Skyview Care And Rehab At Bridgeport
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Nebraska.
- Location
- 505 O Street, Bridgeport, Nebraska 69336
- CMS Provider Number
- 285224
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Skyview Care And Rehab At Bridgeport during CMS and state inspections, most recent first.
A medication aide prepared a resident’s ordered morning meds, including Potassium Chloride used as a nutritional supplement, and mixed them into pudding. When the resident refused the Potassium Chloride tablet, the aide removed the tablet from the pudding and discarded it in the resident’s room trash can, then left the room without removing the trash bag, contrary to the facility’s policy requiring proper disposal of non-controlled medications in accordance with state and federal guidelines. A regional nurse consultant later confirmed this was not the correct disposal method.
Surveyors observed that a medication aide documented multiple medications as administered to two residents when they were not actually given, including a topical barrier ointment, a multivitamin related to a sacral pressure ulcer, nasal sprays, Nystatin powder, and Potassium Chloride tablets. During medication passes, the aide failed to remove or administer certain ordered medications, discarded a refused Potassium Chloride tablet in the resident’s room trash after mixing it in pudding, did not attempt to discuss the need for the refused medication, and did not notify nursing or providers of the refusal, contrary to facility documentation policy. These actions resulted in a medication error rate significantly above the required threshold.
Surveyors found that several residents did not receive appropriate pressure ulcer prevention and wound care. In multiple cases, wound treatments were missed or not completed as ordered, supplies were unavailable, and care plans were not updated to reflect residents' risk for pressure ulcers. Staff failed to reposition residents regularly, set air mattresses to the correct weight, and use the correct wound care products. These failures led to worsening wounds and, in one case, contributed to a resident's death from infection.
Two residents experienced neglect when the facility failed to maintain adequate supplies for wound care and blood glucose monitoring. One resident with a severe pressure ulcer did not receive prescribed wound treatments due to a lack of Anasept cleanser, leading to worsening of the wound and subsequent death from infection. Another resident with diabetes missed multiple blood glucose checks and insulin doses because the facility ran out of monitoring strips and did not secure a backup supply, resulting in a critically high blood glucose level.
A resident with severe cognitive impairment and chronic pain was unable to reliably swallow oral medications, resulting in repeated missed doses of pain and other essential medications. Despite clear non-verbal signs of pain and withdrawal, staff did not effectively communicate the issue to the NP or implement alternative pain management strategies, leading to unmanaged pain and discomfort.
The facility failed to notify providers and family members of significant changes in condition for several residents, including the development of new wounds and episodes of hypoglycemia requiring emergency intervention. Staff did not document or communicate missed wound care and diabetic management orders, such as blood glucose monitoring and insulin administration, due to lack of supplies. These lapses were confirmed by interviews with nursing staff and the DON, who acknowledged the absence of timely provider notification and documentation.
Three residents who were fully dependent on staff for bathing, including individuals with dementia, muscle weakness, and pressure ulcers, experienced significant gaps of up to 11 days between baths. Documentation and interviews confirmed that staff did not provide the required assistance with bathing at the necessary frequency.
Surveyors found that the facility did not follow provider orders and its own protocols for medication and treatment administration for several residents. This included not administering bowel protocol interventions as required, delaying the start of prescribed medications, failing to implement changes to medication regimens in a timely manner, and incorrectly entering and administering ear care orders. These actions resulted in residents not receiving care as ordered by their providers.
Several residents with complex medical needs did not receive timely laboratory testing or blood glucose monitoring as ordered, due to missed sample collections, lack of documentation, and a shortage of blood glucose monitoring strips. Staff did not notify providers of delays or pursue alternative solutions, resulting in missed lab tests and insulin doses for residents requiring close monitoring.
Two residents experienced significant medication errors when one continued to receive a muscle relaxant on a routine schedule despite a provider order to change it to PRN, and another did not receive scheduled blood glucose checks or insulin doses due to a lack of monitoring strips, resulting in missed care and elevated blood glucose levels.
Staff failed to consistently use clean barriers and properly handle wound care supplies during procedures for two residents, resulting in clean supplies being placed directly on bedding and contaminated items being returned to containers with clean supplies, creating a risk of cross-contamination.
A deficiency occurred when the facility did not provide enough nursing staff to safely assist residents with mechanical lifts and activities of daily living. Several residents who required two-person assistance for transfers were often moved by a single staff member, and many did not receive scheduled showers or timely toileting help. Staff shortages led to delays and unsafe practices, with both cognitively impaired and physically dependent residents affected.
Three residents experienced deficiencies in pressure ulcer prevention and care, including the development of new Stage 3 pressure ulcers, lack of timely provider notification, incomplete care plans, missed wound care treatments, and inconsistent documentation of wound assessments and nutritional support. These failures resulted in inadequate monitoring and management of pressure ulcers.
The facility did not ensure an RN was on duty for at least 8 hours daily and failed to assign a full-time RN as DON, as evidenced by staffing records and facility documentation.
Multiple residents did not receive required assistance with ADLs such as bathing, toileting, and personal hygiene, as documented in their care plans. Residents and staff reported missed showers, long waits for help, and the need for residents to perform tasks independently due to staff shortages. Facility records showed inconsistent documentation of care, and the lack of a working bathtub further limited bathing options.
The facility did not ensure that mechanical lift transfers were performed with the required two-person assistance, as outlined in both facility policy and resident care plans. Due to ongoing staffing shortages, staff frequently transferred residents alone using Hoyer and sit-to-stand lifts, despite residents' high acuity and dependence on staff for transfers. Staff and residents confirmed that single-staff transfers had become common practice, leading to concerns about safety and adherence to established protocols.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
Surveyors observed a medication error rate of 20% involving two residents, where staff administered medications late and failed to follow proper administration techniques, such as not allowing an oral disintegrating tablet to dissolve as directed. Both a medication aide and an LPN cited unfamiliarity with the medication cart as a factor in the errors, resulting in multiple medications being given outside the prescribed time window and not according to manufacturer instructions.
A resident with a complex medical history missed three doses of IV meropenem due to failures in medication administration, including lack of IV access after self-removal of a midline and two missed doses by an LPN who did not follow protocol to notify supervisory staff. These omissions were confirmed through documentation and interviews.
A resident experienced a fall with injury, and the facility failed to submit the investigation report to the State Agency within the required 5 working days. The report was submitted late, as confirmed by the Administrator.
A resident with a history of falls and mobility issues experienced multiple falls without new interventions being developed. The care plan lacked updates for specific falls, and interventions were often duplicated, failing to address the resident's fall risk effectively.
The facility failed to prepare foods following the recipe, affecting all 41 residents. The Dietary Supervisor used incorrect weights for pork chops, discarded bad onions, and substituted French onion soup mix for missing ingredients, deviating from the recipe.
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11%. This affected three residents, with issues including late administration, missed doses, and lack of knowledge on medication procedures by a newly trained medication aide.
A resident with severe cognitive impairment and COPD was on Metoprolol Tartrate for hypertension. The facility failed to notify the physician of multiple low blood pressure readings and did not recheck the blood pressure as required. The Medication Administration Record showed that blood pressure and pulse were not monitored daily, and the Medication Regimen Review from the pharmacy consult had no recommendations for nearly a year.
The facility failed to complete the Admission MDS within the required 14-day period for a resident admitted with unspecified dementia. The MDS was completed 18 days after the ARD, as confirmed by the Regional MDS Nurse Coordinator, who is only present in the building two days per week and handles multiple responsibilities.
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with Osteomyelitis. The resident's Comprehensive Care Plan was undated, and no baseline care plan was documented. The MDS coordinator confirmed the absence of the baseline care plan and that the resident was not offered a copy, contrary to the facility's policy.
The facility failed to identify causative factors and implement new interventions to prevent falls for a resident with a history of multiple falls. Despite a care plan indicating a risk for falls, no new interventions were placed after several falls, and incident reports did not identify causative factors, contrary to facility policy.
The facility failed to implement proper infection control practices during medication administration for three residents. An RN and a medication aide did not change gloves after contamination and did not follow proper procedures, leading to deficient infection control practices.
Improper In-Room Disposal of Prescribed Medication
Penalty
Summary
The facility failed to ensure secure disposal of medication when a medication aide (MA-A) improperly discarded a resident’s prescribed drug in the resident’s room trash. Record review showed the resident was admitted on 5/27/2022 and had an active order for Potassium Chloride, indicated as a nutritional supplement, with a start date of 4/16/2025. The facility’s Discarding and Destroying Medication policy, revised November 2022, stated that non-controlled and Schedule V (non-hazardous) controlled substances are to be disposed of in accordance with state regulations and federal guidelines. On 2/18/2026 at 9:42 AM, MA-A prepared the resident’s morning medications, including Potassium Chloride, and carried them into the resident’s room in a medication cup, then mixed the medications into the resident’s pudding. When the resident stated they did not want to take the Potassium Chloride tablet, MA-A scooped the tablet out of the pudding and placed it into the trash can in the resident’s room, then showed the surveyor that the medication cup was empty and left the room without removing the trash bag containing the Potassium Chloride tablet. At 1:15 PM the same day, the Regional Nurse Consultant confirmed this was not the correct way to dispose of medications.
Medication Administration and Documentation Errors Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 6 errors out of 31 medication administration opportunities, resulting in a 19.35% error rate. For one resident, record review showed active orders for Calmoseptine ointment to be applied to the bilateral buttocks four times daily for barrier protection and a daily multivitamin tablet related to a sacral pressure ulcer. During a medication pass observation, the medication aide documented both the Calmoseptine and the multivitamin as “given,” but did not remove either medication from the cart or administer them at that time. In an interview during the observation, the medication aide confirmed charting the Calmoseptine as given but stated it would not actually be administered until the resident left the dining room. For another resident, record review showed active orders for Flonase nasal spray for nasal congestion and drainage, Ipratropium Bromide nasal solution for sinusitis, Nystatin powder ordered both as needed and scheduled for application under the breasts for itching, and Potassium Chloride oral tablets as a nutritional supplement. The facility’s documentation policy required accurate charting, proper correction of errors, and detailed documentation of treatment refusals, including resident response, reasons for refusal, and physician notification. Observation of a medication pass revealed the medication aide charted all of these medications as “given,” but only removed oral tablets from the cart and mixed them into pudding. When the resident refused the Potassium Chloride tablet, the aide removed the pill from the pudding and discarded it in the resident’s trash without attempting to discuss the need for the medication or notifying nursing or providers of the refusal. The resident later confirmed that the Nystatin powder, Flonase nasal spray, and Ipratropium Bromide nasal solution were not offered and described using the nasal spray only after blowing the nose and the Nystatin powder after showering or when excessively sweating.
Failure to Prevent and Treat Pressure Ulcers and Complete Wound Care as Ordered
Penalty
Summary
Surveyors identified multiple deficiencies related to the prevention and treatment of pressure ulcers and wound care. In one case, a resident with dementia, chronic inflammatory demyelinating polyneuritis, and a stage 4 pressure ulcer did not consistently receive wound care as ordered. Documentation showed missed dressing changes, lack of supplies (specifically Anasept cleanser), and infrequent bathing, with gaps of up to ten days between baths. Progress notes indicated that wound treatments were not completed for various reasons, including the resident sleeping, dressing being intact, or supplies being unavailable. The resident's wound worsened, and the nurse practitioner noted a significant decline, ultimately leading to hospitalization for wound evaluation. The resident later died from osteomyelitis and sepsis, with the nurse practitioner attributing the outcome to missed dressing changes and inadequate hygiene. Another resident, also with dementia and generalized muscle weakness, was identified as being at risk for pressure ulcers due to immobility and incontinence. However, the care plan did not address this risk until after a pressure ulcer had developed. Weekly skin assessments were not completed as ordered, and there was a lack of documentation and follow-up when an open wound was first observed. The resident's air mattress was set incorrectly for their weight, and staff failed to reposition the resident as required, with observations showing the resident remained in the same position for extended periods. Additional deficiencies were found with other residents. One resident with multiple stage 2 and unstageable pressure ulcers had an air mattress set for a weight much higher than their actual weight, and staff were unsure of the correct settings. The resident was not repositioned every two hours as required, and staff did not respond to complaints of pain until prompted. Another resident did not receive wound care as ordered, with the DON using the wrong medication for a wound treatment due to not being aware of a recent order change. These findings demonstrate failures in implementing and following care plans, completing wound care as ordered, and ensuring proper preventive measures for pressure ulcer management.
Failure to Maintain Essential Medical Supplies Resulting in Neglect
Penalty
Summary
The facility failed to ensure residents were free from neglect by not maintaining adequate supplies necessary to meet residents' medical needs. For one resident with dementia, chronic inflammatory demyelinating polyneuritis, and a stage 4 pressure ulcer, the required wound care supplies, specifically Anasept cleanser, were not available from 10/31/2025 onward. As a result, prescribed wound care treatments were not performed as ordered, and the resident's wound condition worsened. Documentation and interviews confirmed that the nurse management team and DON were aware of the supply shortage, but the Anasept was not reordered in a timely manner, leading to missed treatments and a significant decline in the resident's health, ultimately resulting in death from osteomyelitis and sepsis as noted by the nurse practitioner. Another resident with type I diabetes and diabetic polyneuropathy did not receive scheduled blood glucose monitoring or insulin doses due to the facility running out of blood glucose monitoring strips. The medication administration records showed missed blood glucose checks and insulin administrations over multiple scheduled times. Staff and the DON confirmed that the facility did not have a backup supply of strips, and no alternative methods were used to obtain them when the pharmacy could not provide any. The resident's blood glucose was not checked for four consecutive scheduled times, and insulin doses were missed, with a critically high blood glucose level documented once strips became available again. In both cases, the facility's failure to maintain essential medical supplies directly resulted in the inability to provide necessary care as ordered by physicians. The lack of timely supply management and failure to implement contingency plans led to significant lapses in care for residents with complex medical needs.
Failure to Address Uncontrolled Pain and Withdrawal in Non-Verbal Resident
Penalty
Summary
The facility failed to identify and address uncontrolled pain and withdrawal symptoms in a resident who could no longer reliably swallow oral medications. The resident, who had severe cognitive impairment, dementia, and generalized muscle weakness, was admitted with chronic pain due to osteopenia and had a care plan in place for pain management. Despite this, documentation showed repeated instances where the resident refused or was unable to take prescribed medications, including pain medications, due to difficulty swallowing and refusal to open their mouth. Nursing staff attempted to administer medications by crushing them and mixing them with food, but the resident only accepted a few bites before refusing further. Progress notes indicated that the resident's pain medications, as well as other essential medications for anxiety, depression, and muscle weakness, were frequently not administered over a period of time. Observations revealed the resident exhibited non-verbal signs of pain, such as facial grimacing, groaning, rigid posturing, and restless legs, which were audible and visible to staff. Despite these clear indications of discomfort and withdrawal, there was no evidence that the facility had a protocol for assessing pain in non-verbal residents, nor was there timely communication with the nurse practitioner regarding the resident's inability to take oral medications. Interviews with staff confirmed that the resident's non-verbal pain was significant and that the nurse practitioner was unaware of the ongoing medication administration issues until informed by the surveyor. The director of nursing acknowledged discussions about comfort care but stated that no changes had been made to the resident's medication regimen due to issues with the power of attorney. The lack of timely intervention and communication resulted in the resident experiencing unmanaged pain and withdrawal symptoms.
Failure to Notify Providers and Follow Diabetic and Wound Care Orders
Penalty
Summary
The facility failed to notify providers and family members of significant changes in residents' conditions and was unable to follow provider orders for diabetic care and wound management for multiple residents. For one resident with dementia and muscle weakness, staff identified a new skin wound but did not document a skin assessment or notify the provider or family until the wound was later found to be an unstageable sacral pressure injury. Documentation gaps were noted in weekly skin assessments, and there was no evidence of timely communication with the provider regarding the wound's development. Another resident with a stage 4 pressure ulcer did not receive prescribed wound care due to the facility running out of the required wound cleanser. The provider was not notified of the inability to complete the treatment as ordered, and the wound worsened significantly before the provider was made aware. Similar failures occurred in diabetic care, where residents with orders for frequent blood glucose monitoring and insulin administration missed scheduled checks and doses due to the facility running out of blood glucose monitoring strips. The provider was not notified of the missed checks or doses, and there was no documentation of attempts to obtain the necessary supplies through alternative means. For several residents with diabetes, blood glucose levels were not monitored as ordered, and insulin was administered without corresponding blood glucose readings. In some cases, residents received emergency glucagon injections for hypoglycemia without the provider being notified, and documentation of provider notification was missing. Interviews with staff and the DON confirmed these lapses in communication and documentation, as well as the lack of backup supplies and failure to notify providers when orders could not be followed.
Failure to Provide Timely Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with bathing for three residents who were fully dependent on staff for activities of daily living. Record reviews showed that one resident with dementia and generalized muscle weakness did not receive a bath for two separate 10-day periods. Another resident with a Stage 2 pressure ulcer and upper extremity impairment experienced gaps of 10 and 11 days between baths. A third resident, diagnosed with dementia, chronic inflammatory demyelinating polyneuritis, and a Stage 4 pressure ulcer, went 10 days without a bath, despite being dependent on staff for bathing and requiring substantial assistance for transfers. Interviews with the Director of Nursing and Regional Nurse Consultant confirmed these lapses in care, as documented in the residents' records. The documentation indicated that the residents were not provided with the necessary assistance for bathing at the frequency required, and refusals were only documented in one instance. The findings were based on a review of admission records, Minimum Data Set assessments, and bathing documentation forms.
Failure to Follow Provider Orders and Facility Protocols for Medication and Treatment Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and facility policy for several residents. For one resident with a history of abdominal pain and no bowel movement for 11 days, the facility did not follow its bowel protocol, which required specific interventions at set intervals without a bowel movement. The resident did not receive the ordered Polyethylene glycol until five days after it was prescribed, and there was no documentation of bowel movements or administration of PRN interventions such as Milk of Magnesia, Bisacodyl suppository, or Fleets enema as outlined in the facility's policy. Additionally, the facility did not implement provider orders as written for multiple residents. One resident was admitted and had several medication orders, but there was no evidence that these medications were started upon admission as required, and there was no directive from the hospital or pharmacy to delay administration. Another resident with a diagnosis of Major Depressive Disorder had an order for escitalopram that was not started for several days after the provider's order, and the provider noted the delay in the resident's follow-up visit. Similarly, a resident with an order to change a muscle relaxant from routine to PRN did not have the order changed until four days after the provider's instruction. Further deficiencies were noted in the administration of ear care for a resident with otitis media. The resident was ordered to receive carbamide peroxide ear drops followed by irrigation, but the orders were entered incorrectly, and the treatment was not completed as prescribed, resulting in the need for the provider to reorder the treatment. Another resident with Major Depressive Disorder had their fluoxetine discontinued without documented reason, then received a one-time dose, and the medication was later re-entered, with the Regional Nurse Consultant confirming the discontinuation was in error. These failures demonstrate a pattern of not following provider orders and facility protocols for medication and treatment administration.
Failure to Provide Timely Laboratory Services and Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide and report timely laboratory services and perform blood glucose monitoring as ordered for several residents. For multiple residents with complex medical conditions, including diabetes, congestive heart failure, and chronic kidney disease, laboratory tests such as Basic Metabolic Panel (BMP), urine microalbumin, creatinine, and Vitamin D levels were not collected or reported within the timeframes specified by provider orders. In several cases, there was no documentation of attempts to collect samples, no notification to providers regarding delays, and no evidence that results were communicated as required by facility policy. For example, one resident's BMP was ordered to be drawn on a specific date but was not collected until several days later, and another resident's urine sample was not collected for over a week after the order was placed, despite repeated requests from the provider. Additionally, the facility failed to perform blood glucose monitoring per provider orders for residents with diabetes. On specific dates, blood glucose checks were not completed as scheduled for multiple residents, and insulin doses were missed as a result. The failure was attributed to the facility running out of blood glucose monitoring strips and not maintaining a backup supply. Despite being aware of the shortage, staff did not notify the provider in a timely manner or pursue alternative means to obtain the necessary supplies, resulting in missed monitoring and medication administration for residents who required frequent blood glucose checks due to their fragile diabetic status. Interviews with facility leadership, including the DON and NP, confirmed that the facility did not follow its own policies regarding laboratory management and diabetes monitoring. There was a lack of documentation regarding efforts to collect samples, communicate delays, or notify providers of issues affecting resident care. The deficiencies affected multiple residents and were confirmed through record reviews, interviews, and the absence of required documentation in the medical records.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. For one resident with a history of postlaminectomy syndrome, chronic pain, and muscle spasms, the provider changed the order for tizanidine from a routine schedule to as needed (PRN) due to the resident experiencing drowsiness and dizziness after a dose increase. Despite this order being given, the medication continued to be administered on a routine basis for several days before the order was updated, resulting in the resident receiving more medication than prescribed during that period. Another resident with Type I Diabetes Mellitus and diabetic polyneuropathy did not receive scheduled blood glucose monitoring or insulin doses for multiple administration times. This occurred because the facility ran out of blood glucose monitoring strips and did not have a backup supply. The staff did not obtain strips from alternative sources, and as a result, the resident's blood glucose was not checked, and insulin was not administered as ordered. When strips became available, the resident's blood glucose was found to be significantly elevated, and an extra dose of insulin was required. Interviews with facility staff and the nurse practitioner confirmed the sequence of events, including the delay in updating medication orders and the lack of timely action to secure necessary supplies for blood glucose monitoring. Documentation in the medical records and medication administration records supported these findings, showing missed doses and lack of provider notification regarding the missed monitoring and medication administration.
Failure to Prevent Cross-Contamination During Wound Care Procedures
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care procedures for two residents. According to the facility's wound care policy, a clean field must be established using a disposable cloth or paper towel before placing wound care supplies on a resident's overbed table. However, during wound care for one resident, the Director of Nursing (DON) placed clean wound care supplies directly on the resident's bed without first placing a clean barrier. The DON also placed items such as a permanent marker, binder, and wound care supplies on the bed, and returned used items like scissors and partially used dressings to the container with clean supplies. Both the DON and the Regional Nurse Consultant confirmed that a clean barrier should have been used. For another resident, the DON initially placed wound care supplies on a paper towel on the resident's bed, but during the procedure, the wound cleanser bottle rolled off the paper towel and came into direct contact with the resident's bedding. The DON then placed the bottle back into the container with other clean wound care supplies. Additionally, open packages of dressings and wound measuring papers were left exposed inside the container with clean supplies. These actions were observed during wound care procedures and confirmed through interviews with the DON. The observations and interviews revealed that the facility did not consistently follow its own infection prevention and control policies during wound care, specifically regarding the use of clean barriers and the handling of wound care supplies. This created the potential for cross-contamination of supplies and compromised the sterile field required for proper wound care.
Failure to Provide Adequate Staffing for Resident Transfers and ADLs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly those requiring assistance with mechanical lifts for transfers and activities of daily living (ADLs). Multiple residents who required two-person assistance for transfers with Hoyer or sit-to-stand lifts were often transferred by a single staff member, contrary to facility policy and individual care plans. This practice was confirmed through staff and resident interviews, as well as direct observation, and was attributed to ongoing staffing shortages. In some cases, staff who were minors and not permitted to operate mechanical lifts were scheduled, further exacerbating the issue. Residents dependent on staff for transfers, such as those with severe cognitive impairment or physical limitations, were left waiting for extended periods for assistance or were transferred unsafely. Documentation and interviews revealed that residents frequently did not receive scheduled showers or timely toileting assistance, with some residents reporting going up to two weeks without bathing. Staff reported working extended hours and being unable to provide adequate care due to insufficient staffing, leading to delays in meeting residents' basic hygiene and mobility needs. Observations showed residents left unattended for long periods, requesting help to go to bed or to the toilet, and not receiving assistance in a timely manner. Staff confirmed that due to the lack of available personnel, they often had to perform transfers alone, even when two-person assistance was required for safety. The deficiency affected both residents with cognitive impairment and those who were cognitively intact but physically dependent, resulting in unmet care needs and deviations from established care plans.
Failure to Prevent and Manage Pressure Ulcers and Inadequate Wound Care Monitoring
Penalty
Summary
The facility failed to prevent the development of avoidable pressure ulcers and did not provide adequate monitoring, treatment, and care for existing pressure ulcers in three residents. One resident, who was re-admitted with multiple risk factors such as Multiple Sclerosis, immobility, and incontinence, had no pressure ulcers upon admission but developed two Stage 3 pressure ulcers during their stay. The care plan for this resident did not address their risk for pressure ulcers, and there was no evidence of timely provider notification or implementation of interventions when skin issues were first identified. Weekly skin assessments and wound monitoring were inconsistently documented, and wound care orders were not always followed as prescribed. Another resident was admitted with a Stage 3 pressure ulcer on the sacrum. The care plan included interventions for wound care and monitoring, but there was no evidence that wound progress was assessed or documented as required. Wound care orders were not completed on several occasions, and weekly skin assessments were either incomplete or missing, with no documentation of wound measurements or changes in wound status. The root cause of additional wounds was not identified, and interventions for these areas were not implemented. A third resident with a history of immobility, incontinence, and a Stage 4 sacral pressure ulcer did not consistently receive prescribed nutritional supplements intended to support wound healing due to unavailability of the product. The supplement was not administered on multiple occasions across several months, and the provider was not notified of the ongoing unavailability in a timely manner. Additionally, wound care documentation revealed lapses in wound vac functioning and the presence of fecal contamination in the wound area, with no evidence of prompt intervention or provider notification.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least 8 hours each day and did not designate a registered nurse to serve as the director of nursing (DON) on a full-time basis. This deficiency was identified through review of staffing schedules and facility records, which showed non-compliance with the required RN coverage and DON assignment.
Failure to Provide Assistance with Activities of Daily Living Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to six residents who were unable to perform these tasks independently, as required by their care plans. Observations and interviews revealed that residents did not consistently receive help with bathing, toileting, and personal hygiene. Documentation showed missed or undocumented showers, and residents reported long waits for assistance or having to perform tasks themselves due to staff shortages. For example, one resident with severe cognitive impairment was observed repeatedly asking for help to go to bed and remained in the dining room for several hours without being assisted to the toilet. Another resident reported not being bathed for two weeks and having to wait extended periods for toileting assistance. Record reviews indicated that scheduled showers were frequently missed or not documented for multiple residents, despite their care plans specifying the need for staff assistance. Several residents, both cognitively intact and impaired, described having to wait for long periods or not receiving showers according to their preferences or schedules. Staff interviews confirmed that staffing shortages contributed to delays and missed care, with some residents having to wait until after midnight to be put to bed or having to perform sponge baths independently due to lack of help. Facility documentation further revealed inconsistencies in the recording of ADL care, with many entries marked as "not applicable" or lacking any documentation for scheduled showers. Residents' accounts and staff interviews consistently pointed to a pattern of insufficient staffing leading to unmet care needs, particularly in bathing and toileting. The lack of a functional bathtub was also noted, requiring all residents to use showers, which may have further impacted the facility's ability to meet residents' bathing preferences and schedules.
Failure to Ensure Two-Person Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to prevent the potential for serious harm or injury by not ensuring that mechanical lift transfers were performed according to policy, which required at least two nursing assistants for safe resident movement. Record reviews showed that multiple residents required two-person assistance for transfers using Hoyer or sit-to-stand lifts, as documented in their care plans and Minimum Data Set (MDS) assessments. Despite these requirements, staff interviews and resident statements confirmed that transfers were frequently conducted by a single staff member due to ongoing staffing shortages. Staff, including medication aides and nurse aides, reported that the facility was often understaffed, with shifts sometimes covered by only the DON and a minor nurse aide who was not permitted to use mechanical lifts. Staff admitted to transferring residents alone with mechanical lifts, including both Hoyer and sit-to-stand lifts, because there were not enough staff available to provide the required two-person assistance. This practice was corroborated by resident interviews, who described feeling unsafe and noted that single-staff transfers had become routine. The facility's own policy, revised in July 2017, specified that two staff members were needed for mechanical lift transfers, and this was reflected in the care plans for residents requiring such assistance. However, due to chronic understaffing, staff were unable to consistently follow these protocols, resulting in transfers being performed by one person. This deviation from policy and care plans created a situation where residents were at increased risk during transfers, as confirmed by both staff and resident accounts.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Medication Error Rate Exceeds 5% Due to Late and Improper Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by policy and regulation. During 25 observed medication administration opportunities, five errors were identified, resulting in a 20% error rate. The errors involved two residents and included late administration of medications, improper administration technique, and lack of staff familiarity with medication protocols. Facility policy requires medications to be administered according to prescriber orders and within specified time frames, with staff expected to verify the correct resident, medication, dosage, time, and route. One resident, who had multiple diagnoses including schizoaffective disorder, anxiety, multiple sclerosis, COPD, and legal blindness, received several medications late, including ondansetron, clonazepam, gabapentin, and lansoprazole. The medication aide prepared all medications in a single cup and administered them together, failing to separate the ondansetron oral disintegrating tablet or allow it to dissolve on the tongue as required by manufacturer instructions. The aide was unaware of the proper administration method for ondansetron and was unfamiliar with the medication cart, contributing to the errors. The resident experienced gagging during administration and reported difficulty swallowing. Another resident with dementia, restlessness, and agitation was also affected by late medication administration. The LPN prepared and administered venlafaxine extended release after the designated morning window, citing unfamiliarity with the medication cart as the reason for the delay. Both staff members involved confirmed the late administration and their lack of familiarity with the assigned medication cart, which contributed to the medication errors observed during the survey.
Missed IV Antibiotic Doses Due to Medication Administration Failures
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection (UTI), type 1 diabetes, right artificial hip with surgical aftercare, urinary retention, and neuromuscular bladder dysfunction was re-admitted to the facility with an order for intravenous (IV) meropenem to be administered every eight hours. Upon return, the resident initially lacked IV access and the medication, requiring EMS intervention and a subsequent hospital visit to re-establish IV access and continue the antibiotic therapy. The resident later had a midline placed for IV administration. On a subsequent occasion, the resident removed their own midline, resulting in a lack of IV access and a missed dose of meropenem. Although the medical provider was notified and an order was given to send the resident to the hospital for a new line, there was a delay in re-establishing IV access, and EMS was eventually contacted to start a new line and administer the antibiotic. There was no evidence that IV access was attempted at the facility before EMS intervention. Additionally, two further doses of meropenem were not administered as scheduled by an LPN, who also failed to notify the Director of Nursing (DON) or a Registered Nurse (RN) about the missed doses, as required by facility protocol. These omissions were documented in employee warning reports and confirmed by the DON, resulting in a total of three missed antibiotic doses for the resident.
Delayed Submission of Investigation Report
Penalty
Summary
The facility failed to comply with the regulatory requirement to submit an investigation report within 5 working days following an incident involving a resident. Specifically, a resident experienced a fall with injury on October 15, 2024, at 10:00 PM. However, the investigation report regarding this incident was not submitted to the State Agency until October 23, 2024, which exceeded the mandated timeframe. This deficiency was confirmed during an interview with the Administrator on January 6, 2025, who acknowledged the delay in submission for the resident involved in the incident.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to develop new interventions for a resident who experienced multiple falls. The resident, admitted with a history of falling and other mobility-related diagnoses, had a series of falls over several months. Despite these incidents, the care plan did not reflect all the falls, and interventions were often duplicated rather than tailored to address the specific circumstances of each fall. For instance, falls on certain dates were not documented in the care plan, and interventions such as using a reacher/grabber or ensuring items were within reach were repeated without apparent effectiveness. The resident's care plan and incident reports revealed that interventions were not consistently updated or individualized following each fall. The resident, who was cognitively intact and required assistance with mobility, continued to fall despite being educated on safety measures and receiving physical and occupational therapy. The Registered Nurse Consultant confirmed that several interventions were duplicates and that the care plan lacked updates for specific falls, indicating a failure to adequately address the resident's fall risk and implement effective preventive measures.
Failure to Follow Recipe for French Onion Pork Chop
Penalty
Summary
The facility failed to prepare foods following the recipe to ensure nutritive value, potentially affecting all 41 residents who ate food prepared in the kitchen. During a continuous observation of meal preparation, the Dietary Supervisor (DS) measured three boneless pork chops, with weights of six ounces, three ounces, and three ounces, respectively, and did not measure the remaining pork chops. The DS used four fresh onions, discarding two that were bad, and substituted a bag of French onion soup mix for the onions and red wine vinegar, as the facility did not have these ingredients. Additionally, no stock chicken and soup base were used. Interviews with the DS confirmed these substitutions and the intended weight of the pork chops. A review of the facility's Patient Menu Substitution Log and the French Onion Pork Chop recipe corroborated these findings, revealing discrepancies in ingredient use and preparation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11%. This deficiency affected three residents. Resident 8 received their Sinemet medication late, as it was administered at 12:17 PM instead of the scheduled 11:00 AM. Resident 16 did not receive their scheduled doses of Albuterol, with the medication aide admitting to missing the AM dose and being unable to administer the mid-day dose due to a lack of knowledge on how to set up the nebulizer machine. Additionally, Resident 34 did not receive their scheduled dose of budesonide because it had to be reordered, and the medication aide was not aware of the proper procedures for handling such situations. The medication aide involved, MA-D, was on their second day of administering medications without assistance and had received only a couple of days of training. Despite feeling that the training was sufficient, MA-D's performance indicated otherwise. The Director of Nursing (DON) confirmed that the standard training period is 2-3 days, followed by a competency check and a follow-up to assess the new staff's comfort level. However, the DON was not aware of the specific medication errors or the need for additional training as identified by RN-C.
Failure to Notify Physician of Low Blood Pressure in Resident on Hypertension Medication
Penalty
Summary
The facility failed to notify the physician of low blood pressures for a resident on blood pressure medication. The resident, who had a primary diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) and severe cognitive impairment, was on Metoprolol Tartrate to manage hypertension. Despite multiple instances of low blood pressure readings, the facility did not inform the physician or recheck the blood pressure as required. Specific instances included blood pressure readings of 71/55 mmHg and 77/55 mmHg, which were below the threshold for administering Metoprolol Tartrate. The facility's policy required monitoring vital signs and notifying the provider of abnormalities, which was not followed in this case. The resident's Medication Administration Record for April 2022 revealed that blood pressure and pulse were not monitored daily with the administration of Metoprolol. An interview with a Registered Nurse confirmed that the medication should not have been given with such low blood pressure readings and that the physician should have been notified. Additionally, the Medication Regimen Review from the pharmacy consult showed no recommendations from June 2023 through April 2024, indicating a lack of oversight in identifying and resolving medication-related problems.
Failure to Complete Admission MDS Within Required Time Frame
Penalty
Summary
The facility failed to ensure the completion of the Admission Minimum Data Set (MDS) within the required time frame for one resident. Resident 95, who was admitted with a primary diagnosis of unspecified dementia, had an Admission MDS with an Assessment Reference Date (ARD) of 4/5/24. However, the MDS was not completed until 4/23/24, exceeding the 14-day requirement as per the Resident Assessment Instrument (RAI) manual. Interviews with the Regional MDS Nurse Coordinator and the MDS Coordinator confirmed the delay and acknowledged the use of the RAI manual guidelines. The Regional MDS Nurse Coordinator also noted that they are only present in the building two days per week, handling multiple responsibilities including MDS, Infection Prevention and Control, and wound care, with the rest of the work done remotely.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was developed within 48 hours of admission for Resident 94, who was admitted with a primary diagnosis of Osteomyelitis. Record review revealed that Resident 94's Comprehensive Care Plan was undated, and there was no baseline care plan documented in the Electronic Medical Records. An interview with the MDS coordinator confirmed the absence of a baseline care plan and that the resident was not offered a copy of it. The facility's policy, dated March 2022, mandates that a baseline care plan be developed within 48 hours of admission and that a written copy be provided to the resident or their representative, with documentation of this provision in the medical record.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify causative factors and implement new interventions to prevent falls for Resident 13, who had a history of multiple falls. Resident 13, admitted with diagnoses including muscle weakness, edema, obstructive sleep apnea, hypertension, and major depressive disorder, had a care plan indicating a risk for falls. Despite this, the care plan did not include new interventions after falls on several dates, and the facility's fall records showed no new interventions were placed after falls on 5/4/2023, 6/3/2023, 6/20/2023, 6/29/2023, 7/16/2023, 8/14/2023, 8/21/2023, and 9/26/2023. Interviews with staff confirmed that new interventions were not implemented after each fall, contrary to the facility's policy requiring immediate intervention placement by the charge nurse. Additionally, the facility's incident reports for falls on 5/4/2023, 7/16/2023, 8/28/2023, and 9/26/2023 did not identify causative factors. This lack of identification of causative factors was confirmed by staff interviews, which is inconsistent with the facility's policy that requires staff to begin identifying possible causes within 24 hours of a fall. The failure to identify causative factors and implement new interventions after falls contributed to the deficiency noted in the report.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration for three residents. An observation revealed that a registered nurse (RN) prepared an insulin syringe, applied gloves, and then touched the inner rim of a trash can without changing gloves before injecting insulin into Resident 16. In another instance, the same RN dialed an insulin pen, applied gloves, touched a doorknob, and their hair before injecting insulin into Resident 31 without changing gloves. Additionally, a medication aide attempted to administer medication to Resident 95, who spit it out. The aide then scooped the medication back into the cup, crushed it, and administered it again to the resident without following proper infection control procedures. The Director of Nursing confirmed these practices were deficient in infection control prevention. A review of the facility's handwashing and hand hygiene policy, last revised in August 2019, indicated that glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Center for Disease Control's guidelines also require changing gloves when they have been contaminated before touching clean surfaces. These observations and record reviews highlight the facility's failure to adhere to established infection control protocols during medication administration.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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