Northfield Retirement Communities Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsbluff, Nebraska.
- Location
- 2100 Circle Drive, Scottsbluff, Nebraska 69361
- CMS Provider Number
- 285271
- Inspections on file
- 19
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Northfield Retirement Communities Care Center during CMS and state inspections, most recent first.
Multiple residents with known fall risks, cognitive impairment, and mobility limitations experienced repeated falls, including unwitnessed falls and falls with major injuries, because staff did not consistently identify fall causes or implement effective interventions. One resident on anticoagulants with delirium and intermittent confusion self-transferred to the bathroom and later self-transferred again, sustaining head and fracture injuries, while a bed alarm cited in the fall investigation was never added to the care plan. Another cognitively impaired resident with dementia and agitation had numerous falls from a w/c and recliner despite dycem and a gel cushion, with fall reports lacking immediate preventive measures and the daily pocket care plan omitting key fall interventions. A third resident with a history of sliding from seating had multiple falls from a w/c and recliner, with inconsistent fall documentation, delayed addition of an intervention that would have required 1:1 supervision, and conflicting care-plan directions about seating after meals. A fourth resident with a BKA and dependence on a mechanical lift had repeated falls from bed and was repeatedly observed sitting on the edge of an elevated bed, while the care-planned low-bed intervention was not included in the pocket care plan or other tools used by NAs and nurses, and staff knowingly did not keep the bed low during meals.
The facility failed to submit complete and thorough investigative reports to the State Agency for two residents who sustained major injuries from falls. In one case, a resident fell in their room, resulting in head laceration and fractures of the wrist and femur, and the report submitted attributed the fall to non-compliance with transfers but omitted documented post-hospital interventions. In the other case, a resident had an unwitnessed fall in a sitting area, leading to facial lacerations and a fractured nose, and the report submitted lacked a thorough investigation of the circumstances surrounding the fall.
The facility did not ensure an RN was on duty for at least 8 consecutive hours each day as required, with multiple days lacking RN coverage due to staffing shortages and absences, despite having procedures in place to address such gaps.
Surveyors found spoiled grapes and a tomato with mold in the walk-in refrigerator, and staff lacked a process for monitoring and disposing of fresh produce. The dietary policy addressed checking expiration dates for packaged foods but did not include guidance for fresh fruits and vegetables. The CDM confirmed these items should have been discarded immediately.
A review of staff records revealed that several new employees did not have documented completion of required orientation training on topics such as resident rights, emergency procedures, dementia care, and medical emergency directives. This lack of training documentation was confirmed by HR and had the potential to impact all residents in the facility.
The facility did not ensure that nurse aides and medication aides completed the required annual training hours, including specific training on abuse/neglect and dementia care. Record reviews showed that sampled staff had not met the mandated training requirements, with some training hours unrelated to their job duties and insufficient or missing dementia and abuse/neglect education. This deficiency had the potential to impact all residents in the facility.
Nursing staff did not inform the medical provider about a resident's repeated high blood pressure readings, despite facility policy requiring notification for significant changes in condition. The resident, who had a history of hypertension and other health issues, had multiple elevated BP measurements over several weeks without any documented physician notification. The DON confirmed that staff failed to act on these abnormal values.
Two residents receiving psychotropic medications did not have gradual dose reductions (GDRs) attempted or clinical rationales documented for not attempting GDRs. One resident with dementia and anxiety was prescribed mirtazapine and quetiapine, and a pharmacist's recommendation for a GDR was not addressed by the physician. Another resident with major depression and behavioral symptoms was prescribed Lexapro, but there was no evidence of a GDR attempt or documented rationale. The DON confirmed that GDRs were only considered if recommended by the pharmacist, and no documentation existed for these cases.
A resident with multiple complex medical conditions and significant care needs was admitted without a baseline care plan (BCP) being developed within 24 hours, as required by state regulation. The facility's policy allowed for BCP development within 48 hours, which did not meet the regulatory requirement, and no BCP was found in the resident's record. The DON confirmed the omission during an interview.
A resident with multiple chronic conditions did not receive bumetanide as ordered by the physician, with several doses missed or only partially administered due to medication unavailability and order clarification issues. Nursing documentation showed ongoing symptoms and a decline in condition, and the DON confirmed the medication should have been administered as ordered.
A resident with Parkinson's Disease developed painful contractures in both hands, but staff did not provide or document any interventions, therapy, or monitoring to address the contractures. The care plan referenced the contractures only in relation to nutrition and ADL assistance, with no specific interventions implemented. Interviews with PT and the DON confirmed the absence of interventions or documentation regarding the management of the contractures.
A resident with a supra pubic catheter and history of urinary retention was prescribed a long-term prophylactic antibiotic without clear clinical indicators or documented rationale for its continued use. Nursing staff questioned the necessity of the antibiotic, and the only justification provided was 'UTI prophylactic,' with no stop date specified in the order.
A facility did not provide a written summary of a baseline care plan to a resident within 48 hours of admission, as required by policy. The policy mandates that a baseline care plan be developed and a summary provided to the resident or their representative. A review of the resident's records showed no evidence of the summary being provided, which was confirmed by the Social Services Director.
The facility did not notify the State Agency of a change in administrator within the required 5 working days. The change occurred, but the notification was sent nearly a month later. This delay was confirmed in an interview with the Administrator and had the potential to affect all 51 residents.
The facility failed to adhere to the recipe for Turkey Tetrazzini, as Cook-K was unable to find the scale and estimated the portions of spaghetti noodles and turkey. This deviation from the recipe potentially affected the nutritive value of the meal for all 47 residents.
The facility failed to ensure proper food storage and sanitation, affecting all 47 residents. Expired food items were found, and some lacked proper labeling. Improper storage practices included food on the floor and raw meat next to uncovered ice cream. Sanitation issues were noted, with debris on shelves and buildup around the ice machine. Staff confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and lacked a comprehensive water management program to prevent Legionella growth. The resident had no signage or PPE indicating precautions, and the facility only used standard precautions unless a resident had an MDRO. The Plant Director confirmed the absence of a detailed water system assessment and monitoring measures.
The facility failed to provide the required CMS-10055 form to three residents, as mandated by their policy. The Minimum Data Set Coordinator found that the correct form was not available, and instead, an incorrect form was used. This issue was confirmed during an interview, highlighting a systemic problem in notifying residents about potential non-coverage of services.
The facility failed to ensure monthly medication regimen reviews by a licensed pharmacist for three residents, as required by policy. These residents, with various medical conditions including hypertension and dementia, had no documented reviews or physician evaluations of pharmacist recommendations since admission. The Director of Nursing confirmed the lack of documentation.
A resident's oxygen concentrator was left on and unattended, with the nasal cannula placed on the bed, contrary to the facility's oxygen safety protocols. The resident was not present in the room, and the Director of Nursing confirmed the oversight.
A resident with severe cognitive impairment and a diagnosis of pain did not receive consistent pain management in a LTC facility. Despite having an order for acetaminophen as needed, the medication was not offered during multiple documented instances of pain. The facility's policy required standardized pain assessments, but interventions were not consistently implemented, leading to unmanaged pain. Interviews with staff confirmed the responsibility for pain assessments, yet the prescribed medication was not administered as needed.
A facility failed to limit PRN antipsychotic medication use to 14 days and lacked documented rationale for continued use for a resident with dementia and anxiety. The resident had an ongoing PRN order for Seroquel without a stop date or duration, and no recent physician documentation was found. Interviews with the DON confirmed these deficiencies.
The facility exceeded the acceptable medication error rate with an 11.11% error rate due to improper crushing of medications. A Medication Aide crushed medications that should be swallowed whole, affecting two residents. The aide confirmed the practice of crushing all tablet medications, leading to errors with Potassium Chloride, Ferrous Sulfate, and Enteric Coated Aspirin.
The facility failed to conduct required background checks and nurse aide registry verifications for five employees, including a Dietary Aid and a Nurse Aide. A Medication Aide with a negative criminal background finding was hired without documented rationale. Human Resources confirmed these oversights, which could potentially affect all 47 residents.
Failure to Implement and Communicate Effective Fall-Prevention Measures for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify causal factors for falls and to implement and communicate effective fall-prevention interventions for multiple residents with known fall risks. One resident with congestive heart failure, atrial fibrillation, dizziness, and intermittent confusion was admitted requiring one-person assist with a walker and gait belt in the room and a wheelchair outside the room. This resident was on anticoagulants and later had a care plan problem for delirium with fluctuating cognition and confusion. The resident experienced an unwitnessed fall in the bathroom after going alone without using the call light, resulting in a head hematoma and subsequent hospital admission for a brain bleed. The care plan contained general fall interventions such as non‑slip footwear, environmental safety, night light, and dycem, and later added a sign to call for assistance and frequent checks, but the resident was known to refuse to use the call light due to embarrassment and was toileted about every two hours. A subsequent fall occurred when the resident was self‑transferring, with major injury including a left femur and wrist fracture and a scalp laceration. The fall investigation cited environmental factors and a bed alarm as an immediate measure, but there was no evidence in the care plan that a bed alarm was actually implemented, and the investigation did not identify why the resident was self‑transferring. Another resident with unspecified dementia with psychotic disturbance, generalized anxiety disorder, restlessness, agitation, severe cognitive impairment, and impaired cognition, mobility, and safety awareness had multiple falls over a short period. These included falls from a wheelchair in the dining room, from a wheelchair with head impact, from a recliner while self‑transferring, and from a wheelchair during a fire drill despite dycem and a gel cushion. The care plan listed interventions such as environmental safety, bed in lowest position, dycem and gel cushion in wheelchair, not leaving the resident alone in the dining room, dycem to recliner, a different lower wheelchair, and routine checks with recognition that the resident did not use the call light. However, the daily pocket care plan used by staff did not include these fall interventions. Fall event reports for several of the falls documented no immediate measures to prevent future falls, and one investigation recorded “I don’t know” as the root cause, with only first aid and rest noted. Progress notes did not document reevaluation of interventions or attempts at different strategies despite repeated falls, and staff confirmed that existing interventions were not successful and that confused residents could not be educated. A third resident with a long‑standing fall care plan and a history of sliding from wheelchair and recliner had multiple falls from wheelchair and recliner, including events in common areas and the hall, with injuries requiring emergency room evaluation and sutures. The care plan contained numerous interventions over time, such as keeping the bed low and locked, frequent checks, dycem on wheelchair, avoiding the recliner, placing the resident in bed after meals, placing food within reach, and not leaving the resident alone in the wheelchair with increased checks. Fall documentation for one event showed inconsistent accounts of when the resident was last toileted and last checked, with one page signed by a dietary aide who would not have known those details. The intervention “do not leave alone in wheelchair, increase checks” was recognized by the MDS nurse as effectively requiring 1:1 supervision, which the facility could not sustain, and this intervention was not added to the care plan until 11 days after the fall review. Staff also confirmed that the care plan contained conflicting guidance about whether to keep the resident in the common area or put them in bed after meals. A fourth resident with a left below‑knee amputation, dependence on staff and a mechanical lift for transfers, extensive assist needs for turning and positioning, and a history of falls had multiple documented falls, including being lowered to the floor during transfer, sliding out of a recliner, falling out of bed, and being found in the doorway after crawling from bed. The care plan included an intervention to keep the bed in the lowest position with brakes locked, later reiterated after falls, and a fall checklist documented that the resident had been in bed five minutes before being found on the floor in the doorway. Observations on the survey date showed the resident repeatedly sitting on the edge of an elevated bed with legs dangling several inches above the floor while eating and reading, with an overbed table in front, and multiple staff entering and leaving the room without lowering the bed. The bed was only observed in low position briefly before being raised again while the resident sat on the edge. Staff interviews confirmed that the bed was not kept in low position at mealtimes because it was considered uncomfortable for the resident, and that nurse aides did not have access to care plans and instead used a pocket care plan that did not include the low‑bed intervention. Nurses also relied on other documents that did not contain the low‑bed requirement, resulting in the care‑planned fall intervention not being communicated or implemented in daily practice. Across these residents, the facility’s fall investigations often lacked clear identification of root causes, did not consistently document or implement immediate measures, and failed to ensure that care‑planned interventions were reflected in the tools actually used by direct care staff. In some cases, interventions were delayed, internally inconsistent, or not feasible given staffing patterns, and documentation about key details such as last toileting or checks was inconsistent or completed by staff who would not have known the information. These actions and omissions led to repeated falls, including unwitnessed falls and falls with major injuries, in residents with known fall risks and documented histories of confusion, impaired safety awareness, and mobility limitations.
Incomplete Investigative Reports Submitted After Falls With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to submit comprehensive investigative reports to the State Agency for two residents who experienced falls with major injuries. Facility policy on Abuse, Neglect, Exploitation and Misappropriation Prevention, revised April 2021, required the facility to investigate and report any allegations within timeframes required by federal requirements. For one resident admitted on an unspecified date and discharged on 2/22/2026, progress notes dated 2/20/2026 documented a fall on 2/19/2026 that resulted in a laceration to the left side of the head, a left wrist fracture, and a left femur fracture. The Investigation Report dated 2/24/2026 described the incident and stated that no permanent measures were put into place to prevent recurrence, noting that the resident was admitted to the hospital and that the family elected not to have surgery due to a heart condition. The outcome section attributed the fall to the resident being non-compliant with transfers, attempting to self-transfer, and not calling for assistance. The Director of Nursing confirmed that this Investigation Report was the document submitted to the State Agency and that it did not contain information regarding interventions implemented after the resident returned from the hospital, despite such information existing. For another resident admitted on an unspecified date and discharged on 10/17/2025, progress notes dated 10/3/2025 documented an unwitnessed fall in a sitting area that resulted in a laceration on the nose requiring sutures and a subsequent diagnosis of a fractured nose. A facility document labeled “October 2025 Reportable” described the incident timeline and indicated that a fall committee would meet to discuss current interventions and decide on modifications, and that staff would increase checks on rounds while the resident was in bed and that the resident was not to be left in a wheelchair without supervision. The DON confirmed that the investigative report submitted to the State Agency for this fall did not contain a thorough investigation into the resident’s fall.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by Nebraska Revised Statute 71-6018.02(2)(a). Record reviews of Payroll-Based Journal Staffing Data Reports and facility-provided timecards revealed multiple days within several months where there was no evidence of RN coverage for the required hours. Specifically, the facility lacked RN hours on several dates, including 8/10/2024, 8/11/2024, 9/22/2024, 2/8/2025, 2/15/2025, 2/16/2025, 4/5/2025, 4/6/2025, and 4/12/2025. These findings were confirmed through interviews with facility staff, including the Nurse Consultant and the Nursing Home Administrator. The facility had a census of 45 residents at the time, and the absence of RN coverage was attributed to factors such as vacations and unexpected staffing turnovers. The process in place for ensuring RN coverage involved scheduling an RN for at least 8 consecutive hours daily and attempting to find replacements in the event of callouts or shortages. Despite these procedures, the facility was unable to provide documentation of RN coverage on the identified dates, resulting in noncompliance with the regulatory requirement.
Failure to Dispose of Spoiled Produce in Kitchen Storage
Penalty
Summary
The facility failed to properly identify and dispose of spoiled fruits and vegetables stored in the walk-in refrigerator, as observed during a kitchen tour. Two bags of grapes with a greenish black fuzzy substance and a cloudy light greenish liquid, as well as a tomato with a fuzzy greenish black substance around the stem, were found in the refrigerator. The facility's dietary policy required staff to check expiration dates and discard expired foods, but did not provide guidance on monitoring or disposing of fresh fruits and vegetables. The Certified Dietary Manager confirmed that these spoiled products should not have been present and acknowledged that staff only check foods with expiration dates, with no clear process for monitoring fresh produce. This deficiency had the potential to affect all 45 residents in the facility.
Failure to Provide Required Initial Staff Training
Penalty
Summary
The facility failed to implement an effective initial training program for new employees, as evidenced by missing documentation of completed orientation training for three out of five sampled staff members. Specifically, a dietary aide had no evidence of completing initial orientation training on resident rights, emergency procedures, or dementia. Additionally, a nurse aide and a medication aide had no documentation of completed training on dementia or medical emergency directives. These findings were confirmed through personnel record reviews and an interview with Human Resources. The facility's own assessment tool rated training on abuse, neglect, emergency preparedness, and resident rights as high priority, and dementia training as medium priority, but there was no evidence of the importance of training regarding medical emergency directives. The lack of documented training for these staff members had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Provide Required Ongoing Training for Nurse Aides and Medication Aides
Penalty
Summary
The facility failed to ensure that nurse aides and medication aides completed the required ongoing training, including at least 12 hours per year on topics appropriate to their job duties, abuse/neglect training, and a minimum of 4 hours of dementia training. Record reviews for five sampled staff members showed significant deficiencies in completed training hours and content. For example, one aide completed only 1.75 hours of ongoing training with no evidence of dementia training, while another completed 3 hours, with some training unrelated to their job duties and no dementia training. Other aides had partial completion of required hours, with minimal or no dementia or abuse/neglect training documented. The facility's own assessment tool identified nurse aide education on abuse and neglect as a high priority and dementia training as a medium priority, but did not specify time requirements for ongoing training. An interview with the Nurse Consultant confirmed that the facility had not met the required ongoing training standards for the sampled staff. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Notify Physician of Elevated Blood Pressure Readings
Penalty
Summary
Nursing staff failed to notify the medical provider of a resident's consistently elevated blood pressure readings over a period of several weeks. The facility's policy required nurses to inform the physician or on-call physician in situations where there was a need to alter medical treatment or when a significant change in the resident's physical, emotional, or mental condition occurred. Despite multiple blood pressure measurements that were significantly above normal parameters, there was no documentation in the nursing progress notes that the physician had been notified. The resident involved had a history of dementia, hypertension, cognitive communication deficit, anxiety, and chronic pain, and was under an active order for blood pressure and pulse monitoring twice daily, with instructions to recheck if out of parameters. However, the care plan and physician orders did not specify a recommended blood pressure range or parameter. The Director of Nursing confirmed that staff did not notify the medical provider of blood pressure values outside the resident's baseline and acknowledged that additional blood pressure measurements should have been taken to ensure the resident's well-being.
Failure to Attempt or Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) were attempted or that clinical rationales for not attempting GDRs were documented for two residents receiving psychotropic medications. For one resident with dementia, anxiety, drug-induced dyskinesia, and chronic pain, active orders for mirtazapine and quetiapine were in place. The consultant pharmacist recommended considering a GDR for one of the medications, but there was no documented response from the physician, nor was there any clinical rationale provided for not attempting a GDR. The Director of Nursing confirmed that no GDR was attempted and no rationale was documented. For another resident with major depression and significant behavioral symptoms, including disorganized thinking and physical behaviors towards others, there was an active order for Lexapro. The care plan indicated that a drug reduction would be done as recommended by the pharmacist and approved by the physician. However, the medical record contained no evidence that a GDR was attempted or that a clinical rationale for not attempting a GDR was documented. The DON stated that GDRs are only completed if identified by the pharmacist during monthly reviews, and confirmed the absence of documentation for this resident.
Failure to Develop Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 24 hours of admission for one resident, as required by state regulation. A review of the facility's policy indicated that BCPs were to be developed within 48 hours, which does not meet the 24-hour requirement. There was no evidence in the medical record that a BCP was created for the resident, and this was confirmed by the Director of Nursing during an interview. The resident involved had multiple complex medical conditions, including dementia with severe cognitive impairment, pressure-induced deep tissue injury, Refsum's disease, pain, acute kidney failure, a history of blood clots, atrial fibrillation, hypertension, depression, anxiety, urinary retention, and abnormal weight loss. The resident required significant assistance with activities of daily living, had a urinary catheter, was always incontinent of bowel, had a history of falls, required a mechanically altered diet, had multiple pressure ulcers, and was on several medications including an antidepressant, anticoagulant, antibiotic, and opioid. Despite these needs, no BCP was developed to address the resident's immediate health and safety needs within the required timeframe.
Failure to Administer Ordered Medication as Prescribed
Penalty
Summary
The facility failed to follow physician's orders for a resident with multiple complex medical conditions, including lobar pneumonia, heart failure, COPD, diabetes type 2, and chronic pulmonary edema. After returning from a hospital stay for respiratory failure and pneumonia, the resident experienced significant weight gain and edema, prompting the physician to order bumetanide, a diuretic, with specific dosages and administration times. Despite these orders, the medication administration record showed several missed doses of bumetanide due to reasons such as waiting for delivery, drug unavailability, and the need for order clarification. In some instances, only partial doses were given, and at other times, the medication was placed on hold. The nursing progress notes documented ongoing symptoms, including persistent edema, shortness of breath, and a decline in the resident's physical condition. The Director of Nursing confirmed that the medication should have been obtained from the contracted or back-up pharmacy and administered as ordered. The resident was eventually placed on comfort care and subsequently died. The deficiency centers on the facility's failure to provide treatment and care according to physician orders, as evidenced by the missed and incomplete administration of prescribed medication.
Failure to Provide Care and Interventions for Hand Contractures
Penalty
Summary
A resident with a primary diagnosis of Parkinson's Disease developed contractures in both hands, which were observed to cause pain and limit the ability to perform certain tasks. The resident reported that staff were not providing any interventions or therapy related to the contractures, and denied receiving services from physical therapy, occupational therapy, or floor staff for this issue. Review of the resident's records showed that earlier Minimum Data Set (MDS) assessments did not indicate any functional limitations, but a later MDS documented functional limitations in both upper and lower extremities, indicating the presence of contractures. The care plan for the resident included a focus on nutrition, noting the risk related to hand contractures and the offer of adaptive silverware, which the resident refused. However, there was no documented evidence of other interventions for the contractures. The care plan also addressed ADL assistance due to contractures, instructing staff to observe for decline and notify the physician or therapy as needed, but lacked specific interventions to address or monitor the contractures. Interviews with the physical therapist and DON confirmed that there were no current interventions in place to monitor or prevent worsening of the contractures, and there was no documentation of previous attempts or refusals of splint use.
Lack of Clinical Justification for Prolonged Prophylactic Antibiotic Use
Penalty
Summary
A review of medical records and interviews revealed that a resident with a history of urinary retention and a supra pubic catheter was prescribed a routine antibiotic, cephalexin, for prophylactic use. The antibiotic order, which began in 2019, was continued with updated orders and diagnoses over the years, including a recent order with no specified stop date and a diagnosis of 'Prophylactic measures, unspecified.' Documentation showed that the resident was taking the antibiotic for UTI prophylaxis, but there was no clear clinical rationale or specific indicators documented to justify the ongoing use of the antibiotic. Further review of progress notes and referral forms indicated that nursing staff questioned the reason for the continued prophylactic antibiotic, and the only documented justification was 'UTI prophylactic.' The Nurse Practitioner confirmed the antibiotic was ordered for prophylaxis. Reference to CDC guidelines in the report highlighted that UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions in nursing homes, but there is little evidence to support this practice, especially in older adults. The facility failed to provide adequate clinical justification for the continued use of the antibiotic in this resident.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan for a resident within 48 hours of admission, as required by their policy. The policy, last revised in March 2022, mandates that a baseline care plan addressing the resident's immediate health and safety needs be developed and a written summary provided to the resident or their representative. A review of the resident's admission and medical records showed no evidence of such a summary being provided. This was confirmed in an interview with the Social Services Director, who acknowledged that the written summary had not been given to the resident or their representative.
Delayed Notification of Administrator Change
Penalty
Summary
The facility failed to notify the State Agency of a change in administrator within the required timeframe of 5 working days. The change in administrator occurred on October 11, 2024, but the facility did not send the notification email to the State Agency until November 8, 2024. This delay in notification was confirmed during an interview with the Administrator on January 15, 2025. The failure to comply with the notification requirement had the potential to affect all 51 residents residing in the facility.
Failure to Follow Recipe for Turkey Tetrazzini
Penalty
Summary
The facility failed to follow a recipe to ensure the nutritive value of a meal was preserved, potentially affecting all 47 residents who reside and eat at the facility. During a continuous observation of meal preparation, Cook-K was unable to find the scale and therefore portioned out an approximate amount of spaghetti noodles for the Turkey Tetrazzini dish. Later, Cook-K found the scale but was unable to weigh the turkey because it was too heavy, leading to an estimation of the turkey amount placed into the meal. Interviews with Cook-K confirmed the inability to find the scale initially and the subsequent guessing of the spaghetti noodle portion. Additionally, Cook-K confirmed that the turkey was too heavy to weigh, resulting in an estimated amount being used. A review of the facility's recipe for Turkey Tetrazzini indicated specific amounts of 3 pounds 12 ounces of spaghetti noodles and 7 pounds 8 ounces of cooked diced turkey, which were not adhered to during the meal preparation.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices, which had the potential to affect all 47 residents. During a kitchen tour, it was observed that several food items, including Thick It Clear Advantage Cranberry Juice Blends, ReaLime Juice, Reduce Fat Ice Cream Chocolate Mixes, and Vanilla Soft Serve Mixes, were past their expiration dates. Additionally, some food items, such as hotdog buns, tortillas, and fruit mixes, lacked proper labeling with preparation or use-by dates. The Assistant Food Supervisor (AFS) confirmed these deficiencies during interviews. Further observations revealed improper storage practices, such as food items being stored on the floor in the walk-in freezer and raw meat being stored next to uncovered ice cream. Expired items, including Smucker's Platescapers Raspberry and various spices, were found on kitchen shelves. The kitchen also had sanitation issues, with old flour, salt, and debris on shelves, and a buildup of fuzzy gray matter around the ice machine. The AFS and Dietary Aides confirmed these findings, acknowledging that the items should have been disposed of and the areas cleaned.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as observed during a survey. The resident was found in their room without any signage or Personal Protective Equipment (PPE) indicating EBP was in place. A review of the resident's physician's orders showed catheter care was to be performed every shift, but there were no orders for EBP. Interviews with the Assistant Director of Nursing (ADON) confirmed that the facility did not have any residents on precautions at the time and only used standard precautions unless a resident had a multi-drug resistant organism (MDRO) like MRSA. Additionally, the facility did not have a comprehensive water management program to prevent the growth and spread of Legionella and other waterborne pathogens. The Plant Director (PD) revealed that the facility had not conducted an assessment of potential growth areas for these pathogens within the water system and lacked a detailed description and diagram of the water system. The facility performed random water temperature checks and ran water in empty rooms monthly, but no other measures or monitoring systems were in place to manage waterborne pathogens effectively.
Failure to Provide Required Medicare Notification Forms
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS)-10055 form, known as the Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), to three residents (Residents 23, 33, and 41) who were sampled during the survey. The facility's policy, last revised in September 2022, mandates that if the director of admissions or benefits coordinator believes Medicare will not cover a skilled service, the resident or their representative must be notified in writing about the potential non-coverage and their liability for payment. However, the facility did not adhere to this policy. The Minimum Data Set Coordinator (MDS) completed reviews for the residents who received Medicare Part A services and found that the SNF-ABN, CMS-10055 form, was not provided to any of the three residents. Instead, the facility only had form 10123, which was not the correct form required for this purpose. The MDS Coordinator confirmed in an interview that the facility did not have the SNF-ABN, Form CMS-10055, and had not provided it to the residents or their representatives, indicating a systemic issue in the facility's process for notifying residents about potential non-coverage of services.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly medication regimen reviews for residents, as required by their policy. This deficiency was identified for three residents out of a sample of five, with a total facility census of 47. The facility's policy, last revised in May 2019, mandates that the pharmacist reviews each resident's medication regimen monthly, documents any irregularities, and makes recommendations. These recommendations are then supposed to be reviewed and documented by a physician as part of the resident's permanent medical record. For Resident 21, who had diagnoses including hypertension, dementia, and anxiety, there was no evidence of a pharmacist's review of medications over the past year. Similarly, Resident 1, with conditions such as hypertension and non-Alzheimer's dementia, had no documented pharmacist reviews since admission. Resident 39, with multiple diagnoses including anemia and heart failure, also lacked evidence of the required monthly medication reviews since admission. Interviews with the Director of Nursing confirmed the absence of documentation for these reviews and the subsequent physician evaluations.
Oxygen Safety Protocols Not Followed
Penalty
Summary
The facility failed to ensure that an oxygen concentrator was turned off when not in use and that the nasal cannula was not left on the resident's unoccupied bed while the concentrator was left on and unattended. This deficiency was observed in the case of one resident, who was cognitively intact and receiving oxygen therapy at 2 liters per minute (LPM) as per physician's orders. The facility's policy on oxygen administration, last revised in October 2010, required that residents, their families, visitors, and roommates be instructed on oxygen safety precautions, including turning off the oxygen when not in use and not placing the cannula on the bed or chair if the oxygen is turned on. During an observation, it was noted that the resident was not in their room, yet the oxygen concentrator was running at 2 LPM, and the nasal cannula was placed on the resident's bed. This was confirmed by the Director of Nursing (DON) during an interview. The facility's failure to adhere to its own oxygen safety policies and procedures resulted in this deficiency, as the oxygen concentrator was left on and unattended, posing a potential safety hazard.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately manage and assess pain for a resident with severe cognitive impairment, as evidenced by the lack of consistent administration of prescribed pain medication. The resident, who had a diagnosis of non-Alzheimer's dementia and pain, was documented to have experienced varying levels of pain, ranging from mild to severe, on multiple occasions. Despite having an order for acetaminophen to be administered as needed for pain, the medication was not offered or documented as given on numerous instances when the resident's pain was recorded. The facility's policy required the use of a standardized pain assessment tool appropriate to the resident's cognitive level, such as the Wong-Baker FACES Pain Rating Scale. However, the resident's Treatment Administration Record (TAR) showed that pain assessments were conducted, but the necessary interventions, including offering the prescribed acetaminophen, were not consistently implemented. The resident's care plan indicated the potential for pain and discomfort, yet the interventions outlined were not followed, leading to the resident experiencing unmanaged pain. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), confirmed that the charge nurse on duty was responsible for completing pain assessments each shift. The RN noted that due to the resident's cognitive impairment, a licensed nurse was required to complete the pain assessment, and various scales were used depending on the resident's orientation. Despite these assessments, the resident's pain was not adequately addressed, as evidenced by the lack of administration of the prescribed pain medication during documented episodes of pain.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that PRN antipsychotic medication use was limited to 14 days and that a rationale for continued use was documented by the provider as required. This deficiency was identified for one resident out of five sampled, with a facility census of 47. The facility's policy on antipsychotic medication use, revised in July 2022, indicated that PRN medications should not be renewed beyond 14 days unless a healthcare practitioner evaluates the resident and documents the rationale for continued use. However, a review of Resident 21's orders revealed an ongoing PRN order for Seroquel 25 mg for agitation, initiated on 9/9/2023, without a stop date or duration. Additionally, there was no recent documentation from a physician justifying the continued use of the antipsychotic. Interviews with the Director of Nursing confirmed the absence of a stop date and documented rationale for the medication's continued use.
Medication Error Rate Exceeds 5% Due to Improper Crushing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an 11.11% error rate observed during medication administration. Out of 36 medications administered, 4 errors were identified, affecting two residents. The errors involved the improper crushing of medications that should not be crushed, including Potassium Chloride, Ferrous Sulfate, and Enteric Coated Aspirin. These medications were administered to residents while they were eating, contrary to the guidelines that specify these medications should be swallowed whole. The errors were observed during the administration of medications by a Medication Aide (MA-A), who confirmed that all medications in tablet form were routinely crushed for the residents involved. This practice was observed with Resident #5, who received crushed Potassium Chloride and Ferrous Sulfate, and Resident #22, who received crushed Enteric Coated Aspirin and Potassium Chloride ER. The Medication Aide, who has been in this role for a year, confirmed the practice of crushing all tablet medications for these residents.
Failure to Conduct Background Checks and Registry Verification
Penalty
Summary
The facility failed to adhere to its policy on conducting background checks and criminal conviction checks for potential direct access employees. The policy, revised in March 2019, required that these checks be initiated within two days of an employment offer and completed before employment commenced. However, a review of employee records revealed that background checks were not completed for five employees, and a nurse aide registry check was not conducted for direct care employees who were not nurse's aides. Specifically, there was no criminal background check or Nurse Aide Registry check for a Dietary Aid (DA) and a Nurse Aide (NA). Additionally, a Medication Aide (MA) with a negative finding on a criminal background check was hired without documented rationale. Interviews with Human Resources (HR) confirmed that the facility did not conduct criminal background checks on employees who were legally minors, as those records are sealed. HR also admitted that they did not run nurse aide registry checks on staff unless they were hired as nurse aides. This oversight included the failure to conduct a nurse aide registry check on the DA and MA, and the lack of documentation for hiring the MA with a criminal record. These actions and inactions had the potential to affect all 47 residents residing within the facility.
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.
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