Nye Summit
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Nebraska.
- Location
- 410 West 5th Street, Louisville, Nebraska 68037
- CMS Provider Number
- 285267
- Inspections on file
- 22
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Nye Summit during CMS and state inspections, most recent first.
The facility failed to properly label and store food items in the kitchen's walk-in refrigerator and freezer. Undated and improperly stored items, including lettuce, celery, turkey slices, and cheeses, were found exposed to air. An expired container of cooked vegetables was also discovered. The Dietary Manager confirmed these items should have been labeled and dated, acknowledging the expired vegetables should have been discarded. This posed a risk of foodborne illness to 47 residents consuming food from the kitchen.
The facility failed to monitor and document weights for three residents, leading to a deficiency in nutritional care. One resident with failure to thrive was not weighed due to lack of equipment, another with multiple diagnoses was not weighed since November, and a hospice resident was not weighed since October. Staff interviews confirmed the absence of necessary equipment and failure to adhere to weight monitoring protocols.
The facility failed to maintain operational ventilation systems in 14 resident bathrooms, affecting 20 residents. Observations showed that the ventilation systems were non-functional, as confirmed by the Maintenance Director, potentially impacting odor control.
A resident with severe cognitive impairment and a history of attempting to leave the facility was not provided with a wander guard as required by their care plan. Despite being identified as at risk for elopement, the resident was able to leave the building unattended multiple times, without appropriate supervision or notification to staff. The facility's failure to implement necessary interventions resulted in the resident being exposed to cold weather conditions without proper clothing.
A resident with a gastrostomy tube did not receive proper care as the LPN failed to clean the G-tube insertion site before applying a new dressing, and the dressing was not correctly positioned. The resident had a history of gastrointestinal hemorrhage, quadriplegia, and other conditions, requiring full assistance for daily activities. The deficiency was due to a lack of communication from bath staff and non-adherence to the facility's wound care policy.
The facility failed to document a diagnosis supporting the use of antipsychotic medication for two residents. One resident was prescribed quetiapine for agitation without a supporting diagnosis, while another was given quetiapine for insomnia without necessary assessments. The facility's pharmacist recommended discontinuing quetiapine due to risks, but the provider did not respond. The ADON confirmed the lack of necessary assessments and communication with the provider.
Two residents with severe cognitive impairments eloped from the facility due to inadequate implementation of safety measures. One resident was found outside twice, resulting in hospitalization for injuries, while the other had a history of elopement risk but lacked proper assessments and documentation. The facility's failure to adhere to its elopement prevention policy contributed to these incidents.
A resident with severe cognitive impairment suffered burns from a hot coffee spill due to the facility's failure to assess their risk for handling hot liquids. The facility's policy required such assessments, but they were not conducted. Observations showed that dietary staff did not consistently check coffee temperatures before serving, contributing to the incident. Interviews revealed a lack of formal risk assessments, relying instead on informal observations to determine the need for lidded cups.
The facility failed to submit investigations to the state agency within the required five working days for three residents involved in separate incidents, including a physical altercation and a fall resulting in injury. The DON confirmed these lapses during interviews.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as observed during an inspection of the kitchen's walk-in refrigerator and freezer. Several food items, including a zip lock bag of lettuce, cut-up celery, turkey slices, and various cheeses, were found undated and improperly stored, exposing them to air. Additionally, a container of cooked vegetables was found with an expired date, and undated bags of unknown substances were discovered in the freezer. The Dietary Manager confirmed that these items should have been labeled and dated, and acknowledged that the expired vegetables should have been discarded. This oversight had the potential to affect 47 residents who consumed food from the kitchen, posing a risk of foodborne illness.
Failure to Monitor Resident Weights and Nutritional Status
Penalty
Summary
The facility failed to obtain and document resident weights for three residents, leading to a deficiency in monitoring potential nutritional problems. Resident 32, who was admitted with diagnoses including adult failure to thrive, a stage 4 pressure injury, and malnutrition, was not weighed since September 2024. The facility lacked the necessary equipment, such as a lift with a scale, to weigh the resident who refused to get out of bed. Interviews with staff confirmed the absence of appropriate equipment and the failure to adhere to the facility's policy of weekly weight monitoring. Resident 3, who had multiple diagnoses including stroke, memory deficit, and malnutrition, was also not weighed since November 2024. Despite being on a mechanically altered diet and having nutritional concerns, the resident's weights were not recorded in the Electronic Medical Record (EMR) after October 2024. Observations revealed that Resident 3 frequently left meals untouched, and interviews with staff confirmed the resident's refusal of the mechanically altered diet and nutritional shakes. The facility's expectation of weekly weight monitoring was not met for this resident. Resident 42, admitted with conditions such as heart failure and chronic kidney disease, was on hospice care and had not been weighed since October 2024. The facility did not have a method to weigh the resident in bed, and hospice staff did not perform weight checks. Interviews with the Assistant Director of Nursing and the dietitian confirmed that residents on hospice or with weight loss should be weighed at least monthly, but this was not done for Resident 42. The lack of equipment and failure to follow weight monitoring protocols contributed to the deficiency in nutritional care for these residents.
Non-Functional Ventilation System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in 14 occupied rooms, specifically in the bathrooms of rooms 201, 202, 203, 204, 205, 206, 208, 209, 210, 211, 212, 213, 214, and 215. This deficiency affected 14 bathrooms used by 20 residents, potentially impacting odor control within the facility. Observations conducted on two separate occasions revealed that the ventilation systems in these bathrooms were not functional, as demonstrated by a test using a 1-ply square of toilet paper that did not adhere to the ventilation cover, indicating no air draw. The Maintenance Director confirmed the non-functionality of the ventilation system in the bathrooms along the 200 hallway, acknowledging that the system should be operational.
Failure to Implement Elopement Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate interventions were implemented to protect a resident from elopement. The resident, who was severely cognitively impaired with a BIMS score of 4, had a history of attempting to leave the facility without informing staff. Despite being identified as at risk for elopement, the resident did not have a wander guard as required by the care plan. Observations revealed that the resident attempted to leave the facility multiple times without appropriate supervision or notification to staff. The resident's care plan included interventions for elopement risk, such as wearing a wander guard on the wheelchair, but these were not implemented. The Assistant Director of Nursing (ADON) confirmed that the resident's care plan included an intervention for a wander guard, but there was no order for it, and the resident did not have one. Interviews with staff, including the Registered Nurse (RN), Office Manager (OM), and Medication Aide (MA), confirmed that the resident was not safe to be outside alone due to impulsivity and poor safety awareness. The facility's failure to implement the necessary interventions resulted in the resident being able to leave the building unattended on multiple occasions. Staff observed the resident exiting the facility without appropriate clothing for the cold weather, and the resident was stopped by staff only after leaving the building. The Director of Nursing (DON) acknowledged the need for a wander guard due to the resident's exit-seeking behaviors and safety concerns, but it was not in place at the time of the incidents.
Inadequate G-Tube Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a gastrostomy tube (G-tube). The resident, who was dependent on staff for all activities of daily living and mobility, had a medical history including gastrointestinal hemorrhage, quadriplegia, traumatic brain injury, and depression. The facility's wound care policy required the G-tube insertion site to be cleansed with sterile water and gauze, and a clean, dry dressing applied. However, during an observation, it was noted that the Licensed Practical Nurse (LPN) did not clean the G-tube insertion site before placing a new split sponge dressing, which was not positioned correctly between the G-tube insertion site and the G-tube flange. The site appeared to have blood-tinged drainage, indicating improper care. The deficiency was further highlighted during interviews, where the LPN confirmed the failure to clean the site and the absence of a split sponge due to a lack of communication from the bath staff after the resident's shower. The Infection Preventionist (IP) also confirmed that the bath staff should have notified the LPN about the removal of the split sponge, and the LPN should have cleaned the site before applying a new dressing. This oversight in communication and adherence to the facility's wound care policy led to inadequate care for the resident's G-tube site.
Lack of Diagnosis for Antipsychotic Use in Two Residents
Penalty
Summary
The facility failed to have a diagnosis in place to support the use of an antipsychotic medication for two residents. Resident 32 was admitted with diagnoses of dementia with behavioral disturbance and depression, but there was no documented diagnosis to support the use of quetiapine, an antipsychotic medication prescribed for agitation. The Assistant Director of Nursing (ADON) confirmed the absence of a documented diagnosis for the antipsychotic medication. Resident 7 was prescribed quetiapine for insomnia, despite having no documented sleep test, sleep diary, or sleep assessment to support the diagnosis of insomnia. The resident's care plan included quetiapine as an intervention for insomnia, but the ADON confirmed that necessary assessments were not completed. The facility's pharmacist recommended discontinuing quetiapine due to potential risks and suggested an alternative medication, but the provider did not respond to this recommendation. Interviews with the ADON and the facility's contracted pharmacist revealed that the provider who prescribed quetiapine for Resident 7 did not follow the necessary steps, such as conducting a sleep assessment or responding to pharmacy recommendations. The ADON acknowledged that the provider, who was not the facility's provider, took months to address pharmacy recommendations, and no attempts were made to contact the provider to address the issue. The pharmacist confirmed that quetiapine is not approved for treating insomnia and recommended a sleep assessment, which had not been completed.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility staff failed to evaluate and implement interventions to prevent elopement for two residents, leading to significant safety incidents. Resident 1, who was severely cognitively impaired and receiving hospice care, was found outside the facility on two occasions. The first incident occurred when Resident 1 was discovered in the facility parking lot, and the wander guard did not alarm. The second incident resulted in Resident 1 being found on the ground in the driveway, requiring hospitalization for multiple injuries, including subdural brain bleeds and fractures. It was later revealed that the wander guard was not transferred to a new wheelchair provided by hospice personnel. Resident 4, also severely cognitively impaired, had a history of elopement risk and had previously eloped to the assisted living side of the building. Despite this, the facility failed to conduct quarterly elopement risk assessments as required by their policy. Additionally, there were multiple instances of missing documentation for the monitoring of Resident 4's wander guard, indicating a lack of consistent oversight and adherence to safety protocols. The facility's policy outlined specific procedures for preventing elopement, including the use of wander guards and regular assessments. However, these measures were not effectively implemented or documented, contributing to the residents' ability to leave the facility unsupervised. The lack of timely updates to care plans and failure to conduct necessary risk assessments further exacerbated the situation, compromising the safety and well-being of the residents involved.
Failure to Assess Hot Liquid Burn Risk Leads to Resident Injury
Penalty
Summary
The facility failed to evaluate Resident 1's risk for hot liquid burns, resulting in a burn from a hot coffee spill. Resident 1, who had severe cognitive impairment due to Alzheimer's disease and other neurological conditions, required supervision with eating. Despite this, the resident was not assessed for their ability to handle hot liquids prior to the incident. On the day of the incident, Resident 1 spilled hot coffee in their lap, leading to burns on the inner thighs. The facility's policy on hot liquid safety, which was in place at the time, required that all residents be assessed for their ability to handle hot liquids, but this was not done for Resident 1. Observations revealed that the dietary staff did not consistently check the temperature of the coffee before serving it to residents. On the day of the incident, coffee was served at temperatures exceeding the facility's safe limit of 140 degrees Fahrenheit. The dietary aides were observed serving coffee without taking the temperature after it had been poured, and the coffee was served to residents, including Resident 1, without ensuring it had cooled to a safe temperature. This lack of adherence to the facility's hot liquid safety policy contributed to the incident. Interviews with staff, including dietary aides and nursing staff, indicated a lack of formal hot liquid risk assessments for residents. The staff relied on informal observations to determine which residents required lidded cups, and there was no systematic approach to identifying residents at risk for burns from hot liquids. The facility administrator confirmed that no hot liquid risk assessments had been completed for residents prior to the incident, highlighting a significant oversight in the facility's safety protocols.
Failure to Submit Timely Investigations
Penalty
Summary
The facility failed to submit an investigation to the state agency within the required five working days for three residents involved in separate incidents. For Resident 2, a progress note revealed that the resident was involved in a physical altercation with another resident, resulting in both residents hitting each other. The incident was reported to the primary care physician, supervisor, and Adult Protective Services (APS), but no investigation was completed and submitted to the state agency within the required timeframe. The Director of Nursing (DON) confirmed this oversight during an interview. For Resident 3, a progress note indicated that the resident was found on the floor with a laceration on their forehead after falling from their wheelchair. Emergency services were called, and the resident was transported to the hospital. APS was notified, but again, no investigation was completed and submitted to the state agency within the required five working days. The DON confirmed this lapse during an interview. These failures to report and investigate incidents in a timely manner were identified during a review of the facility's records and interviews with staff.
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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