiple diagnoses, including vertebral fracture, scoliosis, osteoarthritis, and depression, was admitted from a hospital and had mild cognitive impairment. The resident exhibited behavioral symptoms that disrupted care and required significant assistance with daily activities. On a specific date, the resident began yelling out in pain despite receiving pain medication and other interventions. The on-call provider was notified and prescribed Risperidone 0.25 mg every 12 hours as needed for behaviors, with instructions to follow up with the primary care provider. The medication was administered, and the resident's behavior calmed after about 30 minutes. However, there was no documented evidence that the resident or their representative was notified of the new antipsychotic medication. Interviews with the resident's representative confirmed they were not informed of the medication change until much later and would not have agreed to its use if notified. Facility staff, including an LPN and a unit manager, confirmed that the expectation is to notify representatives of such changes and acknowledged that this notification did not occur or was not documented.
Failure to Individualize Care Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement resident-specific interventions to address or minimize the behaviors of a resident with dementia, Alzheimer's disease, and depression. The resident had a history of moderate to severe cognitive impairment and minimal symptoms of depression, as documented in their assessments. Despite a care plan noting the potential for physical aggression related to dementia, the interventions listed were generic and not tailored to the resident's specific triggers or behaviors. Multiple incident and behavior notes documented ongoing aggressive and agitated behaviors, including verbal and physical altercations with a roommate and other residents, as well as aggression toward staff. Staff interviews revealed that concerns about placing two residents with histories of aggression in the same room were raised with the Social Services Director, but these concerns were dismissed, and staff felt their input was not sought or valued. Staff also reported a lack of communication from management regarding behavioral interventions and were unsure where to find documentation of such interventions for the resident. The Nursing Home Administrator confirmed a lack of awareness regarding staff concerns and acknowledged that the care plan was not individualized for the resident. Oversight of the unit was fragmented, with no dedicated unit manager, contributing to the lack of individualized care planning and communication among staff. The deficiency was identified through observation, record review, and staff interviews, highlighting the facility's failure to develop and implement a comprehensive, resident-specific care plan as required.
Failure to Perform Wound Care as Ordered
Penalty
Summary
The facility failed to perform wound care as ordered for one resident with a chronic surgical wound to the right shoulder. The resident's care plan and physician orders specified daily dressing changes, including cleansing with normal saline, application of a no sting barrier film, and covering with a silicon border dressing. However, documentation in the Treatment Administration Record (TAR) for March showed that dressing changes were completed only 20 out of 31 days. Interviews with the resident and an LPN confirmed that dressing changes were sometimes missed for up to three days, and dressings were occasionally found undated or dated from previous days. The resident involved had no cognitive impairment and required partial to moderate assistance with activities of daily living. The resident reported that the wound dressing was not always changed daily as ordered. The DON confirmed the discrepancy in the TAR and acknowledged that the facility expectation was for dressing changes to be completed as ordered, with missed treatments to be passed on to the next shift. The failure to follow the wound care orders as prescribed led to the identified deficiency.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision and Response to Behavioral Risks
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with a history of adverse behaviors. The resident in question had diagnoses including dementia, Alzheimer's disease, and depression, and was assessed as having moderate to severe cognitive impairment. Despite a care plan identifying the potential for physical aggression and interventions such as analyzing triggers and seeking psychiatric consultation, the resident was involved in multiple incidents of aggression toward others, including a physical altercation with a roommate and striking another resident during lunch. Staff interviews revealed that concerns were raised about placing two residents with histories of aggression in the same room, but these concerns were not addressed by facility management. Staff reported that their input regarding behavioral triggers and interventions was not solicited by the management team, and that the Social Services Director communicated that corporate priorities were focused on bed occupancy rather than resident safety. The memory support unit where the incidents occurred lacked a dedicated unit manager, and oversight was split between other managers, leading to staff feeling unsupported and overlooked. Documentation showed repeated behavioral incidents, including verbal and physical aggression, and recommendations from healthcare providers to change the resident's room assignment to reduce irritability. Despite these documented behaviors and provider recommendations, the facility did not implement effective interventions or adjust supervision to prevent further incidents, resulting in continued altercations and a failure to ensure a safe environment for all residents.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to perform wound care according to the provider's order for a resident with an open wound on their right shoulder. The resident was admitted with this condition, and the physician's order specified a detailed wound care regimen, including cleansing with normal saline or wound cleanser, applying a No-Sting barrier film, and covering with a silicone border dressing. This care was to be performed daily on the day shift and as needed for drainage or dislodgement. During an observation, a registered nurse (RN) did not follow the prescribed wound care procedure. The RN prepared the wound dressing without establishing a clean field and omitted the application of the No-Sting barrier film as ordered. Additionally, the RN had to retrieve forgotten supplies during the procedure, which interrupted the process. An interview with the RN confirmed the omission of the No-Sting barrier film, indicating a failure to adhere to the physician's order for wound care.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident with an open wound on their right shoulder. The facility's policy required staff to establish a clean field using a disposable cloth on the resident's overbed table and to perform hand hygiene at specific points during the procedure. However, during an observation, a registered nurse (RN) did not follow these protocols. The RN placed the wound dressing directly on the overbed table without establishing a clean field and did not perform hand hygiene after placing supplies on the table, after removing the soiled dressing, or after completing the wound care. Additionally, the RN did not adhere to the physician's order for the wound care procedure. The order specified the use of a no-sting barrier film, which the RN failed to apply. The RN also used non-sterile gloves obtained from the resident's bathroom and did not maintain a sterile environment throughout the procedure. These actions and inactions led to a deficiency in the facility's infection prevention and control program, as they increased the risk of cross-contamination during wound care.
Failure to Follow Advance Directives for CPR/DNR
Penalty
Summary
The facility failed to adhere to the advance directives for cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR) orders for three residents, leading to a deficiency. Resident 40 was listed as a DNR in the facility's code listing report, but their medical record and a signed advance directive indicated a preference for CPR and full treatment. This discrepancy was confirmed through interviews with the Unit Manager and the resident, who verified their choice for CPR. Resident 32's records showed a preference for DNR, as indicated in their resuscitation orders and care plan. However, the facility's code book inaccurately listed them as a Full Code, contradicting their documented wishes. Similarly, Resident 46 had a DNR order signed by their physician, but the facility's code book also incorrectly listed them as a Full Code, not reflecting their choice for no CPR. These discrepancies in code status documentation and the failure to follow residents' advance directives were identified during a survey, resulting in an immediate jeopardy finding. The facility's failure to ensure accurate and consistent documentation of residents' code statuses in their records and emergency crash carts led to the deficiency being cited at the immediate jeopardy level, which was later lowered after corrective actions were verified.
Removal Plan
- All residents' signed code status forms will be audited to ensure physician orders match resident preferences.
- Code status spreadsheet will be updated to reflect accurate and current code statuses for each resident.
- Social Services will contact residents without current code status preferences and discuss resident or representative wishes related to code status.
- The Admissions Department will verify and obtain code statuses prior to admission with responsible party.
- Current code status forms will be placed in the code status binder and placed inside crash cart.
- Director of Nursing (DON) will start in-services regarding: Code status policy, Code status spreadsheet, Code status form: DNR/Full Code/Do Not Hospitalize (DNH), Identifying a resident's code status, Education will be provided to all staff currently on duty and prior to any staff coming off duty.
- Resident profile and code status icon on PCC will be audited and updated with current resident wishes related to code status by Unit Managers or designee weekly or upon admission or re-admit.
- Social Services will audit code status book weekly to ensure code statuses for residents are accurate.
- Admissions Department will audit code status forms received and obtained from hospital records weekly for new residents.
- New admissions will be reviewed during clinical meetings to discuss and determine resident code statuses.
- Auditing results will be submitted to Quality Assurance and Performance Improvement (QAPI) and addressed as appropriate.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility staff failed to ensure that the dishwashing machine reached the required temperatures necessary to prevent potential foodborne illness, affecting all residents who consumed food from the kitchen. Observations revealed that the dishwasher's wash cycle temperature was 145 degrees Fahrenheit, and the rinse cycle was 163 degrees Fahrenheit, both below the required minimums of 160 and 180 degrees Fahrenheit, respectively. Interviews with dietary aides and maintenance personnel indicated a lack of knowledge regarding the dishwasher's temperature requirements and the significance of a blinking light on the dishwashing monitor, which signaled low detergent levels. The facility had a census of 75 residents at the time of the observation.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to ensure that pre-employment health history screens were reviewed to prevent the potential transmission of contagious diseases for five staff members. The records for Medication Aide-E, Maintenance Worker-H, Nurse Aide-F, Transportation Driver, and Medication Aide-G all showed that their Employee Health Screening forms were not reviewed or signed by a Registered Nurse, as required. The Human Resources department confirmed that these forms were placed in employee files without being reviewed by nursing staff to assess for potential communicable diseases. Additionally, the facility did not ensure that multi-use equipment, such as a Hoyer lift, was sanitized between uses. Observations revealed that Medication Assistants did not sanitize the Hoyer lift after using it with different residents. The Infection Control Coordinator stated that cleaning multi-use equipment should be done between uses by the nursing department. Furthermore, the facility lacked a water management plan to prevent waterborne illnesses, such as Legionella. The Maintenance Director confirmed that there were no measures or monitoring processes in place to prevent the growth of Legionella, and there was no documentation or communication regarding a water management plan.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by several deficiencies observed during a survey. In the 200 wing, the baseboard trim was missing, exposing unfinished and flaking drywall, and there was a visible buildup of gray-black substance in the cracks where the trim was absent. The tile floor was scuffed and stained, with yellow-brown buildup along the edges. Additionally, the wooden handrail was rough and porous due to the varnish wearing off, changing its color from light tan to white-gray. In the 400 wing, the commons sitting area had a television with a splintering crack, rendering part of the screen non-functional. The floor trim was missing, exposing soiled underlayment. The hallway carpet had multiple large stains, and the wallpaper was peeling. An electrical panel had crumbling spackling and warped wallpaper, while the dining room ceiling had reddish-brown stains and a loose electrical outlet. The window was obstructed by a white-gray film and old tape. These issues were confirmed by the facility's Maintenance Director, indicating an unsafe and un-homelike environment.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was reviewed with the resident or their representative and that a copy was provided to them within 48 hours of admission. This deficiency was identified for four residents during the review. The baseline care plan is crucial as it includes instructions needed to provide effective, person-centered care for residents until a comprehensive care plan is developed. For Resident 22, who was admitted with diagnoses including Hemiplegia following a stroke, Pneumonia, and Parkinson's Disease, there was no baseline care plan identified in the medical record. Additionally, there was no documentation that the resident or their representative received a written summary of the baseline care plan. The Director of Nursing Trainer (DONT) confirmed the absence of these documents and the lack of evidence that the required information was provided to the resident or their representative. Similar deficiencies were found for Residents 127, 23, and 13, each with their own set of medical conditions. Resident 127, admitted with Encephalopathy, Severe Malnutrition, and Acute Kidney Failure, also lacked a baseline care plan and documentation of its provision to the resident or representative. Resident 23, with Chronic Respiratory Failure and Severe Obesity, and Resident 13, with Malnutrition and Transient Ischemic Attacks, similarly had no baseline care plans or documentation of their provision. In each case, the DONT confirmed the absence of these critical documents and the failure to provide them to the residents or their representatives.
Improper Blood Glucose Testing Procedures
Penalty
Summary
The facility failed to ensure that staff performed blood glucose testing in accordance with current professional standards for five residents diagnosed with diabetes. The deficiency was identified through observations, record reviews, and interviews, revealing that staff did not follow the proper procedure for blood glucose testing. Specifically, the staff did not wipe away the first drop of blood and obtain a second drop for testing, as required by the facility's procedure. For Resident 47, the medication aide did not follow the procedure of wiping away the first drop of blood before testing, resulting in a blood sugar reading of 130. This was documented in the Medication Administration Record (MAR) for the resident, who had an order for sliding scale insulin. Similar observations were made for Residents 40, 48, 21, and 1, where the staff failed to wipe away the first drop of blood before applying it to the glucometer test strip, leading to potentially inaccurate blood sugar readings. Interviews with the Director of Nursing and the medication aides confirmed that the staff were either unaware or did not adhere to the procedure of using the second drop of blood for testing. The Director of Nursing acknowledged that not following this procedure could result in inaccurate blood sugar readings, which are critical for residents with diabetes who require precise insulin dosing.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16%. This was identified through multiple observations of medication administration errors involving insulin pens and eye drops. The errors were primarily due to incorrect procedures followed by medication aides during insulin administration, such as not priming the insulin pen correctly by holding the needle tip upward and failing to apply the needle before priming. Additionally, there was an error in administering eye drops, where the medication was not placed in the lower eyelid as required. One specific incident involved a resident with diabetes who was supposed to receive 6 units of Lispro insulin. The medication aide did not prime the insulin pen correctly and failed to apply the needle before priming, leading to a medication error. Another resident with diabetes was observed receiving 2 units of Lispro insulin, but the medication aide again did not prime the pen correctly by holding the needle tip downward instead of upward. These procedural errors were confirmed by the Director of Nursing, who reiterated the correct steps for insulin administration. In another case, a medication aide incorrectly administered Systane eye drops to a resident by placing the drops on the top of the eyelid instead of pulling down the lower eyelid and placing the drop in the lower eyelid pocket. This resulted in the eye drop not being administered correctly, as confirmed by the Director of Nursing. These errors highlight the facility's failure to adhere to established procedures for medication administration, contributing to the high medication error rate.
Deficiency in Staff Training and Competency for Blood Glucose and Insulin Administration
Penalty
Summary
The facility failed to ensure that staff received adequate training and competency assessments for obtaining resident blood glucose levels and using insulin pens, as observed in three staff members. This deficiency was identified through observations, record reviews, and interviews. The facility's procedure for measuring blood glucose using a handheld glucometer requires staff to wipe away the first drop of blood and use the second drop for testing to ensure accuracy. However, staff members did not follow this procedure, potentially leading to inaccurate blood sugar readings. In one instance, a medication aide did not wipe away the first drop of blood when checking the blood glucose level of a resident with diabetes, resulting in a documented blood sugar reading of 130. The Director of Nursing confirmed that the expectation is for staff to follow the procedure to ensure accurate readings. Additionally, the facility's competency checklist for insulin administration did not include steps for using an insulin pen, and the medication aide did not prime the pen correctly, which could lead to incorrect insulin doses. Another medication aide also failed to follow the correct procedure for blood glucose testing and insulin pen use. The aide did not wipe away the first drop of blood and did not prime the insulin pen correctly. The facility was unable to provide adequate training or competency documentation for the staff involved, and the Director of Nursing was unsure of the timeframe for competency assessments. This lack of proper training and assessment could result in potential harm to residents with diabetes due to inaccurate blood sugar readings and incorrect insulin administration.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 27, who was cognitively intact with a BIMS score of 15. Despite the resident's request for a bed bath, the facility staff insisted on showers, which the resident consistently refused. The resident's care plan did not document any preferences regarding bathing methods, and the facility's policy required that such preferences be accommodated. Interviews with staff revealed that the resident's request for a bed bath was denied, and the staff believed that bed baths would not adequately clean the residents. Documentation in the Hall Bath Book and the electronic medical record showed multiple instances of the resident refusing scheduled showers, with no evidence of alternative arrangements being made. The facility's policy stated that if a resident refused a bath due to a preference for a different method, such as a bed bath, the preference should be accommodated. However, the facility did not adhere to this policy, resulting in a failure to support the resident's right to self-determination and choice in their care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately investigate and implement interventions to prevent falls for Resident #24, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident experienced several unwitnessed falls over a period of time, with documented incidents on specific dates. Despite the resident's severe cognitive impairment and dependence on staff for mobility and toileting, the facility did not consistently apply the prescribed interventions to mitigate fall risks. Observations and interviews revealed discrepancies in the implementation of fall prevention measures. Although a scoop mattress was recommended as an intervention, the resident's bed was found to have a regular flat mattress on multiple occasions. Additionally, staff interviews indicated a lack of awareness regarding the specific interventions required for the resident, such as the use of a scoop mattress. This inconsistency in applying fall prevention strategies contributed to the resident sustaining a hematoma and laceration requiring emergency room treatment after a fall.
Failure to Conduct Monthly Medication Review
Penalty
Summary
The facility failed to ensure a monthly medication review (MRR) was performed for a resident, identified as Resident 37, which is a requirement to minimize or prevent adverse consequences or unnecessary drug administration. The record review revealed that Resident 37, who was admitted with diagnoses including diabetes, hypertension, and major depressive disorder, did not have MRRs completed for several months, specifically from September 2023 to February 2024. This oversight had the potential for significant medication irregularities to go unidentified, as the resident was on multiple medications, including insulin, antipsychotic, antianxiety, antidepressant, and antiplatelet medications. The care plan for Resident 37 indicated the use of diuretic therapy, which could cause dizziness, hypotension, fatigue, and increased risk for falls. The resident's care plan also noted an increase in antipsychotic medication due to increased anxiety. Despite these complexities in the resident's medication regimen, the facility did not conduct the required monthly reviews for several months, as confirmed by the facility's Infection Control Coordinator, who is responsible for following up on MRRs. This lapse in protocol could have led to unaddressed medication issues, as previous MRRs had noted recommendations for medication adjustments.
Failure to Limit PRN Antipsychotic Use and Inform Resident
Penalty
Summary
The facility failed to ensure that as-needed antipsychotic medications were limited to 14 days of use and that residents or their representatives were informed of the risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. This deficiency affected one resident, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident was severely cognitively impaired, requiring assistance with daily activities, and was receiving antipsychotic medications without a gradual dose reduction being attempted or documented as clinically contraindicated. The resident's care plan indicated a potential for verbal and physical aggression, wandering, and care rejection, with interventions including medication administration, offering choices, and psychiatric evaluation. However, there was no documentation of behaviors in July 2024, and the resident's as-needed Haloperidol order lacked a 14-day discontinuation date. The Assistant Director of Nursing confirmed the indefinite use of Haloperidol and acknowledged that the resident had not been seen by a psychiatric provider as planned, nor were the resident or their representative informed about the antipsychotic medication's risks and benefits.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that staff administered insulin correctly, leading to significant medication errors for three residents with diabetes. The errors were observed during insulin administration by medication aides who did not follow the proper procedure for priming insulin pens. Specifically, the aides did not hold the insulin pen with the needle tip upward while priming, which is necessary to remove air and ensure the correct dose is administered. For Resident 40, the medication aide did not apply the needle before priming the pen and attempted to administer insulin without proper priming, resulting in a failed injection attempt. The aide then replaced the needle but did not prime the new needle before administering the insulin. Similarly, for Resident 48, the medication aide primed the pen with the needle tip downward, contrary to the required procedure, before administering the insulin. Resident 16 also experienced a similar error, where the medication aide primed the pen incorrectly by holding the tip downward. The Director of Nursing confirmed that the facility's procedure requires the needle to be applied before priming and the pen to be held with the needle tip upward during priming. These observations indicate a failure to adhere to the established insulin administration protocol, resulting in significant medication errors for the residents involved.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, which had the potential to affect all 75 residents residing in the facility. During an observation, flying insects were seen gathering in the corner of a window in the courtyard, across from two rooms. A resident was observed sitting in their wheelchair in the gazebo in the courtyard area. A wasp nest, approximately the size of a softball, was present in the upper right-hand corner of the window frame, with multiple wasps visibly crawling on the nest and flying to and from it. In an interview, a registered nurse confirmed that residents frequently use the courtyard to enjoy the flowers and weather but denied awareness of any issues with flying insects. The Maintenance Director confirmed the presence of the active wasp nest, which had been observed about a week prior, and admitted not having had the time to exterminate the wasps. The Maintenance Director also stated that the exterminator visits monthly for pest and insect control and acknowledged that the active wasp nest posed a potential hazard to residents wishing to use the courtyard.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to ensure that background checks were completed prior to staff working in the facility, which is a violation of their policy on abuse, neglect, exploitation, and misappropriation prevention. The policy mandates that the facility conduct employee background checks and not employ individuals with findings of abuse, neglect, exploitation, or related offenses. However, a review of the employee file for a Medication Aide (MA-E) revealed that the Nebraska Central Registry Check was completed 13 days after the hire date, during which time the employee had already worked with residents. The facility's hiring process checklist requires a Nebraska state-specific APS/CPS Registry Check to be completed, but this was not done before MA-E began working. The timecard report showed that MA-E attended orientation and worked several shifts before the background check was completed. An interview with the facility's Human Resources confirmed that the Central Registry check was not completed before MA-E started working with residents, exposing the facility to potential risks of abuse and neglect.
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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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