Omaha Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 4835 South 49th Street, Omaha, Nebraska 68117
- CMS Provider Number
- 285240
- Inspections on file
- 26
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Omaha Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a stage four pressure ulcer and chronic pain received a wound dressing change without appropriate pain management, despite exhibiting clear signs of severe pain such as crying, yelling, and verbalizing distress. Staff did not pause the procedure to assess or address the pain, and interviews confirmed that additional pain medication should have been administered prior to the treatment but was not.
An LPN did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The LPN changed gloves multiple times during the procedure without using hand sanitizer or washing hands in between, and later confirmed this omission.
The facility did not follow individualized care plan interventions for two residents: one with a history of falls did not have required fall-prevention measures in place, and another dependent on staff for transfers was assisted by only one staff member instead of two, resulting in a significant leg injury. Staff interviews confirmed a lack of awareness and adherence to care plan requirements.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple chronic conditions and significant pain did not receive several scheduled doses of prescribed medications, including pain management and other treatments, due to delays in pharmacy delivery and the absence of a facility policy for handling unavailable medications. Facility staff confirmed the missed doses and the lack of a system to ensure medication availability.
Two residents with documented medication allergies were prescribed and administered drugs to which they had known or potential allergies. In both cases, alerts for allergies were either overridden or not followed up, and there was no evidence of provider consultation or evaluation. The DON confirmed that the facility lacked a policy for addressing medication allergies.
A resident with multiple chronic conditions and moderate cognitive impairment had conflicting documentation regarding CPR preferences, with both DNR and full code forms present in the record. The facility did not consistently update or confirm the resident's code status in the electronic health record, and staff interviews revealed inconsistent processes for verifying advance directives, leading to a failure to ensure the resident's wishes were clearly documented and communicated.
A resident with multiple medical conditions and a vegetarian diet experienced significant unaddressed weight loss. Staff did not complete a requested re-weigh, failed to assess the weight loss, and did not implement new interventions. Dietary staff were unaware of the resident's nutritional needs, and the resident was observed receiving inadequate meals.
Staff did not follow ordered interventions to prevent pressure ulcers for two residents at risk. One resident was observed in bed without the required Prevalon boot, and another was repeatedly found without heel elevation or use of heel protection boots, despite care plans and practitioner orders. Both staff and residents confirmed these interventions were not consistently implemented.
A resident with multiple diagnoses and a high risk for falls experienced two falls during care due to staff not implementing additional interventions beyond those already in place. The care plan required two staff for bed mobility and proper positioning, but these measures were not consistently followed, and no new interventions were added after the incidents, as confirmed by the DON.
Facility staff did not complete all required background and registry checks for two housekeeping staff members prior to hire, as confirmed by the facility administrator. Facility policy mandates screening for abuse, neglect, exploitation, or misappropriation history before employment, but documentation was missing or incomplete for these employees.
A resident with hypertension, severe sepsis, and diabetes had specific wound care orders for their left foot's second toe, which were not followed by an LPN. Instead of using mild soap and water as ordered, the LPN used saline to cleanse the toe. The LPN acknowledged the deviation from the practitioner's orders during an interview.
The facility failed to maintain a safe and clean environment in nine resident rooms, affecting 14 residents. Observations included unsanitary conditions, structural issues, and non-functional equipment, confirmed by the Maintenance Director and Administrator.
The facility failed to maintain functional ambulation for a resident post-toe amputation surgery, as therapy services were discontinued without a follow-up mobility program, leading to a decline in ambulation. Additionally, another resident did not receive follow-up audiology services for hearing aids, despite a prior recommendation, due to the facility's inaction.
A resident with multiple medical conditions, including post-traumatic seizures, did not receive a complete dose of Dilantin as ordered due to improper medication administration via a gastric tube. The LPN responsible failed to ensure all medication particles were fully dispersed in water, leaving remnants in the cup. This resulted in a significant medication error, as confirmed by the DON.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, including not wearing gowns during high-contact care activities and improper handling of medical equipment. A nursing assistant did not wear a gown while performing catheter care for a resident, and an RN failed to wear a gown while flushing a feeding tube. Additionally, an oxygen nasal cannula was used on a resident after being on the floor, and a stethoscope was not sanitized after use on a resident under EBP.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
Facility staff failed to implement appropriate pain management interventions during wound care for a resident with a stage four pressure ulcer. The resident, who had diagnoses including depression, osteoarthritis, and chronic pain, was admitted with a significant sacral wound and had a history of almost constant pain, frequently rated as severe. The resident's care plan included both scheduled and as-needed pain medications, specifically acetaminophen and oxycodone, and the facility's policy required staff to anticipate, evaluate, and manage pain in accordance with the resident's assessment and plan of care. On the day of the observed incident, the resident received scheduled acetaminophen and a PRN dose of oxycodone several hours before a negative pressure wound therapy (NPWT) dressing change. During the procedure, the resident exhibited clear signs of pain, including yelling, crying, facial grimacing, and verbalizing distress. Despite these indications, the staff performing the wound care did not pause the procedure to assess the resident's pain or offer additional pain relief. Instead, they continued the treatment while providing only verbal encouragement and distraction techniques. Interviews with staff confirmed that the procedure was known to be painful and that the resident was in significant distress during the dressing change. The Assistant Director of Nursing acknowledged that a PRN dose of oxycodone should have been administered prior to the treatment but was not. The resident later reported experiencing pain at the highest level during the procedure and stated that staff did not offer the option to stop the treatment or address the pain further.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During wound care treatment for one resident, an LPN failed to perform hand hygiene between glove changes as required by facility policy. The facility's hand hygiene policy, revised in October 2022, specifies that staff must use an alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after handling used dressings and contaminated equipment, and after removing gloves. Observation revealed that the LPN washed hands and donned gloves and a gown at the start of the procedure, but subsequently removed gloves and donned new ones multiple times without performing hand hygiene in between. This sequence occurred while providing wound care to the resident's posterior thighs and right posterior heel. The LPN confirmed in an interview that hand hygiene was not performed between glove changes and acknowledged that it should have been done.
Failure to Implement Care Plan Interventions for Transfers and Fall Prevention
Penalty
Summary
The facility failed to implement and follow individualized care plan interventions for two residents, resulting in a significant injury for one and failure to prevent potential falls for another. For one resident with moderate cognitive impairment and a history of repeated falls, the care plan included specific interventions such as pinning the top blankets to the fitted sheet to prevent entanglement and offering bathroom assistance at designated times. Multiple observations revealed that the top covers were not pinned as required, and staff interviews confirmed a lack of awareness regarding this intervention. This failure to implement the care plan intervention was directly observed on several occasions and acknowledged by both nursing assistants and an LPN. For another resident with cirrhosis, muscle weakness, generalized edema, and diabetes, the care plan specified that transfers from bed to wheelchair required two staff members and the use of a slide board or Hoyer lift. Despite this, the resident was transferred by only one staff member, a Certified Medication Aide, without the use of a gait belt or slide board. The aide reported that the resident claimed to transfer independently and instructed the aide on how to position the wheelchair. During the transfer, the resident sustained a laceration to the left lower leg after hitting the wheelchair pedal bracket, requiring hospital transport and stitches. Interviews with staff and the resident confirmed that only one staff member was present during the transfer, contrary to the care plan requirements. Facility policies reviewed indicated that individualized care plans are to be developed and interventions provided according to professional standards and the resident's needs. The failure to follow these care plans and ensure staff awareness of required interventions led to a significant injury and the lack of fall prevention measures for the residents involved. The deficiencies were identified through observation, record review, and staff interviews.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for a resident with multiple chronic conditions, including pneumonia, chronic inflammatory demyelinating polyneuritis, neuropathy, chronic pain, and osteoarthritis. Record reviews showed that the resident was admitted with significant pain and required scheduled and PRN pain medications, among other treatments. Despite these needs, the Medication Administration Records (MARs) revealed multiple instances where prescribed medications, including buprenorphine for pain, fish oil, polyethylene glycol, lubiprostone, Bactrim DS, and Metamucil, were not administered on several dates across multiple months. Notably, there were 11 consecutive missed doses of buprenorphine and several other missed doses of various medications. Interviews with facility staff, including the Unit Manager and DON, confirmed that the resident did not receive all scheduled medications on the identified dates. The DON further confirmed that some missed doses were due to waiting for pharmacy delivery, and acknowledged that the facility did not have a policy regarding unavailable medications. The lack of a system or policy to ensure timely medication availability and administration directly contributed to the resident not receiving necessary medications as ordered.
Failure to Evaluate and Address Medication Allergies
Penalty
Summary
The facility failed to properly evaluate and address medication allergies for two residents. For one resident with a history of respiratory failure, COPD, pneumonia, and chronic inflammatory demyelinating polyneuritis, records showed an allergy to Bactrim with a previously observed mild adverse reaction resulting in increased serum creatinine. Despite this documented allergy, the resident was prescribed and administered Bactrim DS on multiple occasions, and the provider overrode the allergy alert without documented consultation or follow-up in the electronic health record. The Director of Nursing confirmed that the allergy was not addressed at the time of order entry and that there was no facility policy regarding medication allergies. Another resident with acute respiratory failure and documented allergies to aspirin, codeine, penicillin, and zaleplon was prescribed Diclofenac sodium gel, a nonsteroidal anti-inflammatory drug. An alert for a possible drug allergy was generated in the electronic medical record, but there was no evidence of evaluation or follow-up regarding the potential allergy to Diclofenac. The Director of Nursing confirmed that no follow-up was completed and that the facility lacked a policy for addressing potential drug allergies when alerts were triggered.
Failure to Ensure Accurate and Updated Advance Directive Documentation for Code Status
Penalty
Summary
The facility failed to ensure that a signed Advance Directive Code Status Form was properly completed and updated to confirm a resident's directives for Cardiopulmonary Resuscitation (CPR). The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, congestive heart failure, and chronic obstructive pulmonary disease, and was assessed as having moderate cognitive impairment. Upon admission, the resident's care plan indicated full code status, and interventions required quarterly review of code status during care plan conferences. However, there were inconsistencies in the documentation of the resident's code status. The medical record contained both a form signed by the resident's representative indicating Do Not Resuscitate (DNR) and a form signed by the resident indicating full code. Hospital discharge orders also indicated DNR status, but the facility's electronic health record did not reflect an updated Advance Directive Code Status form confirming the DNR status. Multiple orders and practitioner notes alternated between DNR and full code, and the process for updating and confirming code status was not consistently followed as outlined in facility policy. Interviews with facility staff revealed that code status was typically determined at admission and entered into the medical record, but there was no consistent process for verifying or updating this information, especially on readmission or during care plan reviews. The facility's policy required that advance directives be reviewed, validated, and communicated to the care team, but this was not consistently documented or implemented for the resident. As a result, there was a failure to ensure the resident's wishes regarding CPR were clearly documented and communicated prior to an emergency event.
Failure to Address Significant Weight Loss and Dietary Needs
Penalty
Summary
Facility staff failed to evaluate and implement interventions to prevent significant weight loss for a resident with multiple medical conditions, including hyperlipidemia, hypokalemia, muscle weakness, dysphagia, and protein calorie malnutrition. The resident, who followed a lacto-ovo-vegetarian diet, experienced a weight loss of 20.4 lbs (11.11%) over 90 days. Despite this significant weight loss, there was no documented assessment or follow-up by the registered dietitian (RD) or other staff after a re-weigh was requested. The care plan did not include specific interventions to address the resident's vegetarian diet or food preferences, and the dietary staff were unaware of how to meet the resident's nutritional needs. Observations showed the resident was served inadequate meals, such as a salad without protein or dressing and a small drink, which the resident expressed dissatisfaction with. Interviews with the dietary supervisor and RD revealed a lack of awareness regarding the resident's significant weight loss and dietary needs. The director of nursing confirmed that the re-weigh requested by the RD was not completed and that no new interventions were implemented despite the resident's ongoing weight loss.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Facility staff failed to implement ordered interventions to prevent pressure ulcer development for two residents identified as at risk. For one resident with multiple diagnoses including malnutrition, muscle weakness, and impaired cognition, the care plan and practitioner orders required the use of a Prevalon boot on the left foot while in bed. Observations on multiple occasions revealed the resident was in bed without the Prevalon boot, and the device was found on the chest of drawers instead of being used as ordered. A nursing assistant confirmed the boot was not in place during an interview. For another resident with diagnoses including schizoaffective disorder, depression, and obesity, the care plan and practitioner orders required the resident's heels to be elevated while in bed to prevent skin breakdown. Multiple observations showed the resident in bed without their feet elevated, and heel protection boots were found on top of the dresser rather than in use. The resident reported that staff did not elevate their feet or use the heel boots, and a nursing assistant confirmed the resident's feet were not elevated during an interview.
Failure to Implement Additional Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement additional interventions to prevent falls for a resident who was identified as being at risk for falls. The resident, who had diagnoses including schizoaffective disorder, depression, obesity, and required assistance with personal care, was assessed as cognitively intact and dependent on staff for transfers and bed mobility. The resident's care plan included interventions such as keeping the bed in the lowest position, ensuring appropriate footwear, and requiring two staff members for bed mobility. Despite these interventions, the resident experienced two falls during care provision, one in which the resident's legs hung over the bed and they were lowered to the floor, and another where the resident slid off the bed. After the first fall, the only intervention added was to ensure the resident was positioned in the middle of the bed. Following the second fall, the intervention was updated to require two staff for bed mobility. The Director of Nursing confirmed that two staff should have been assisting during both incidents and that the resident should have been positioned in the middle of the bed, but no new interventions were implemented after these falls.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
Facility staff failed to complete required background and registry checks for two of five employee files reviewed. Specifically, one housekeeping staff member was hired without documentation of a Nurse Aide registry check, and another housekeeping staff member was hired with only Adult/Child Protection Services background checks completed, lacking other required screenings. The facility administrator confirmed during interview that the necessary background checks had not been completed for these two staff members. Facility policy requires screening of potential employees for history of abuse, neglect, exploitation, or misappropriation prior to hire, including documentation from licensing or registration boards and other registries.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility staff failed to follow the practitioner's orders for wound care for a resident with a history of hypertension, severe sepsis with septic shock, and diabetes. The resident was admitted with a specific treatment order for the left foot's second toe, which included cleaning with mild soap and water, applying betadine, and covering with a non-adherent dressing. However, during an observation, an LPN was seen using saline instead of mild soap and water to cleanse the toe, which was not in accordance with the practitioner's orders. The LPN confirmed during an interview that the correct procedure was not followed.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed in nine rooms on the second-floor north hallway. These deficiencies included unsanitary conditions such as a dark brown smeared substance resembling bowel movement on a toilet riser and seat, and a ventilation cover in a resident bathroom covered with a gray fuzzy substance resembling dust. Structural issues were also noted, such as an open and exposed floor radiator cover, missing and damaged drawer components in dressers, gouged and broken floor tiles, and protruding sharp edges from vent covers and baseboards. Additional observations included a continuously running shared toilet, a non-functional bathroom vent, and various holes and cracks in the drywall. The environmental tour conducted with the Maintenance Director and Administrator confirmed these issues, which had the potential to affect all 14 residents utilizing the affected rooms. The facility census at the time was 58, indicating that a significant portion of the resident population was impacted by these environmental deficiencies.
Failure to Maintain Ambulation and Follow Up on Audiology Appointment
Penalty
Summary
The facility staff failed to maintain functional ambulation for a resident who had undergone toe amputation surgery earlier in the year. Despite being cognitively intact and having a history of high blood pressure, peripheral vascular disease, end-stage renal disease, diabetes mellitus type 2, and heart failure, the resident reported not receiving therapy and feeling weaker post-surgery. The resident's last recorded physical and occupational therapy session was in mid-February, and there was no subsequent functional mobility program implemented. The Director of Rehabilitation confirmed the resident had not received therapy services since then, leading to a decline in the resident's ability to ambulate. Additionally, the facility staff did not follow up on an audiology appointment for another resident who was supposed to be fitted for hearing aids. This resident, also cognitively intact, had a history of diabetes mellitus, Parkinson's disease, heart failure, and high blood pressure. The resident had an audiology appointment in March of the previous year, with a recommendation to be fitted for hearing aids within 1-3 months. However, there were no further audiology appointments recorded, and the Director of Nursing confirmed the facility did not assist the resident in obtaining the hearing aids.
Incomplete Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received a complete dose of seizure medication as ordered, resulting in a significant medication error. Resident 34, who was admitted with multiple diagnoses including cerebral infarction, hydrocephalus, and post-traumatic seizures, was dependent on staff for all activities of daily living and received all nutrition and medications through a gastric tube. The resident had a physician's order for Dilantin 100 mg every 8 hours via the g-tube. During an observation, it was noted that the LPN responsible for administering the medication crushed the Dilantin tablet and mixed it with water, but visible remnants of the medication remained in the cup after administration, indicating that the full dose was not delivered to the resident. The facility's policy for medication administration via feeding tube requires that tablets be crushed to a fine consistency and fully dispersed in water before administration. However, the LPN did not ensure that all particles were in solution, leading to the incomplete administration of the medication. The Director of Nursing confirmed that the resident did not receive the complete dose of Dilantin, which constituted a significant medication error. This incident highlights a failure in adhering to the facility's medication administration procedures, resulting in a deficiency in the care provided to Resident 34.
Infection Control Deficiencies in EBP and Equipment Handling
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during care activities for several residents, as observed by surveyors. For Resident 215, nursing assistants NA-D and NA-E did not wear gowns while performing catheter care, despite the EBP sign on the resident's door indicating the requirement for gown and glove use. Both the nursing assistants and the Director of Nursing (DON) acknowledged the oversight. Similarly, for Resident 53, Registered Nurse (RN) F did not wear a gown while flushing the resident's feeding tube, even though the care plan and EBP signage specified the need for gown and glove use due to the resident's high risk of infection from a multidrug-resistant organism (MDRO). In another instance, the facility failed to maintain proper infection control practices concerning oxygen equipment. An oxygen nasal cannula for Resident 3 was observed lying on the floor, and later, a nursing assistant placed the same cannula into the resident's nose without cleaning it. The facility's policy requires that any nasal cannula that comes into contact with the floor should be replaced, a fact confirmed by both the nursing assistant and the DON. Additionally, the facility did not ensure proper sanitization of medical equipment used on residents under EBP. LPN H used a stethoscope on Resident 34, who was under EBP, and failed to sanitize it before leaving the room. The stethoscope was then carried to another area of the facility, potentially risking cross-contamination. The DON confirmed that the stethoscope should have been cleaned before being taken out of the resident's room.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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