Quality Living, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 6404 North 70th Plaza, Omaha, Nebraska 68104
- CMS Provider Number
- 28A060
- Inspections on file
- 12
- Latest survey
- March 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Quality Living, Inc. during CMS and state inspections, most recent first.
Facility staff failed to follow hand hygiene protocols during meal preparation, as observed with a dietary assistant who did not wash hands between glove changes. Additionally, staff with full beards did not wear beard restraints while preparing food, violating the facility's hygiene policy. These deficiencies affected residents in the Summit area and House 4.
The facility failed to follow proper infection control and medication handling procedures. An LPN did not perform hand hygiene between glove changes during wound care for a resident with multiple sclerosis. Additionally, a urinary drainage bag for another resident was found on the floor, and medications were handled without gloves for two residents. These actions were confirmed by staff and the DON.
A resident with multiple sclerosis and severe cognitive impairment developed a stage 3 pressure ulcer on the coccyx, but the facility failed to notify the medical provider of this significant change. The facility's policy required prompt reporting of such changes, but this was not followed, as confirmed by the DON.
A facility failed to re-evaluate a protective device as a potential restraint for a resident with severe cognitive impairment. The resident was observed with a trunk restraint, and the facility did not update or re-evaluate the interventions since 2022. Despite a physician's order for a floor alarm, seat belt, and video monitoring, these interventions were not fully implemented, as confirmed by observations and an interview with the administrator.
A resident with intact cognitive function developed an abrasion on the right heel, which was not properly documented or treated by the facility. The nurse failed to record the wound's condition when it was found, and treatment orders for Mepilex dressing and triple antibiotic ointment were not transcribed to the MAR/TAR, leading to a lack of treatment monitoring.
A resident with multiple sclerosis and severe cognitive impairment developed a stage 3 pressure ulcer due to the facility's failure to conduct weekly skin evaluations and adhere to treatment orders. The LPN applied incorrect treatment, and the DON confirmed the lack of proper documentation and adherence to orders, leading to a decline in the resident's skin condition.
A resident dependent on staff for all care and movements did not receive adequate Range of Motion (ROM) exercises as per their care plan. The resident's care plan required passive ROM exercises three times a week for the upper extremities and neck, but documentation showed inconsistent performance of these exercises. ROM for the lower extremities was not included in the care plan, and therapy staff failed to document the exercises. The facility's policy emphasizes the importance of ROM exercises, but the care plan was not updated, and documentation was lacking, leading to a deficiency in care.
A facility failed to evaluate a G-tube for drainage or migration before administering tube feeding to a resident with aphasia, quadriplegia, and traumatic brain disorder. Despite the resident's abdominal pain, an LPN did not inspect the G-tube site, contrary to facility policy. The resident's care plan required nutrition via G-tube, and the facility's policy mandated physician notification if drainage or migration was suspected.
A facility failed to identify and monitor specific target behaviors for a resident's as-needed antianxiety medications. Despite the resident having intact cognition and a diagnosis of anxiety disorder, the Comprehensive Care Plan lacked specific target behaviors for the use of hydroxyzine and clonazepam. The facility's policy required monitoring of psychotropic medication use, but this was not adhered to, as confirmed by a Registered Nurse Coordinator.
The facility's QAPIP failed to identify and address deficiencies found during an annual survey, including issues with physician notification, skin and pressure ulcer treatments, range of motion services, tube feeding, anxiety medication use, and hand hygiene. Staff interviews revealed a lack of awareness of the QAPIP, and the DON confirmed the absence of effective Performance Improvement Programs, affecting all 95 residents.
Failure in Hand Hygiene and Beard Restraint Compliance
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols during meal preparation, as observed on multiple occasions. Dietary Assistant (DA)-R was seen putting on gloves without washing hands, handling various food items, and changing gloves without performing hand hygiene. This occurred during the preparation of pureed fish and corn, where DA-R used the same gloves to handle different food items and equipment, and placed soiled gloves on a spice table before donning a new pair without washing hands. An interview with DA-R confirmed the failure to wash hands after glove removal, which is against the facility's hand hygiene policy. Additionally, the facility staff did not comply with the policy requiring beard restraints in the food preparation area. Observations revealed that House Supervisor (HS)-H and Physical Therapist (PT)-I, both with full beards, prepared food without wearing beard nets. This was confirmed by interviews with the facility Compliance Coordinator and the House Coordinator for House 4, where 10 residents were affected by the food prepared in the house kitchen. The lack of beard restraints during food preparation is a violation of the facility's hygiene policy, which mandates hair and beard restraints to prevent contamination.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care, urinary drainage bag handling, and medication administration. For Resident 39, who has multiple sclerosis and severe cognitive impairment, an LPN did not perform hand hygiene between glove changes while providing wound care. This was confirmed by both the LPN and the Director of Nursing (DON). Additionally, a Medication Aid (MA) administered medications to Resident 39 without wearing gloves, directly handling omeprazole and potassium chloride capsules, which was also acknowledged as improper by the MA and the DON. For Resident 47, who also has severe cognitive impairment and requires total assistance, the external urinary catheter drainage bag was observed lying on the floor on two separate occasions. This was confirmed by a Nurse Aid (NA) and a Campus Leader (CL), who acknowledged that the bag should have been placed in a designated basin to prevent infection. Furthermore, another incident involved an LPN opening a Dantrolene capsule without gloves for Resident 5, which was confirmed as a breach of protocol by both the LPN and the DON.
Failure to Notify Physician of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to notify the medical practitioner of a change in wound condition for a resident with multiple sclerosis. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 4, required extensive assistance with daily activities and had a pressure ulcer. On a specific date, a stage 3 pressure ulcer was identified on the resident's coccyx, but there was no documentation indicating that the physician had been notified of this significant change in the resident's condition. An interview with the Director of Nursing confirmed that the medical provider was not informed about the stage 3 pressure ulcer. The facility's policy, dated December 2023, emphasized the importance of notifying medical providers of significant changes in a resident's condition to ensure effective medical care. However, in this instance, the facility did not adhere to its policy, resulting in a failure to communicate a critical change in the resident's health status to the medical provider.
Failure to Re-evaluate Protective Device as Potential Restraint
Penalty
Summary
The facility failed to re-evaluate a protective device as a potential restraint for a resident with severe cognitive impairment. The resident, identified as having a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, was observed with a trunk restraint while in a chair or out of bed. The resident's Minimum Data Set (MDS) dated February 11th, 2025, confirmed the use of a trunk restraint. A Physical/Occupational Therapy Evaluation and Consent for Use of Protective Devices dated April 8th, 2021, indicated the use of a rear buckling lap belt due to falls and decreased awareness. However, the facility did not update or re-evaluate the interventions since 2022, as confirmed by an interview with the facility's administrator. The physician's order for the resident's protective device, dated March 16th, 2021, included interventions such as a floor alarm, seat belt, and video monitoring due to the resident's diffuse weakness, poor balance, and unawareness of deficits. Observations on February 25th and March 3rd, 2025, revealed the resident had a seatbelt across their lap, but no transfer pole or video monitoring was in place as ordered. The facility's policy on restraints/protective devices requires a medical provider order for any type of restraint or protective device, but the facility failed to adhere to this policy by not updating or re-evaluating the interventions for the resident.
Failure to Document and Administer Treatment for Heel Abrasion
Penalty
Summary
The facility failed to properly evaluate and document the condition of an abrasion on a resident's right heel when it was initially discovered. The resident, who had intact cognitive function and was independent in walking and transfers, developed a small abrasion on the right heel due to rubbing against the toenail of the left foot while sleeping. Despite the resident's report that staff checked the area daily, there was no documentation of the wound's condition until a late entry note was made during the annual survey. The nurse who initially found the abrasion did not document any information, measurements, or the condition of the wound at the time it was discovered. Additionally, the facility did not ensure that treatment orders for the resident's heel abrasion were transcribed to the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Orders for Mepilex dressing and triple antibiotic ointment were not recorded, resulting in a lack of monitoring to confirm that the treatments were administered. The Residential Nurse Coordinator confirmed these omissions and acknowledged that the nurse should have documented the wound assessment and condition when it was first identified.
Failure to Monitor and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly evaluate, implement treatment orders, and monitor a pressure ulcer for a resident with multiple sclerosis and severe cognitive impairment. The resident required extensive assistance with daily activities and had a pressure ulcer. The facility's care plan included following physician orders for treatment, monitoring, and documenting the condition of skin injuries. However, the facility did not conduct weekly skin and wound evaluations as ordered, resulting in a decline in the resident's condition, including the development of a stage 3 pressure ulcer on the coccyx. Additionally, the facility did not adhere to treatment orders for the resident's buttocks wounds. Observations revealed that the LPN applied calmoseptine cream to both wounds, contrary to the order to crust the buttocks with calmoseptine and stoma powder. The DON confirmed that the observed treatment was not in line with the current orders, and there were no treatment orders documented for the right buttock. This lack of adherence to treatment protocols contributed to the resident's deteriorating skin condition.
Inadequate Range of Motion Exercises for a Resident
Penalty
Summary
The facility staff failed to provide adequate Range of Motion (ROM) exercises to maintain mobility for a resident, identified as Resident 29, who was dependent on staff for all care and movements. The resident's Minimum Data Set (MDS) indicated impairments on both sides of the body involving upper and lower extremities, and the care plan specified that the resident was to receive passive ROM exercises three times a week for the bilateral upper extremities and neck. However, documentation revealed that ROM exercises were inconsistently performed, with significant gaps in the frequency of exercises provided. For instance, ROM to the neck was performed only six times out of twelve potential visits in December 2024, three times in January 2025, and five times in February 2025. Similarly, ROM for the upper extremities was performed only four times in December 2024, once in January 2025, and once in February 2025. ROM for the lower extremities was performed only twice in December 2024 and not at all in January and February 2025. The facility's policy on exercise and ROM, dated April 25, 2012, outlines the importance of these exercises in maintaining joint mobility and preventing complications such as contractures and muscle atrophy. Despite this, the care plan was not updated to include lower extremities, and therapy staff failed to document the ROM exercises. An interview with the Administrator confirmed these deficiencies, highlighting a lack of adherence to the care plan and documentation requirements. This failure to provide consistent and documented ROM exercises represents a deficiency in the care provided to Resident 29, potentially impacting their mobility and overall health status.
Failure to Evaluate G-Tube Before Feeding
Penalty
Summary
The facility failed to evaluate the gastrostomy tube (G-tube) for drainage or migration prior to administering tube feeding for one resident. The resident, who had diagnoses of aphasia, quadriplegia, and traumatic brain disorder, required tube feeding for nutrition and hydration. The facility's policy stated that if drainage or migration was suspected, the physician should be notified for further assessment. However, during an observation, a Licensed Practical Nurse (LPN) administered tube feeding without checking the G-tube site for drainage or migration, contrary to the facility's policy. The resident's Minimum Data Set (MDS) indicated that the resident was rarely or never understood, and the Comprehensive Care Plan (CCP) highlighted the need for nutrition and hydration via G-tube. Despite the resident experiencing abdominal pain the night before, the LPN did not inspect the G-tube site before proceeding with the feeding. An interview with the LPN revealed that tube placement checks were only performed when ordered by a physician, and a Registered Nurse Coordinator confirmed that without direct inspection, leakage or migration could not be detected.
Failure to Monitor Specific Target Behaviors for Antianxiety Medication Use
Penalty
Summary
The facility failed to identify and monitor specific target behaviors for the continued use of as-needed antianxiety medications for a resident. The interdisciplinary team was responsible for ensuring appropriate use, evaluation, and monitoring of psychotropic medications, as per the facility's undated policy. However, a review of the resident's Comprehensive Care Plan (CCP) revealed no evidence of specific target behaviors, despite the resident receiving antianxiety, antidepressant, and hypnotic medications. The resident had a diagnosis of anxiety disorder and was prescribed hydroxyzine and clonazepam for anxiety. The Minimum Data Set (MDS) indicated that the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. The Medication Administration Record (MAR) included an order for behavior monitoring for anxiety to be documented every shift, but the lack of specific target behaviors was confirmed during an interview with the Registered Nurse Coordinator. This deficiency highlights the facility's failure to adhere to its policy on monitoring psychotropic medication use, which is crucial for ensuring the appropriate and safe use of such medications.
Ineffective QAPIP and Unaddressed Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement Program (QAPIP) effectively identified and addressed concerns related to deficient practices identified during the annual survey. These deficiencies included issues such as failure to notify physicians of changes in resident conditions, inadequate skin and pressure ulcer treatments, insufficient services for range of motion, improper tube feeding services, inappropriate use of anxiety medication, and repeated issues with hand washing and gloving during care and medication pass. The facility also did not maintain correction for a repeat deficiency related to hand hygiene from a previous survey. Interviews with several staff members, including nurse aides and a registered nurse, revealed a lack of awareness of the QAPIP within the facility. Additionally, the Director of Nursing and the Compliance Coordinator confirmed that the facility did not have Performance Improvement Programs in place to address the new deficiencies identified during the survey. They acknowledged that the QAPIP process had not been effective in identifying and addressing current issues, which had the potential to affect all 95 residents residing in the facility.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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