Ridgewood Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seward, Nebraska.
- Location
- 624 Pinewood Avenue, Seward, Nebraska 68434
- CMS Provider Number
- 285279
- Inspections on file
- 13
- Latest survey
- January 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ridgewood Rehabilitation & Care Center during CMS and state inspections, most recent first.
The facility did not ensure that two nursing assistants completed the required 12 hours of in-service training for 2024. NA-D completed 8.59 hours and NA-E completed 11.05 hours of education through Relias. Interviews with the IP/SD confirmed the deficiency, which had the potential to affect all 57 residents.
The facility's Life Enrichment kitchen, serving 10-12 residents, was found to have unclean appliances, including a microwave with food splatters and a refrigerator/freezer with food drippings. Cleaning logs for the past two months were incomplete, despite a schedule requiring daily cleaning. The facility's RD and Administrator confirmed these findings.
A facility failed to obtain a physician's order for the settings of a CPAP machine for a resident with Obstructive Sleep Apnea. The resident had moderate cognitive impairment and was prescribed CPAP use at bedtime, but the specific settings were not documented. An interview with the ADON confirmed the absence of CPAP settings, and facility education materials lacked instructions on CPAP settings.
A facility failed to provide justification for extending PRN Alprazolam use beyond 14 days for a resident with anxiety disorder, dementia, and other conditions. The physician did not document the rationale for the extended prescription, and facility records lacked documentation of behaviors justifying the medication's use on several occasions. Observations showed the resident appeared calm, questioning the necessity of the PRN medication.
Two residents in a LTC facility experienced significant medication errors due to staff not following proper procedures. One resident received Phenobarbital from an LPN who did not verify the medication, while another resident with diabetes received insulin without the pen being primed, contrary to policy. These actions were against the facility's medication administration protocols.
The facility failed to label and date food stored in the Life Enrichment refrigerator and freezer as per policy. Observations revealed various food items, including grapes, cake, cheese, beef snack sticks, and ice cream, were not properly labeled or dated. The RD confirmed the non-compliance with the facility's Visitor Food policy, which requires food to be labeled, dated, and stored safely.
The facility failed to maintain proper infection control practices, as evidenced by improper catheter care for two residents and inadequate cleaning of nebulizer kits for three residents. A nursing assistant used contaminated gloves and failed to perform hand hygiene during catheter care, while nebulizer kits were left with residual medication and facial oils, indicating they were not cleaned after use. These deficiencies were confirmed by facility staff and highlight systemic issues in infection control.
The facility failed to properly label and date food items, ensure proper handwashing techniques by kitchen staff, maintain cleanliness in storage areas, and test the sanitizing solution. These deficiencies were confirmed by the cook and RD, affecting the safety and quality of food served to residents.
The facility failed to ensure the oxygen concentrator's cabinet filters were present and clean for four residents, and the PAP masks for two residents were cleaned daily. Additionally, the PAP filter for one resident was not clean. Observations and interviews confirmed that the required maintenance and cleaning were not performed consistently.
A resident with multiple medical conditions was frequently observed with thick oral secretions extending from their mouth to their lap. Despite having a suction machine in the room, it was not set up or used as per physician orders. Staff only suctioned the resident when they choked during oral care, leading to a deficiency in maintaining the resident's dignity and proper care.
Deficiency in Required In-Service Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that two nursing assistants, NA-D and NA-E, completed the required 12 hours of in-service training for the year 2024, as mandated by licensure reference number 175 NAC 12.006.04(B)(ii)(1). Record reviews revealed that NA-D completed only 8.59 hours and NA-E completed 11.05 hours of education through Relias, a healthcare training provider. NA-D was hired on July 11, 2013, and NA-E on December 17, 2022. Interviews with the Infection Preventionist/Staffing Development (IP/SD) confirmed that the facility's training year runs from January 1st to December 31st, and both nursing assistants did not meet the required training hours for 2024. This deficiency had the potential to affect all 57 residents in the facility.
Unclean Kitchen Appliances in Life Enrichment Kitchen
Penalty
Summary
The facility failed to maintain cleanliness in the Life Enrichment kitchen, which serves food to 10-12 residents. Observations revealed that the microwave had multi-colored food splatters and debris, while the refrigerator/freezer contained food drippings and debris. A review of the facility's Deep Cleaning schedule indicated that these appliances should have been cleaned daily. However, the Weekly Cleaning logs for the past two months did not show completion of these tasks. Both the facility's Registered Dietician and Administrator confirmed the unclean state of the kitchen appliances.
Failure to Obtain CPAP Settings for Resident
Penalty
Summary
The facility failed to obtain a physician's order for the settings of a CPAP machine for a resident diagnosed with Obstructive Sleep Apnea. The resident, who was admitted to the facility with moderate cognitive impairment, had a physician's order for CPAP use at bedtime and discontinuation in the morning. However, the specific settings for the CPAP machine were not documented in the physician's orders, care plan, or treatment administration record. An interview with the Assistant Director of Nursing confirmed the absence of CPAP settings for the resident. Additionally, the facility's educational materials on CPAP/Bi-Level units did not include instructions regarding the CPAP settings.
Failure to Justify Extended PRN Use of Alprazolam
Penalty
Summary
The facility failed to provide a valid rationale and justification for extending the use of PRN Alprazolam (Xanax) for a resident beyond the 14-day limit. The resident, who had a history of anxiety disorder, pain, dementia, COPD, and pneumonia, was prescribed Alprazolam to be taken twice daily and as needed every eight hours for anxiety. However, the physician did not document the rationale for the PRN prescription exceeding 14 days, as required by regulations. The facility's records, including the Physician Visit/Communication Form, did not include any justification for the extended use of the medication. Additionally, the facility's documentation did not support the administration of PRN Xanax on several occasions, as there were no documented behaviors or clinical indications justifying its use on those dates. Observations of the resident showed that they appeared calm and in no distress, further questioning the necessity of the PRN medication. The facility's administrator confirmed the lack of documented rationale and behaviors to justify the use of Xanax on specific dates, indicating a failure in adhering to the required medication management protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 5, a Registered Nurse (RN) improperly removed a Phenobarbital pill from the narcotic drawer and handed it to a Licensed Practical Nurse (LPN-A) for administration, which is against the facility's policy. The LPN-A then administered the medication to Resident 5 via a peg tube without verifying the medication against the medication record, which was confirmed as the normal practice for this resident. Interviews with the RN and LPN-A confirmed the improper handling and administration of the medication. For Resident 36, who has a history of Type 2 Diabetes Mellitus and moderate cognitive impairment, a medication error occurred during insulin administration. The LPN-B administered 21 units of Novolog insulin without priming the needle, contrary to the facility's Pre-filled Insulin Pen Competency Policy. The policy requires priming the pen before each administration to ensure the correct dose is delivered. The LPN-B was under the impression that priming was only necessary the first time the pen was used, which was incorrect according to the Interim Director of Nursing (DON). These incidents highlight a failure in following established medication administration protocols, leading to significant medication errors for both residents. The facility's policies clearly outline the correct procedures for medication handling and administration, which were not adhered to in these cases, resulting in deficiencies noted by the surveyors.
Improper Labeling and Dating of Resident Food
Penalty
Summary
The facility failed to ensure that food stored in the Life Enrichment refrigerator and freezer was properly labeled and dated according to the facility's Visitor Food policy. During observations on multiple occasions, it was noted that various food items, including grapes, cake, cheese, beef snack sticks, and ice cream, were not labeled with the resident's full name or dated. The facility's policy requires that food brought in by visitors for residents be labeled, dated, and stored safely in a designated area following food safety guidelines. The Registered Dietician (RD) confirmed the observations, acknowledging that the items in the refrigerator and freezer should have been sealed, labeled with the resident's name, and dated with the date they were placed in storage. Despite the facility's policy, the food items were found to be non-compliant, lacking proper labeling and dating, which is essential for maintaining food safety and ensuring that residents receive safe and appropriate food storage.
Infection Control Deficiencies in Catheter and Nebulizer Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Resident 4's catheter care was compromised when a nursing assistant (NA-C) used contaminated gloves to handle cleansing wipes and failed to perform hand hygiene after removing gloves. The NA-C also touched the resident's catheter tubing without gloves and engaged in other activities of daily living without washing hands. These actions were confirmed by both the interim Director of Nursing (DON) and the NA-C, who acknowledged the lapses in infection control procedures. Resident 11's catheter care was similarly deficient. The NA-C placed the catheter drainage bag on the floor and used contaminated gloves to handle cleansing wipes. The NA-C did not perform hand hygiene or change gloves during the procedure, which was confirmed by both the interim DON and the NA-C. Additionally, the facility lacked a specific catheter care policy, which contributed to the improper handling of the catheter drainage bag and the failure to maintain proper hygiene. The facility also failed to properly clean nebulizer kits for Residents 2, 22, and 50. Observations revealed that the nebulizer kits were left with residual medication and facial oils, indicating they were not cleaned after use. The Assistant Director of Nursing (ADON) confirmed that the nebulizer kits should have been cleaned and dried after each treatment, as per the facility's policy. These deficiencies in infection control practices were observed across multiple residents, highlighting a systemic issue within the facility.
Multiple Deficiencies in Food Storage, Handwashing, and Sanitizing Procedures
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in refrigerators and freezers. Observations revealed multiple opened containers and bags of food items, such as chicken base, mozzarella cheese, and various vegetables, that were not labeled or dated. The facility's cook and Registered Dietician (RD) confirmed these items should have been labeled and dated after being opened. Additionally, food stored for residents in the side-by-side refrigerator/freezer in the North dining room was also found to be improperly labeled and dated, with items such as a bowl covered with plastic wrap and a green cup without proper labeling or dating. The facility also failed to ensure proper handwashing techniques were followed by kitchen staff. Observations showed the cook performing handwashing for only 12 seconds and changing gloves multiple times without washing hands in between tasks. The RD confirmed that the cook should have washed hands for at least 20 seconds and performed handwashing before and after glove changes. Furthermore, the floors in the walk-in refrigerator, walk-in freezer, and locked dry storage room were found to be dirty, with gray fuzzy substances and scattered food items observed. The cook and RD confirmed that these areas should have been clean. Lastly, the facility did not test the sanitizing solution in the sanitizing bucket to ensure its effectiveness. The cook was observed wiping the prep table with a rag from the sanitizing bucket without testing the solution's dilution. A review of the kitchen's logbooks revealed no records of testing the sanitizing bucket. The cook confirmed that the sanitizing bucket had not been tested since being re-hired and should have been tested twice a day to ensure the sanitizer was effective. The RD also confirmed that the sanitizing bucket should have been tested regularly.
Failure to Maintain Oxygen Concentrator Filters and Clean PAP Masks
Penalty
Summary
The facility failed to ensure the oxygen concentrator's cabinet filters were present and clean for four residents (Residents 2, 4, 31, and 60) out of five sampled residents. Observations revealed that the oxygen concentrators in the rooms of these residents were missing cabinet filters, which should have been cleaned and replaced weekly. Interviews with staff confirmed that the filters were not maintained as required, leading to the presence of gray fuzzy substances on the internal filters of the concentrators. The Assistant Director of Nursing (ADON) confirmed that the external cabinet filters should have been cleaned and replaced every week, but this was not done consistently. Additionally, the facility failed to ensure that the positive airway pressure (PAP) masks for two residents (Residents 2 and 60) were cleaned daily. Observations showed that the PAP masks had an oily film on the mask seals, indicating they were not wiped daily as required by the facility's policy. Interviews with the residents and staff confirmed that the masks were only cleaned weekly, not daily. The ADON acknowledged that the staff did not follow the policy for daily cleaning of the PAP masks. Furthermore, the facility did not ensure that the PAP filter for one resident (Resident 20) was clean. Observations revealed that the PAP filter had a gray fuzzy substance on it, indicating it had not been cleaned or replaced as required. Interviews with the resident and staff confirmed that the filter maintenance was not performed as per the manufacturer's recommendations. The ADON confirmed that the PAP filter should have been cleaned and changed but was not, leading to the deficiency.
Failure to Manage Resident's Oral Secretions
Penalty
Summary
The facility failed to ensure the dignity of a resident by not properly managing their oral secretions. Resident 4, who has multiple medical diagnoses including Cerebral Palsy and Dysphagia, was observed multiple times with thick strands of secretions extending from their mouth to their lap. Despite having a suction machine in the room, it was not set up or used as per the physician's orders, which stated that the resident should be suctioned orally as needed every hour for secretions. Staff confirmed that they only suctioned the resident when they choked during oral care, and not as a routine measure to manage the secretions. Observations over several days revealed that the resident was frequently seen with thick secretions and a towel covering their chest and abdomen, which was held by clips around the neck. The suction machine in the resident's room was consistently found without the necessary canister or tubing set up, rendering it unusable. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the presence of thick secretions was considered normal for the resident, and the staff did not routinely suction the resident unless they were choking. The Administrator acknowledged that the excessive secretions could be a dignity issue and admitted that the staff had not attempted to suction the resident throughout the day to see if it would reduce the secretions. The facility did not know how the resident felt about the excessive secretions and the use of a towel to protect their clothing. This lack of action and failure to follow physician orders led to the deficiency in maintaining the resident's dignity and proper care.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
