Oglala Sioux Lakota Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rushville, Nebraska.
- Location
- 7835 Elders Drive, State Highway 87, Rushville, Nebraska 69360
- CMS Provider Number
- 28E300
- Inspections on file
- 20
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Oglala Sioux Lakota Nursing Home during CMS and state inspections, most recent first.
The facility failed to implement fall prevention interventions for three residents with cognitive impairments and high fall risk. Despite multiple falls, including one resulting in a hip fracture, no new interventions were put in place, and fall huddles were inconsistently conducted. This lack of action left residents vulnerable to repeated falls.
A resident experienced severe weight loss over six months, dropping from 113.3 lbs to 98.7 lbs, without new interventions being implemented. Despite being on a mechanically altered diet and having a care plan for potential nutritional problems, the facility did not update the care plan with new strategies to address the weight loss. The Registered Dietitian recommended continuing current interventions and offering snacks, but no new actions were taken, as confirmed by the DON.
The facility failed to dispose of expired food items and did not adhere to proper food storage practices, potentially affecting all 47 residents. Expired items were found in storage, and some food items were not labeled with dates. Additionally, the facility did not monitor food temperatures before serving, as required, which was confirmed by the Dietary Manager.
A facility experienced a medication error rate of 35.71% due to late administration of medications to three residents. Medications were administered beyond the one-hour window prescribed by facility policy, with reasons including staff running behind schedule and avoiding disturbing a resident in the morning. The delays were confirmed through observations and staff interviews.
A facility failed to follow its infection control policies, including daily cleaning of a PAP mask for a resident with muscular dystrophy, implementing Enhanced Barrier Precautions for a resident with dementia, and ensuring hand hygiene during care activities. Staff did not wear gowns during high-contact care for a resident with an open wound, and a Medication Aide did not perform hand hygiene between peri-care and medication administration.
A resident with dementia was transferred to the hospital without a complete written notice. The notice lacked the resident's name, a specific medical reason for the transfer, and contact information for the state LTC agency and ombudsman. The Social Services Director confirmed these omissions.
A resident with dementia experienced a decline in ADLs and significant weight loss, requiring a significant change MDS, which the facility failed to complete. The MDS Coordinator confirmed the oversight during a survey, indicating non-compliance with OBRA regulations and the RAI Manual.
A facility failed to complete and transmit a Discharge MDS for a resident with dementia who was hospitalized for dehydration. The MDS Coordinator confirmed that the required assessment was not completed within the mandated timeframe.
The facility failed to ensure accurate MDS assessments for two residents. One resident's use of a CPAP device was not documented, despite daily use, and another resident's anticoagulant medication was not recorded, despite an ongoing prescription for Xarelto. These inaccuracies were confirmed by the MDS Coordinator.
A resident with dementia, depression, and anxiety had a care plan that failed to address specific behavioral symptoms like yelling and hallucinations. The plan focused on medication management without including effective non-pharmacological interventions identified by staff, such as offering snacks and engaging in activities. The MDS Coordinator confirmed the care plan's lack of comprehensiveness.
A facility failed to update a resident's ADLs care plan to reflect their current needs. The resident's quarterly MDS assessment showed they required moderate assistance with eating and were dependent for oral hygiene, toileting, dressing, and personal hygiene. However, the care plan, last revised months earlier, indicated different levels of assistance. The MDS Coordinator confirmed the care plan was outdated.
A resident with severe cognitive impairment experienced prolonged periods without bowel movements due to the facility's failure to implement prescribed interventions. Despite having orders for various constipation medications, the resident did not receive them as needed, leading to extended periods without bowel movements. Interviews with staff confirmed the absence of a bowel protocol and insufficient documentation and action during these periods.
A resident identified as at-risk for wandering did not have a care plan or interventions in place to prevent elopement, despite facility policy requirements. The resident eloped twice in one day, and there was no evidence of 15-minute checks being conducted as part of fall interventions. Interviews confirmed that preventive measures were not implemented in a timely manner.
A facility failed to include necessary settings in a PAP device order for a resident with muscular dystrophy, as required by their CPAP/BiPAP support policy. The resident's records showed orders without specified settings, confirmed by interviews with an LPN and the DON. This deficiency was identified during a review of records and interviews, affecting one of two residents sampled for respiratory care.
A facility failed to attempt a gradual dose reduction for a resident on psychotropic medications, despite the resident showing no symptoms of depression and no noted behaviors. The facility's policy requires such reductions unless clinically contraindicated, but there was no documentation to support contraindication, and the Director of Nursing confirmed that a reduction should have been attempted.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for three residents, all of whom were at high risk for falls due to various health conditions. Resident 1, who had severe cognitive impairment and required substantial assistance for mobility, experienced two falls in January 2025, one of which resulted in a hip fracture requiring surgery. Despite these incidents, no new interventions were implemented, and there was no evidence of fall huddles being conducted to assess and address the causes of the falls. Resident 3, with moderate cognitive impairment and a history of multiple falls, experienced numerous falls between October 2024 and January 2025. The facility's documentation showed that while some fall huddles were conducted, many falls did not result in new interventions being put in place. The lack of consistent follow-up and intervention implementation left Resident 3 vulnerable to repeated falls, as evidenced by the numerous incidents recorded without corresponding preventive measures. Resident 2, who had severe cognitive impairment and was at high risk for falls due to factors such as wandering and balance problems, also experienced falls in December 2024. The facility's records indicated that no new interventions were developed following these falls, and the care plan remained unchanged. Interviews with staff confirmed the absence of updated interventions, highlighting a systemic issue in the facility's approach to fall prevention and risk management.
Failure to Implement Interventions for Severe Weight Loss
Penalty
Summary
The facility failed to implement new interventions to prevent significant weight loss for a resident, identified as Resident 20, who experienced severe weight loss over a period of three and six months. The resident's weight dropped from 113.3 pounds to 98.7 pounds over six months, representing a 12.89% loss, which is considered severe. Despite the resident's care plan indicating a potential for nutritional problems due to dementia with behavioral disturbance and Type 2 Diabetes Mellitus, and a goal to maintain weight within 5% of a baseline weight of 135 pounds, the facility did not update the care plan with new interventions to address the severe weight loss. The resident was on a mechanically altered diet due to loose teeth, and the care plan included monitoring for swallowing difficulties, providing supplements, and serving a diet as ordered. However, despite recommendations from the Registered Dietitian to continue current nutrition interventions and offer snacks, no new interventions were implemented after significant weight loss was noted. The Director of Nursing confirmed that no new interventions were put in place to mitigate the resident's severe weight loss, and the care plan was not updated accordingly.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food items were disposed of or consumed before their best-by and use-by dates, and did not adhere to proper food storage and preparation practices, potentially affecting all 47 residents. During an initial kitchen tour, several expired food items were found in the dry food storage area, including nutrition drinks, gelatin, pudding mix, prune juice, and nacho cheese dip. Additionally, graham crackers were stored without a date, and a container of pickle relish and a can of crushed pineapple were improperly sealed or damaged. In the walk-in refrigerator, bread loaves, hamburger buns, and dinner rolls were not labeled with dates, and a partially consumed Gatorade bottle was stored above food items meant for residents. The Dietary Manager confirmed these items should have been dated and disposed of appropriately. The facility also failed to monitor food temperatures as required. Observations revealed that Cook-N did not check the temperatures of foods held in the steam table before serving them to residents. The routine process involved checking temperatures only after cooking and placing food on the steam table, not before serving, regardless of how long the food had been held. This practice was confirmed by both Cook-M and the Dietary Manager, who acknowledged that food temperatures should have been checked prior to serving to ensure safety.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to administer medications at the correct times, resulting in a medication error rate of 35.71%, which is significantly higher than the acceptable threshold of less than 5%. This deficiency was observed in three out of five sampled residents. The facility's policy, revised in April 2019, mandates that medications should be administered within one hour of their prescribed time. However, observations and interviews revealed that medications for Residents 11, 43, and 98 were administered late by Medication Aides (MAs) due to various reasons, including the MA running behind schedule and a preference not to disturb a resident in the morning. Resident 98 was prescribed cephalexin to be administered at 7:00 AM, but it was given at 8:20 AM. Resident 43 was prescribed Miralax and omeprazole for 7:30 AM, but these were administered at 8:48 AM. Resident 11, who was in pain and crying out for help, had multiple medications prescribed for 8:00 AM, but they were administered at 9:22 AM. The delay in administering medications was confirmed through interviews with the MAs involved, who acknowledged the late administration and provided reasons for the delays.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 2, who was cognitively intact and had a primary diagnosis of muscular dystrophy, the facility did not follow its policy for cleaning the PAP mask. Observations revealed that the mask had light-colored debris and yellow residue, and the head strap was discolored. Despite the facility's policy requiring daily cleaning of the mask, interviews with staff confirmed that this was not being done. For Resident 22, who had severe cognitive impairment and a primary diagnosis of dementia, the facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care activities. Observations showed that staff did not wear gowns while performing personal care and wound care, despite the presence of a CDC EBP sign on the resident's door. Interviews with staff confirmed the lack of gown availability and the failure to follow EBP requirements. Additionally, the facility did not ensure proper hand hygiene during care activities. For Resident 11, a Medication Aide failed to perform hand hygiene between providing peri-care and administering medications. This was confirmed through observation and interview, indicating a breach in the facility's hand hygiene policy, which requires hand hygiene before moving from a soiled to a clean body site and after glove removal.
Deficient Transfer Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide the required information in the written notice of transfer for a resident who was transferred to the hospital. The resident, who had a primary diagnosis of dementia, was transferred on 8/16/2024. The notice of transfer lacked the resident's name, a specific medical reason for the transfer, and contact information for the state long-term care agency and the state long-term care ombudsman. This deficiency was confirmed during an interview with the Social Services Director, who acknowledged the omissions on the form.
Failure to Complete Significant Change MDS for Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) for a resident who experienced a major decline in their health status. According to the facility's policy and the MDS RAI 3.0 Manual, a significant change in condition, such as a decline in Activities of Daily Living (ADLs) and unplanned weight loss, requires a comprehensive assessment. Resident 20, who was admitted with a diagnosis of dementia, showed a decline from requiring partial assistance to full assistance with oral hygiene and experienced significant weight loss between two quarterly MDS assessments. The MDS Coordinator confirmed that these changes in Resident 20's condition over the prior months warranted a significant change MDS, which was not completed. This oversight was identified during a survey, highlighting the facility's failure to adhere to the required assessment protocols as outlined by the Omnibus Budget Reconciliation Act (OBRA) regulations and the Resident Assessment Instrument (RAI) Manual.
Failure to Complete Discharge MDS for Hospitalized Resident
Penalty
Summary
The facility failed to complete and transmit a Discharge Minimum Data Set (MDS) for a resident upon hospitalization, as required by federal regulations. The resident, who had a primary diagnosis of dementia, was admitted to the facility and later transferred to a hospital for dehydration. Despite the hospitalization, a review of the facility's records showed that no Discharge MDS was completed within the mandated 14-day period following the resident's discharge to the hospital. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the discharge MDS should have been completed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, which is a federally mandated comprehensive assessment of each resident's functional capabilities. For one resident with muscular dystrophy, the MDS did not accurately reflect the use of a Continuous Positive Airway Pressure (CPAP) device during the look-back period, despite records showing daily use. The MDS Coordinator confirmed that the resident had used the CPAP device during the specified period, and the assessment should have indicated this. Another resident's MDS inaccurately reported that they were not taking an anticoagulant, despite having an order for Xarelto for atrial fibrillation since 2018. The MDS Coordinator confirmed that the resident was indeed taking the anticoagulant, and this should have been documented in the MDS. These inaccuracies affected the facility's ability to provide accurate assessments for 2 of the 12 residents reviewed, with a total facility census of 47.
Incomplete Care Plan for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 40, who was admitted with diagnoses of dementia, depression, and anxiety. The care plan lacked specific interventions to address the resident's behavioral symptoms, such as hitting or scratching self, pacing, rummaging, or making disruptive sounds, which were observed 1-3 days during a 7-day period. The care plan primarily focused on administering psychotropic and anti-anxiety medications, monitoring for side effects, and discussing medication use with the physician and family, but did not include non-pharmacological interventions tailored to the resident's specific behaviors. Interviews with facility staff revealed that Resident 40 exhibited behaviors such as yelling, refusing to lay in bed, and experiencing hallucinations, particularly in the evenings. Effective interventions identified by staff included offering snacks, toileting, providing one-on-one time, engaging in activities, and placing the resident in a recliner in common areas. However, these interventions were not documented in the care plan. The MDS Coordinator confirmed that the care plan was not comprehensive, as it did not address the specific behaviors or include the effective interventions used by staff.
Failure to Update Resident's ADLs Care Plan
Penalty
Summary
The facility failed to revise the activities of daily living (ADLs) care plan to reflect the current status of a resident. The facility's policy requires that care plans be revised as information about residents and their conditions change, at least quarterly. A review of the resident's quarterly Minimum Data Set (MDS) assessment revealed that the resident required moderate assistance with eating and was dependent for oral hygiene, toileting, dressing, and personal hygiene. However, the resident's care plan, last revised several months prior, indicated that the resident required extensive assistance with bathing, dressing, and personal hygiene, and only supervision with eating. An interview with the MDS Coordinator confirmed that the care plan was not updated to reflect the resident's current needs.
Failure to Implement Bowel Care Interventions
Penalty
Summary
The facility failed to implement interventions to prevent constipation for Resident 22, who had a primary diagnosis of dementia and severe cognitive impairment. The resident's records indicated prolonged periods without bowel movements, specifically from 8/19/2024 to 8/30/2024 and from 9/5/2024 to 9/9/2024. Despite having orders for various medications to treat constipation, including Senokot S, Miralax, Milk of Magnesia (MOM), Dulcolax suppository, and Fleet Oil enema, the resident did not receive these medications as needed. The Medication Administration Record (MAR) showed that the resident only received MOM on two occasions, with one instance marked as ineffective. Interviews with facility staff, including a Registered Nurse (RN), a Nurse Practitioner (NP) from hospice, and the Director of Nursing (DON), confirmed the lack of bowel movements and the absence of a bowel protocol. The DON acknowledged that the resident should have been given a PRN dose of Dulcolax when MOM was ineffective. The facility's night shift duty sheet provided some direction, but it was insufficient to address the resident's needs, as evidenced by the lack of documentation and action taken during the periods without bowel movements.
Failure to Implement Elopement Prevention for At-Risk Resident
Penalty
Summary
The facility failed to develop and implement interventions to prevent elopement for a resident identified as at-risk for wandering. The facility's policy on Wandering and Elopements, revised in March 2019, mandates that residents at risk of unsafe wandering should have a care plan with strategies and interventions to ensure their safety. However, a review of the resident's records revealed that despite being identified as at-risk on February 13, 2024, no care plan or interventions were in place prior to the resident's elopement on March 3, 2024. The resident was found outside the facility twice on the same day, indicating a lack of preventive measures. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the resident was recognized as at-risk for wandering and elopement, and interventions should have been developed and implemented earlier. The MDS Coordinator was in the process of obtaining consent to place a Wander guard when the resident eloped again. Additionally, the facility's documentation did not show evidence of 15-minute checks being conducted on the day of the elopement, which were supposed to be part of the resident's fall interventions. This lack of documentation and implementation of preventive measures contributed to the deficiency.
Failure to Include PAP Device Settings in Resident's Order
Penalty
Summary
The facility failed to ensure that a resident had a Positive Airway Pressure (PAP) device order that included the necessary settings. This deficiency was identified during a review of records and interviews, affecting one of two residents sampled for respiratory care. The facility's policy on CPAP/BiPAP support, last revised in March 2015, requires checking the physician's order to determine the pressure settings for the machine. However, the records for the resident, who was admitted with a primary diagnosis of muscular dystrophy, showed orders for a CPAP device without any specified settings. The resident's order summary and written orders from 2017 lacked the required pressure settings for the PAP device. Interviews with an LPN and the Director of Nursing confirmed the absence of these settings in the resident's orders. The deficiency was further highlighted by a review of the ResMed website, which states that a CPAP prescription should include a pressure setting determined by the prescribing physician based on a sleep study. This oversight in the resident's care plan indicates a failure to adhere to the facility's policy and standard practices for respiratory care.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications as required for one resident. The facility's policy, revised in July 2022, mandates that residents on psychotropic medications should receive a GDR alongside non-pharmacological interventions unless clinically contraindicated. However, for Resident 16, who was on sertraline and trazodone, no such reduction was attempted despite the resident showing no symptoms of depression and no noted behaviors since December 2024. Resident 16's records indicated a Patient Health Questionnaire score of 0, suggesting no symptoms of depression, yet the resident continued to receive sertraline for major depressive disorder and trazodone for sleep. Gradual Dose Reduction Requests dated April and August 2024 showed no changes in medication orders, and there was no documentation from the physician indicating that a GDR was clinically contraindicated. The Director of Nursing confirmed the lack of evidence for contraindication and acknowledged that a GDR should have been attempted.
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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