Old Mill Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 1131 Papillion Parkway, Omaha, Nebraska 68154
- CMS Provider Number
- 285289
- Inspections on file
- 24
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Old Mill Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that ventilation covers in several resident bathrooms were coated with dust due to insufficient cleaning frequency and unclear documentation practices. The facility's cleaning assignments and policy did not specify how often or how to document the cleaning of these covers, leading to inconsistent maintenance.
The facility did not maintain operational ventilation systems in 11 resident bathrooms on one hallway, as observed when the ventilation failed to draw a single ply of toilet paper to the vent cover. The Maintenance Director confirmed that routine checks were not performed as required, and documentation showed the last facility-wide check occurred several months prior.
A resident with hypertension received Hydralazine outside of physician-ordered blood pressure parameters on several occasions, and the physician and resident representative were not notified as required. The MAR showed medication was given when the resident's systolic blood pressure was below the ordered threshold, and in some cases, blood pressure readings were not documented. Facility policy required notification and documentation, but these actions were not taken.
Two residents with orders for oxygen therapy and respiratory treatments did not have their respiratory care needs addressed in their comprehensive care plans, despite facility policy and physician orders requiring such documentation. Observations confirmed the use of oxygen and nebulizer equipment, and staff interviews acknowledged the omission of these needs from the care plans.
A resident with a history of repeated falls and osteoarthritis, who required two-person assistance for transfers per care plan, was transferred with only one staff member on multiple occasions. The resident reported a recent fall and pain, and staff interviews confirmed that the two-person transfer protocol was not followed.
A nurse aide was rehired without the facility completing the required criminal background, APS, or CPS checks as mandated by policy and state regulations. The administrator confirmed that these screenings, which had been done at initial hire, were not repeated at rehire.
A facility failed to ensure timely response to residents' call lights, with multiple instances of delays exceeding 20 minutes. Residents with varying medical needs and cognitive abilities experienced significant delays, leading to accidents and unmet care needs. The facility's policy lacked a specific timeframe for call light response, contributing to the deficiency.
A resident with gastrointestinal issues did not receive Dulcolax as ordered due to an entry error marking it as PRN instead of BID. Additionally, despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once, even though the resident experienced frequent diarrhea. The RN and DON confirmed these oversights, leading to a deficiency in care.
A resident with a history of heart and respiratory issues experienced a significant medication error when warfarin was administered despite an APRN's order to hold the medication due to a high INR. The resident received doses on two consecutive days, leading to an increased INR, which was confirmed by the DON and an LPN as a significant error.
The facility failed to complete tracking/discharge MDS for 17 residents. A review of discharge Electronic Health Records revealed the missing MDS. The newly hired MDS Coordinator confirmed the requirement to complete the MDS within 3 days of discharge. The facility Administrator was unaware of the incomplete MDS and acknowledged the oversight.
A facility failed to have a physician's order for CPAP for a resident with COPD, Obstructive Sleep Apnea, heart failure, and hypertension. The resident's care plan indicated CPAP use, but no order was found in the records. The resident confirmed nightly use of the CPAP with nursing staff assistance, and an LPN confirmed the absence of an order.
The facility failed to provide written notification and a reason for discharge to a resident or the resident's representative, despite the resident being transferred to the hospital due to urgent medical needs. This deficiency was confirmed through interviews with the facility Administrator.
The facility staff failed to notify the practitioner or responsible party of falls for two residents. One resident experienced a fall with injuries, and the family was not informed. Another resident fell multiple times, and neither the family nor the physician was notified. This was confirmed through record reviews and interviews with the facility administrator.
Failure to Maintain Clean Ventilation Covers in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain the cleanliness of interior and exterior ventilation covers in eight occupied resident rooms along the south hallway. During a walkthrough with the Administrator and Maintenance Director, it was noted that the ventilation covers in resident bathrooms were coated with a white and gray fuzzy substance resembling dust. The Administrator confirmed the presence of this buildup and acknowledged that the current practice was to clean the covers monthly or upon resident discharge, which was not sufficient to prevent dust accumulation. A review of facility cleaning documentation revealed inconsistencies, with some records undated and lacking clear evidence of when cleaning was completed. The facility's cleaning assignments included a general note to check and wipe vents, but did not specify the frequency or documentation requirements for cleaning ventilation covers. Additionally, the facility's policy on routine cleaning and disinfection did not address the cleaning of ventilation covers in resident bathrooms. The Administrator confirmed that both the cleaning assignments and policy lacked necessary specificity regarding these tasks.
Failure to Maintain Operational Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation systems in resident bathrooms were operational in 11 out of 21 occupied bathrooms located on the south hallway. During an observation conducted with the Administrator and Maintenance Director, it was found that the ventilation system in these bathrooms was not functional, as evidenced by the inability of the system to draw a single ply of toilet paper to the surface of the ventilation cover. The Maintenance Director confirmed that the ventilation systems had not been routinely checked for proper function in these areas and that only one check had been performed since the Maintenance Director began employment in October 2024. Further review of facility records revealed that the last documented check of the ventilation systems facility-wide was on 11/24/25, with no other documentation available regarding ongoing checks. The facility's policy requires the Maintenance Director to maintain documentation of all inspections, tests, and maintenance of the HVAC system. The Administrator confirmed that staff should have been checking the ventilation system at least monthly, and ideally weekly, to ensure proper operation, but this was not done.
Failure to Notify Physician and Representative of Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to notify the physician and resident representative when a resident received Hydralazine outside of the physician-ordered blood pressure parameters. The resident, who was cognitively intact with a BIMS score of 14, had an order for Hydralazine to be held if the systolic blood pressure (SBP) was less than 150. Despite this, the medication was administered multiple times when the resident's SBP was below the ordered threshold, as documented in the Medication Administration Record (MAR). In some instances, blood pressure readings were not recorded on the MAR at all. Interviews confirmed that the family member was concerned about the administration of blood pressure medication outside of prescribed parameters, and the Director of Nursing acknowledged that the physician should have been notified when the medication was given outside of parameters. Facility policy required staff to obtain and record vital signs, hold medications outside of parameters, and notify the physician in the event of a medication error, but these steps were not followed in this case.
Failure to Develop Comprehensive Care Plans for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CCPs) that addressed the respiratory care and oxygen needs for two residents who required such services. Facility policy required that CCPs include specific interventions for oxygen therapy, such as the type of delivery system, administration schedule, flow rates, monitoring requirements, and potential complications. However, for both residents sampled, the CCPs did not contain any information related to their respiratory care or oxygen use, despite physician orders and assessments indicating the need for continuous or as-needed oxygen therapy. One resident was observed using an oxygen concentrator set at 3 liters per minute and had diagnoses of chronic respiratory failure with hypoxia and acute pulmonary edema. The resident's Minimum Data Set (MDS) and physician orders documented the need for continuous oxygen and specific parameters for administration, yet the CCP lacked any mention of these needs. Interviews with the MDS coordinator and Director of Nursing confirmed that the care plan did not address the resident's respiratory care or oxygen use, and that this was not in accordance with facility policy. Another resident had physician orders for nebulizer treatments and as-needed oxygen to maintain saturation above 90%, with the MDS also indicating continuous oxygen use. Observations confirmed the presence of oxygen and nebulizer equipment in the resident's room, but the CCP did not reflect any respiratory care needs. Additionally, an LPN was unaware of the current nebulizer orders, and the MDS coordinator confirmed the omission of respiratory care needs from the care plan.
Failure to Implement Two-Person Transfer Protocol for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with a history of repeated falls, primary osteoarthritis, and a recent urinary tract infection. The resident's care plan specified the need for assistance from two staff members (Ax2) for all transfers and use of a wheelchair for mobility. Despite this, documentation and interviews revealed that the resident was transferred with only one staff member assisting on at least one occasion, contrary to the care plan requirements. The provider was notified of an incident where the resident was transferred with only one staff member, and the resident reported experiencing a fall in the bathroom a couple of days prior, resulting in pain in the right arm and shoulder. Observation further confirmed that the resident was transferred from the bed to a chair with only one staff member assisting, despite the presence of both an occupational therapist and a nursing assistant in the room. Interviews with staff confirmed that the resident should have been transferred with two staff members, and that this protocol was not followed during the observed transfer. These actions demonstrate a failure to provide adequate supervision and implement fall prevention interventions as assessed and documented in the resident's care plan.
Failure to Complete Required Background Checks at Rehire
Penalty
Summary
The facility failed to complete required criminal background checks (CBG), Adult Protective Services (APS) checks, and Child Protective Services (CPS) checks at the time of rehire for one nurse aide. According to the facility's abuse prohibition policy, all potential employees, including rehires, must undergo background, reference, and credential checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. Documentation of these screenings is required to be maintained by the facility. Record review showed that the nurse aide in question had previously worked at the facility, with all required checks completed at the time of initial hire. However, upon rehire, there was no documentation that the necessary CBG, APS, or CPS checks were repeated. The facility administrator confirmed during an interview that these checks were not completed at the time of rehire, as required by facility policy and state regulations.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to ensure that residents' call lights were answered within 20 minutes, as expected, for four sampled residents. The facility's policy on call light response did not specify a timeframe for answering call lights, which contributed to the deficiency. The facility's Patient Concern Forms revealed multiple complaints about long call light response times from residents and their families. Resident 1, who was cognitively intact and had specific medical conditions requiring prompt assistance, experienced multiple instances where call lights were not answered within 20 minutes. The resident's family reported incidents where the resident had to wait for assistance after vomiting and during a diarrhea episode, leading to significant delays in care. The Past Calls log documented numerous instances of call lights running for over 20 minutes, with some exceeding 30 minutes. Resident 4, also cognitively intact, required substantial assistance with daily activities and experienced similar delays in call light responses, with some instances exceeding 40 minutes. The resident confirmed having accidents while waiting for assistance. Residents 2 and 3, with varying levels of cognitive impairment and assistance needs, also experienced prolonged call light response times, with logs showing multiple instances of delays over 20 minutes. The Director of Nursing confirmed that the facility's goal was to answer call lights within 6-7 minutes, but the expectation was within 20 minutes.
Failure to Administer Medications as Ordered for Gastrointestinal Issues
Penalty
Summary
The facility failed to administer Dulcolax as per the provider's orders for a resident with a suspected bowel obstruction. The resident, who was cognitively intact and required assistance with daily activities, had a medical history of partial intestinal obstruction and other gastrointestinal issues. A verbal order for Dulcolax suppository twice daily was given by an APRN and documented by an RN, but the medication was only administered once due to an error in entering the order as PRN instead of BID. This oversight was confirmed by the RN and the Director of Nursing (DON) upon review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Additionally, the facility did not adequately address the resident's recurrent diarrhea. Despite having an active PRN order for Loperamide to manage loose stools, the medication was only administered once during a period when the resident experienced loose stools almost daily. The RN acknowledged being informed by nursing assistants about the resident's condition but did not assess the resident or administer the medication, citing instructions from the APRN not to administer it starting on a specific date. However, the order for Loperamide remained active and was not placed on hold. The DON confirmed the resident's frequent loose stools and the lack of consistent administration of the PRN Loperamide, which should have been offered to the resident even if not requested. The failure to follow the provider's orders for both Dulcolax and Loperamide resulted in a deficiency in the facility's care for the resident's gastrointestinal issues.
Significant Medication Error with Warfarin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of warfarin, an anticoagulant medication. The resident, who had a history of respiratory failure, heart failure, atrial fibrillation, venous insufficiency, and a pacemaker, was prescribed warfarin with specific dosing instructions. Despite an order from the Advance Practice Registered Nurse (APRN) to hold the medication due to a high International Normalized Ratio (INR) of 5, indicating an increased risk of bleeding, the resident received doses of warfarin on two consecutive days. This administration occurred on 07/19/2024 and 07/20/2024, contrary to the APRN's directive to hold the medication and recheck the INR on 07/21/2024. The error was confirmed through interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged that the warfarin should not have been administered given the elevated INR levels. The INR further increased to 8.0 by 07/21/2024, exacerbating the risk of bleeding. The facility's policy on medication errors defines a significant error as one that jeopardizes the resident's health and safety, which was the case here due to the failure to adhere to the physician's orders and the subsequent increase in the resident's INR levels.
Failure to Complete Tracking/Discharge MDS for 17 Residents
Penalty
Summary
The facility failed to complete tracking/discharge Minimum Data Sets (MDS) for 17 residents (2, 4, 5, 10, 15, 17, 19, 21, 22, 25, 27, 33, 37, 39, 40, 41, 42, and 44). A record review of the sampled residents' discharge Electronic Health Records revealed that these residents did not have a tracking discharge MDS completed. During an interview, the newly hired MDS Coordinator confirmed that a tracking discharge MDS should be completed within 3 days of a resident's discharge from the facility. The MDS Coordinator had started their position on 04/08/2024. Additionally, the facility Administrator confirmed they were unaware that the tracking discharge MDS were not completed for the mentioned residents and acknowledged that they should have been completed after the residents' discharge from the facility.
Lack of Physician's Order for CPAP
Penalty
Summary
The facility failed to have a physician's order for Continuous Positive Airway Pressure (CPAP) for one resident. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, unspecified diastolic heart failure, and essential hypertension, was admitted on a specified date. The resident's care plan indicated the use of a CPAP machine due to sleep apnea, but no order for the CPAP was found in the resident's Order Summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). An observation confirmed the presence of a CPAP machine in the resident's room, and the resident confirmed its nightly use with assistance from nursing staff. An interview with an LPN confirmed the absence of an order for the CPAP or the oxygen bled into the CPAP.
Failure to Provide Written Notification of Discharge
Penalty
Summary
The facility failed to provide written notification of discharge to Resident 50 or to the resident's representative, and did not provide a written reason for the discharge. Resident 50 was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, sepsis, lymphocytosis, major depressive disorder, and mixed hyperlipidemia. On the day of the incident, the resident's oxygen saturation levels were critically low, and the night nurse found the resident visibly struggling to breathe. The resident's provider was notified, and an order was given to transfer the resident to the hospital. The resident's daughter was informed of the transfer, and the resident was taken to the hospital by rescue squad. However, no written notice or reason for the discharge was provided to the resident or the resident's representative as required by the facility's policy and regulatory guidelines. The facility's Transfer and Discharge policy mandates that notice must be provided at least 30 days prior to a facility-initiated transfer or discharge, with exceptions for urgent medical needs. In such cases, notice must be provided as soon as practicable. Despite these guidelines, the facility did not send a written reason for discharge or a notice of discharge to Resident 50 or the resident's representative. This deficiency was confirmed through interviews with the facility Administrator, who acknowledged the failure to provide the required documentation.
Failure to Notify Practitioner or Family of Resident Falls
Penalty
Summary
The facility staff failed to notify the practitioner or responsible party of falls for two residents. Resident 1, admitted with multiple diagnoses including Respiratory Syncytial Virus Pneumonia and Diabetes Type II, experienced a fall on 2/12/24. The incident report indicated that Resident 1 was found on the floor with injuries including skin tears and a bump on the left temple. However, the facility did not notify Resident 1's family about the fall, as confirmed by both the resident's emergency contact and the facility administrator during interviews conducted on 3/5/24. Resident 3, admitted with conditions such as Acute Respiratory Failure and a history of stroke, fell multiple times between 11/05/2023 and 12/19/2023. The facility's records revealed that neither the resident's family nor the physician was notified of these falls. This was confirmed through a review of progress notes and an interview with the facility administrator. The facility's policies on fall prevention and notification of changes were not adhered to, leading to a failure in communication regarding the residents' falls and injuries.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
