Sandhills Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ainsworth, Nebraska.
- Location
- 143 N Fullerton Street, Ainsworth, Nebraska 69210
- CMS Provider Number
- 285298
- Inspections on file
- 18
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sandhills Care Center during CMS and state inspections, most recent first.
The facility failed to maintain proper hand hygiene, monitor dishwasher temperatures, and ensure the cleanliness of food preparation equipment, potentially leading to foodborne illness. Staff were unaware of required temperature levels for sanitation, and improper glove use was observed. The CDM confirmed the absence of cleaning schedules and logs for dishwasher temperature checks.
The facility failed to prevent the spread of infection by not using required PPE during feeding tube care, neglecting hand hygiene during incontinence care and meal service, and not implementing a legionella water management plan.
The facility failed to protect residents from staff-to-resident verbal abuse. Several residents with severe cognitive impairments were roughly handled by a nurse aide (NA-N) during transfers, and another resident was verbally abused by an LPN (LPN-P). Despite assigning retraining, the staff returned to work without completing the required training.
The facility failed to maintain a medication error rate of less than 5%, with errors including crushing medications that should not be crushed, administering medications outside of recommended times, and not ensuring a resident consumed the entire dose. These actions were observed in multiple residents, leading to an error rate of 19.23%, significantly higher than the acceptable threshold.
A resident with severe cognitive impairment was not treated with dignity and respect during care assistance. The resident was addressed in a demeaning manner by an LPN and physically assisted in a way that did not honor their dignity. The Director of Nursing and the Administrator confirmed the incident.
The facility failed to notify a physician of a significant weight loss in one resident and a representative of increased edema, shortness of breath, persistent cough, and new physician orders in another resident. Both residents had severe cognitive impairments and multiple diagnoses, and the facility did not meet its own expectations for timely communication of these changes.
The facility failed to complete a Discharge Recapitulation Summary for a resident who was discharged. The facility's policy requires a comprehensive discharge summary, but a review of the resident's EMR revealed no evidence of its completion. The DON confirmed this omission.
A resident with multiple diagnoses and high fall risk experienced repeated falls due to the facility's failure to identify causal factors and update interventions. Despite having a fall alarm, the resident continued to fall, and staff did not consistently revise or create new interventions to prevent further incidents.
The facility failed to evaluate and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition and hydration. Despite recommendations for nutritional supplements, the facility did not implement these interventions, and the residents continued to lose weight. Interviews confirmed a lack of awareness and communication regarding the residents' weight loss and the recommended nutritional interventions.
The facility failed to ensure medications were always kept locked, outdated medications were not available for administration, and medications placed for destruction were accounted for until destroyed. Unlogged medications were found in a locked cupboard, and medications scheduled for return were in an unlocked cupboard. Outdated medications were also found in the locked medication refrigerator.
The facility failed to check the Nurse Aide/Medication Aide Registry for findings of abuse, neglect, exploitation, or theft for 4 out of 6 sampled staff members. The Business Office Manager confirmed that these checks were not being performed for all staff members.
Failure to Maintain Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to implement and maintain proper hand hygiene practices, monitor dishwasher temperatures, and ensure the cleanliness of food preparation equipment and surfaces, which could potentially lead to foodborne illness affecting all residents. During an initial kitchen tour, it was observed that there was no log for recording dishwasher temperatures, and staff were unaware of the required temperature levels for proper sanitation. Additionally, the kitchen had soiled and uncleanable surfaces, and the Ninja cooker used for food preparation was heavily soiled with grease and food debris. The Certified Dietary Manager (CDM) confirmed the absence of cleaning schedules for food service equipment and a lack of awareness among staff regarding dishwasher temperature checks. Further observations revealed that a Dietary Aide (DA) did not follow proper hand hygiene and glove use protocols. The DA was seen turning off the water with the same towel used for drying hands, wearing the same gloves while handling various food items and kitchen surfaces, and not changing gloves between tasks. This improper practice was confirmed by the CDM, who acknowledged that staff must perform hand hygiene before and after changing gloves and that gloves must be changed when touching potentially unclean surfaces. Interviews with dietary staff confirmed their lack of awareness regarding the importance of recording dishwasher temperatures and the required temperature levels for proper sanitation. The CDM also confirmed that there was no evidence or log to show that kitchen equipment and surfaces were being cleaned regularly to prevent potential foodborne illness. These deficiencies highlight significant lapses in the facility's food safety and hygiene practices, which could impact the health and safety of all residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to prevent the potential spread of infection due to several lapses in infection control practices. Staff did not wear the required Personal Protective Equipment (PPE) during the care of a resident with a feeding tube. Specifically, a Registered Nurse (RN) administered the feeding tube solution without wearing an isolation gown, which was required under the facility's Enhanced Barrier Precautions (EBP) policy. The RN confirmed a lack of knowledge about the EBP requirements, and the Director of Nurses (DON) and the administrator acknowledged that EBP had not been implemented for the resident or others who met the criteria. Additionally, staff failed to implement proper hand hygiene measures during incontinence care and meal service. During the care of a resident who was incontinent of bowel movement, a Nurse Aide (NA) did not wash or sanitize hands between changing gloves after cleaning the resident's buttocks. This was confirmed by the NA during an interview. Furthermore, staff assisting residents during meal service did not perform hand hygiene between resident contacts, handling multiple residents' utensils and cups without sanitizing their hands in between. The facility also failed to implement a legionella water management plan to prevent potential water-borne illnesses. The facility's policies required a comprehensive water management program, including risk assessments, environmental sampling, and staff education. However, the facility administrator confirmed that no such plan had been identified or implemented. This lack of action was in direct violation of the facility's own policies and procedures aimed at preventing the spread of infections and ensuring a safe environment for residents.
Failure to Protect Residents from Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect the rights of several residents to be free from staff-to-resident verbal abuse. Resident 24, who had severe cognitive impairments and required substantial assistance, was reportedly handled roughly by a nurse aide (NA-N) during a transfer using a sit-to-stand lift. Similarly, Resident 18, also with severe cognitive impairments, was roughly pulled by NA-N during a transfer, causing the resident to voice discomfort. Resident 15, who had severe memory loss and was dependent on staff for all activities of daily living, was also roughly handled by NA-N during a transfer, with the aide using an elbow to keep the resident in position. Despite these allegations, the facility's investigation concluded that NA-N did not intend harm and was unaware of their own strength. NA-N was assigned retraining but returned to work without completing the required training. Another incident involved Resident 9, who was reportedly grabbed and roughly handled by NA-N, leading to the aide's resignation. Additionally, Resident 1, who had severe cognitive impairments, was verbally abused by an LPN (LPN-P) who compared the resident's behavior to that of a 2-year-old and physically assisted the resident in a manner that resulted in bruising. The facility's investigation did not substantiate the abuse allegations but assigned retraining to LPN-P, who also returned to work without completing the required training. The Director of Nursing (DON) and the Administrator confirmed the incidents and the failure of staff to complete the required abuse training before returning to work. The facility's actions and inactions in handling these allegations and ensuring staff training contributed to the deficiency in protecting residents from abuse.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as required by their policies and professional standards of practice. Specifically, the facility staff crushed medications that should not be crushed for two residents, administered medications outside of the recommended times for two other residents, and did not ensure a resident consumed the entire dose of a medication. These actions were observed during medication administration for a sample size of 8 residents, with a facility census of 28 residents. The error rate observed was 19.23%, significantly higher than the acceptable threshold of 5%. Resident 20, who had a feeding tube due to nutritional problems and risk for aspiration, received Tamsulosin HCL in a crushed form, which should not be crushed as it could cause a potential drop in blood pressure. Similarly, Resident 28, who had heart disease and other health issues, received Isosorbide Mononitrate ER in a crushed form, which should be administered whole to prevent adverse side effects. These actions were contrary to the facility's medication administration policy and manufacturer specifications. Additionally, Resident 1, who was confused and forgetful, received Omeprazole after consuming 75% of breakfast, instead of 30 minutes before the meal as required. The same resident was also given Wheat Dextrin without ensuring the entire dose was consumed. Resident 26, who had physical and cognitive limitations, received Pantoprazole after consuming 100% of the meal, instead of 30-60 minutes before the meal. These deviations from the prescribed medication administration times and procedures were confirmed by the Director of Nursing during an interview, highlighting the facility's failure to adhere to its own policies and professional standards of practice.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident 1 with dignity and respect during care assistance. Resident 1, who had severe cognitive impairment due to non-traumatic brain dysfunction, Alzheimer's, dementia, and depression, required partial to moderate assistance with toileting, dressing, and personal hygiene. On 5/5/24, when Resident 1 was incontinent, LPN-P documented that the resident slapped NA-Y during an attempt to assist the resident in getting dressed. LPN-P then addressed the resident in a demeaning manner, comparing their behavior to that of a 2-year-old and insisting that the resident could either get up on their own or be assisted by LPN-P and NA-Y. The resident, who was resistive, was then physically assisted into a seated position on the bed and subsequently ambulated to the bathroom and later to the dining room for breakfast. The Director of Nursing and the Administrator confirmed during an interview on 5/21/24 that Resident 1 was not treated with respect and dignity by LPN-P on 5/5/24. The facility's list of Resident's Rights, which is provided to each resident and/or their responsible party upon admission, states that all residents have the right to be treated with respect and dignity. This incident highlights a failure to uphold these rights, as evidenced by the inappropriate and disrespectful manner in which LPN-P interacted with Resident 1 during care assistance.
Failure to Notify Physician and Representative of Resident Changes
Penalty
Summary
The facility failed to notify Resident 11's physician of a significant weight loss and Resident 24's representative of increased edema, shortness of breath, persistent cough, and new physician orders related to the resident's change in condition. Resident 11, who had severe cognitive impairment and multiple diagnoses including dementia and cancer, experienced a weight loss of 22 lbs. over six months. Despite the facility's policy requiring staff to report significant weight losses to the physician, there was no evidence that Resident 11's physician was notified of this weight loss. The resident's care plan indicated a risk for nutritional decline and required extensive staff assistance with eating, but the necessary communication with the physician was not documented. Resident 24, who also had severe cognitive impairment and diagnoses including heart failure and dementia, exhibited increased edema, shortness of breath, and a persistent cough. Although the resident's physician was notified and new orders were received, there was no evidence that the resident's representative was informed of these changes and new orders. The facility's Director of Nursing confirmed that there was no policy related to notification of change for a physician and/or responsible party, and that the charge nurses were expected to notify the resident's physicians and representatives within 24 hours of a change in condition. The facility failed to meet these expectations for both residents, leading to the identified deficiencies.
Failure to Complete Discharge Recapitulation Summary
Penalty
Summary
The facility failed to complete a Discharge Recapitulation Summary for Resident 29, who was admitted on an unspecified date and discharged on 4/17/24. The facility's policy, revised in October 2022, mandates that a discharge summary and post-discharge plan be developed for anticipated discharges. This summary should include comprehensive details such as diagnoses, medical history, treatment, functional status, and medication reconciliation. However, a review of Resident 29's Electronic Medical Record (EMR) revealed no evidence of a completed discharge summary. The Director of Nursing (DON) confirmed during an interview on 5/22/24 that the comprehensive Discharge Recapitulation Summary was not completed for Resident 29.
Failure to Prevent Ongoing Falls for High-Risk Resident
Penalty
Summary
The facility failed to identify causal factors and develop or revise interventions to prevent ongoing falls for a resident identified as high risk for falls. The resident, who had diagnoses including osteoarthritis, atrial fibrillation, heart failure, non-Alzheimer's dementia, anxiety, and depression, experienced multiple falls over several months. Despite the resident's high fall risk score and repeated incidents, the facility did not consistently update or create new interventions to address the falls effectively. For instance, after falls on 2/3/24, 3/10/24, 3/20/24, and 4/26/24, staff did not determine causal factors or revise current interventions. The resident's fall incidents included situations where the fall alarm was either not functioning or not responded to in a timely manner. On 1/19/24, the resident fell in the dining room despite having a fall alarm in place. On 2/3/24, the resident fell out of a chair, and the incident report noted that nothing could be done to avoid future falls, with no causal factors identified. On 3/10/24, the resident was found on the floor by the Nurse's Station, but no new interventions were developed. Similar patterns were observed in subsequent falls, with staff failing to revise interventions or identify new ones. The Director of Nursing confirmed that the resident was at high risk for falls and that the fall alarm was sometimes rendered dysfunctional due to the resident's restlessness. Despite this, the facility continued to use the alarm without ensuring its consistent functionality. The DON also verified that staff were supposed to develop new interventions or revise current ones with each fall, but this was not done consistently. The lack of timely and effective intervention updates contributed to the ongoing falls and potential injuries for the resident.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition and hydration. Resident 11, who had severe cognitive impairment and multiple diagnoses including dementia and cancer, experienced a weight loss of 12% over six months. Despite the Registered Dietician's recommendation for a Complete Nutrition Supplement (CNS), the facility did not implement this intervention, and the resident continued to lose weight. Observations revealed that the resident was not provided with the CNS during meals, and there was no documented evidence that the supplement was given as recommended by the RD. Resident 15, who also had severe cognitive impairment and was totally dependent on staff for assistance, experienced a weight loss of 17.07% over six months. The resident had a physician's order for a nutritional supplement to be given if meal consumption was 50% or less. However, the facility failed to document the resident's meal intake percentages and the amount of nutritional supplement provided. Multiple instances were noted where the resident ate less than 50% of their meals, but no supplement was documented as given. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Dietary Manager (DM) confirmed the lack of awareness and communication regarding the residents' weight loss and the recommended nutritional interventions. The facility's failure to monitor, document, and implement appropriate nutritional interventions contributed to the ongoing weight loss in both residents, highlighting a significant deficiency in the facility's care practices.
Medication Storage and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure medications were always kept locked, outdated medications were not available for administration, and medications placed for destruction were accounted for until destroyed. During an observation of the medication storage, it was found that there was no accounting or logged amounts of the current medication placed for destruction in a locked cupboard at the nurse's station. Various unlogged medications, including Spiriva inhaler, Colace, multivitamin tablets, Aspirin, Requip, Nicotine patches, Pain Relief tablets, Eliquis, Zofran, Nitroglycerin, Novolog insulin, Levemir insulin, Acetaminophen, lidocaine patches, Lasix, Nyst/Hydrac/Zinc cream, Breo, Voltaren gel, and Antacid were present in the cupboard. Additionally, medications scheduled to be returned to the pharmacy were observed in an unlocked cupboard at the nurse's station, including Trazadone, Olanzapine, Bumetanide, Anti-diarrheal, Tylenol, Ibuprofen, and Zoloft tablets. Furthermore, outdated medications were found in the facility's locked medication refrigerator, including Tuberculin injectable and COVID-19 vaccine, which were still available for use despite being past their expiration dates. Interviews with the LPN and DON confirmed that all outdated medications should not be available for administration and should be placed for destruction. The DON also confirmed that all facility medications were to be locked and secure at all times while being stored in the facility. The medications scheduled to be returned to the pharmacy had been stored in an unlocked cabinet at the nurse's station, and the medications that had been discontinued and stored in a locked cabinet at the nurse's station had not been logged to ensure accountability for those medications in the interim between the time they were placed in the cabinet and the time when they would be destroyed. The facility's policies on medication storage and destruction of unused drugs were not adhered to, leading to these deficiencies.
Failure to Check Nurse Aide/Medication Aide Registry for Staff
Penalty
Summary
The facility failed to check the Nurse Aide/Medication Aide Registry for findings of abuse, neglect, exploitation, or theft for 4 out of 6 sampled staff members. Personnel files reviewed on May 23, 2024, showed no evidence that the registry was checked for a Housekeeping/Laundry staff member, an LPN, a Dietary Aide, and a Domestic Aide. During an interview on the same day, the Business Office Manager confirmed that the facility was not performing these checks for all staff members.
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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