St. Joseph Villa Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 2305 South 10th Street, Omaha, Nebraska 68108
- CMS Provider Number
- 285078
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at St. Joseph Villa Nursing Center during CMS and state inspections, most recent first.
Multiple residents experienced failures in ordered monitoring and follow-up. A resident with heart failure did not receive ordered daily weights or documented fluid intake tracking despite a fluid restriction. A resident with diabetes and a foot ulcer used an air mattress that repeatedly showed a low-pressure warning without timely action. Another resident with recurrent UTIs had a specialized urine test completed, but the positive results were misdirected to an outdated email and not communicated to the provider until much later. A resident with CHF on diuretics had an order for weekly weights, yet weight records showed repeated multi-week gaps despite visible edema. In addition, after an unwitnessed fall, a resident did not receive the neurological checks required by the facility’s post-fall policy.
A resident with anxiety disorder, bipolar disorder, and schizophrenia was receiving multiple doses of Seroquel and required total assistance with activities of daily living. Facility policy required that an AIMS score of 2 or higher, suggesting possible TD, be communicated to the physician and discussed with the resident and family. The resident’s AIMS score increased from 0 to 4 after antipsychotic dose increases, but the physician and resident representative were not notified of this change. The DON confirmed that the increase occurred and that required notifications were not made.
A resident with hemiplegia, dysphagia, and dementia, who required staff supervision for oral hygiene, did not receive or was not offered morning oral care as required by facility policy and physician orders. Despite a care plan calling for staff assistance with hygiene and a dental note documenting very poor oral hygiene and the need for daily assisted tooth brushing, staff progress notes showed only two documented refusals over several months. During a surveyed morning care episode, a NA assisted the resident with getting out of bed, dressing, hair care, and eyeglasses but did not provide or offer tooth brushing, later confirming that oral hygiene was omitted even though it should have been part of the morning routine.
A resident with malnutrition, Inclusion Body Myositis, moderate cognitive impairment, total dependence for ADLs, incontinence, recent weight loss, and identified risk for pressure ulcers had a care plan that included use of an air pressure mattress to maintain skin integrity. Surveyors observed multiple times that the air mattress pump was either turned off while the resident was in bed or displaying a persistent low-pressure warning light while in use. A MA confirmed the mattress should have been on when it was not, and the wound nurse acknowledged the low-pressure light but was unsure of its meaning without consulting the manual, demonstrating a failure to ensure the ordered pressure-relieving device was properly functioning for this high-risk resident.
An LPN did not wear a gown while providing wound care to a resident with a left heel wound, despite facility policy requiring both gowns and gloves for such procedures. The LPN acknowledged the omission, and the facility's policy specified that PPE must be used during high-contact activities like wound care.
A resident with Alzheimer's and dementia, requiring extensive assistance, was improperly transferred using a Hoyer lift with an incorrect sling, leading to a tibial and fibula fracture. Nursing staff lacked guidance on determining sling size, as the facility's policy did not provide instructions, resulting in a major injury.
Facility staff failed to secure medications properly, with two incidents of unlocked and unattended medication carts on the 100 hall. These lapses were confirmed by interviews with staff, who acknowledged the carts should have been locked. The facility's policy requires all medications to be stored in locked compartments when not in use.
The facility did not adhere to the planned menu for residents on pureed diets, affecting several individuals. Instead of receiving the scheduled pureed hot dog with bun and gravy, they were mistakenly served pureed mashed potatoes with gravy, resulting in a lower intake of protein and calories. This error was confirmed by staff, including the RD.
The facility failed to follow Enhanced Barrier Precautions (EBP) and infection control protocols, as staff did not wear gowns during high-contact care for residents on EBP. Instances included an LPN administering water via a G-tube and NAs providing care without gowns. Additionally, an oxygen nasal cannula was found on the floor, and the Laundry Supervisor mishandled laundry, risking cross-contamination.
A facility breached a resident's privacy by posting dietary instructions on their door, revealing personal health information. The resident, with moderate cognitive impairment and Diabetes Mellitus, had a sign indicating dietary restrictions, which was confirmed by the DON as a privacy violation.
A resident with Peripheral Vascular Disease and Cellulitis did not have compression stockings or Prevalon boots applied as per physician's orders. Observations confirmed the absence of these items, and an LPN noted that the orders were entered incorrectly, leading to the oversight.
A facility failed to evaluate and implement a toileting program for a cognitively intact resident who was frequently incontinent of urine and always incontinent of bowel. Despite the resident's ability to express the need to use the toilet and use a bedpan, the care plan lacked a toileting program, contrary to the facility's policy. Interviews confirmed the absence of such a program, highlighting a deficiency in care planning.
The facility failed to document the indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. One resident received Amoxicillin/Augmentin without a documented reason, and another was prescribed doxycycline without a stop date or rationale. This indicates a lapse in the facility's adherence to its antibiotic stewardship policy, which emphasizes appropriate use and documentation of antimicrobials.
The facility failed to offer and document the updated COVID-19 vaccination for 2024-2025 to two residents, despite their vaccination history. The EHR lacked documentation of education or opportunities for these residents to accept or decline the vaccine, as confirmed by the DON. This oversight violated the facility's policy and CDC recommendations.
Multiple Failures to Follow Orders for Monitoring, Equipment, Lab Results, and Post-Fall Assessments
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to practitioner orders and facility policies for several residents. One resident with heart failure was discharged from the hospital with orders for a 2000 ml fluid restriction and daily weights. Record review showed multiple gaps where no daily weights were documented over several multi‑day periods, and the Assistant Director of Nursing confirmed that daily weights were not done as ordered. The resident’s electronic health record also lacked documentation of daily fluid intake monitoring, and interviews with a nursing assistant and an LPN confirmed that the resident’s fluid intake was neither recorded nor tracked to ensure compliance with the 2000 ml restriction. Another resident with diabetes and a documented diabetic foot ulcer had a care plan intervention for use of an air mattress to protect skin and promote healing. Over several days of observation, the air mattress consistently displayed a low‑pressure warning light. The wound nurse acknowledged the low‑pressure light and indicated the need to consult the owner’s manual to determine its meaning. The ADON later confirmed that the mattress was being replaced and provided manufacturer information stating that if the low‑pressure light remained on for longer than 30 minutes, the mattress should be serviced, indicating that the mattress had not been functioning properly for an extended period while in use for this resident. A third resident with a history of recurrent UTIs, ESBL resistance, and prior sepsis had a provider order for a DNA/Microgen urinalysis after completing an antibiotic course. Progress notes documented that a urine specimen was collected and sent, and the physician documented that staff were to monitor closely and await culture and sensitivity results. The MicroGenDX report showed the specimen was collected, received, and reported as positive for a UTI, but the results were not present in the resident’s record and were not communicated to the provider until much later. The DON confirmed that the Microgen UA results had been sent to the ADON’s old email address and were not discovered until they were specifically requested, resulting in a delay in notifying the provider and initiating a new antibiotic. Another resident with chronic diastolic CHF, abnormal weight loss, and diuretic therapy had an order for weekly weights and a care plan intervention to monitor weights and notify the physician of changes. The weight record showed repeated multi‑week gaps where no weights were obtained, despite the resident having documented weight fluctuations and edema requiring additional diuretic therapy. Observations noted significant edema in both legs and feet, and an LPN confirmed that cardiology was following the resident and adjusting medications. The DON confirmed that weekly weights were not being completed as ordered. A further deficiency involved a resident with delusional disorder, epilepsy, and a history of falls, who experienced an unwitnessed fall when staff found the resident on the floor in front of a wheelchair after rolling out of bed. The facility’s post‑fall assessment policy required initiation of neurological assessments for all falls and documentation every shift for 72 hours. Review of the resident’s electronic medical record, including progress notes and scanned documents, revealed that neurological checks were not completed following this unwitnessed fall. The DON confirmed that no neurological checks were found in the resident’s record for this event.
Failure to Notify Physician and Representative of Significant AIMS Score Increase
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative of a significant change in the resident’s Abnormal Involuntary Movements Scale (AIMS) score. Facility policy dated 02-2021 stated that an AIMS score of 2 or higher is evidence of Tardive Dyskinesia (TD), and that if a resident’s score suggests TD, the results should be discussed with the physician, resident, and family, and the need for continued antipsychotic therapy should be considered. Record review showed that the resident, who had anxiety disorder, bipolar disorder, and schizophrenia, was rarely able to make self understood and required total assistance with activities of daily living. The resident was receiving Seroquel 25 mg daily, and additional doses of Seroquel 100 mg at bedtime and 25 mg at noon were later added. An AIMS assessment conducted on 09-17-2025 showed a score of 0, but a subsequent AIMS assessment on 11-04-2025 showed an increased score of 4. Despite this documented increase, which met the facility’s policy threshold for possible TD and required discussion with the physician and family, there was no evidence that the physician or the resident’s representative were informed of the change in the AIMS score. In an interview on 01-08-2026, the DON confirmed that the resident had an increase in the AIMS score and that the facility did not update the resident’s representative or the physician of this increase and acknowledged that they should have done so.
Failure to Provide Required Morning Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide or offer required oral hygiene during the morning routine for one resident who was dependent on staff assistance. Facility policy on oral hygiene, last reviewed in May 2021, required oral care every morning and at bedtime. The resident, admitted in late December 2024, had diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, dysphagia, and dementia, and was assessed on the MDS as rarely or never understood, rejecting care on one to three days during the assessment period, and requiring supervision to complete oral hygiene. The resident’s comprehensive care plan included an intervention for assistance of one staff member for dressing and hygiene, and a nursing order dated July 2025 directed staff to assist with tooth brushing every morning and night, with refusals to be documented in progress notes. Progress notes from October 2025 through early January 2026 documented refusals of oral care only on two dates in October. A dental visit note from late October 2025 described the resident’s oral hygiene as very poor, with heavy plaque and food debris and moderate tartar accumulation, and stated that the resident’s special needs rendered them incapable of maintaining adequate oral health without daily assistance, encouraging staff to assist with tooth brushing. On a morning in early January 2025, observation showed the resident in their bedroom with food debris in their mouth. A subsequent continuous observation of the resident’s morning care showed a nursing assistant assisting the resident out of bed, dressing them, styling their hair, and cleaning and donning their eyeglasses, but not offering or providing assistance with tooth brushing. In an interview immediately afterward, the nursing assistant confirmed that oral hygiene was not performed or offered and acknowledged it should have been part of the resident’s morning care.
Failure to Ensure Proper Functioning of Ordered Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper functioning of an ordered air pressure mattress for a resident assessed as at risk for pressure ulcer development. The resident’s MDS documented diagnoses of malnutrition and Inclusion Body Myositis, moderate cognitive impairment (BIMS score 10), total dependence for all ADLs including bed mobility, and constant bowel and bladder incontinence, with recent weight loss and a current weight of 93 pounds. The care plan identified the resident as at risk for pressure ulcers related to weakness and reduced mobility, with a goal for skin to remain intact, and included use of an air pressure mattress as a specific intervention. Surveyor observations over multiple days showed repeated problems with the air mattress not being powered on and/or not functioning properly. On one occasion, the resident was observed in bed with the air mattress pump not on; on several other occasions, the pump was on but the low-pressure light was illuminated, and on multiple subsequent observations the air mattress was again off while the resident was in bed. A medication aide confirmed that the air mattress was not on and should have been. The wound nurse confirmed the low-pressure light was on and stated they would need to refer to the owner’s manual to determine its meaning. The ADON confirmed the mattress was being replaced and provided manufacturer information indicating that if the low-pressure light remained on for longer than 30 minutes, the mattress should be serviced.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a left heel wound. The resident had a practitioner order for wound treatment, and the facility's EBP policy required the use of gowns and gloves for residents with wounds, regardless of known infection or colonization status. During an observed wound care procedure, an LPN performed hand hygiene and donned gloves but did not wear a gown at any point while providing care, including when removing soiled dressings and cleaning the wound. The LPN confirmed during an interview that a gown should have been worn during the procedure. The facility's EBP policy, revised in March 2024, specifically states that PPE, including gowns and gloves, must be worn during high-contact resident activities such as wound care. The failure to don a gown during the wound care procedure constituted noncompliance with the facility's infection prevention and control program.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer a resident, identified as Resident 9, in a manner that would prevent injury. Resident 9, who was admitted to the facility, had both short-term and long-term memory problems and was diagnosed with Alzheimer's and dementia with behavioral disturbances. The resident was dependent on staff for eating, bed mobility, transfers, and toileting, requiring extensive to total assistance with activities of daily living. The Comprehensive Care Plan indicated that two staff members were needed to transfer the resident using a full body sling, but it did not specify the size of the sling required. During a transfer from the bed to a wheelchair using a Hoyer lift, Nursing Assistants Q and R used a divided leg Hoyer sling instead of a full body sling. As a result, Resident 9 began to slide out of the sling, causing the nursing assistants to intervene to prevent further sliding. Despite their efforts, Resident 9 experienced extreme pain during the transfer and was later diagnosed with a tibial fracture and an anterior displaced fibula fracture after being sent to the emergency room. Interviews with the nursing staff, including NA Q, NA R, LPN N, and the MDS Coordinator, revealed a lack of knowledge regarding the appropriate sling size for the Hoyer lift. The facility's Nursing Policy and Procedure Manual did not provide instructions on determining the correct sling size, contributing to the improper transfer and subsequent injury of Resident 9. The Director of Nursing confirmed the incident resulted in a major injury for the resident.
Medication Security Lapses in Facility
Penalty
Summary
The facility staff failed to secure medications properly, as observed on two separate occasions. On the first occasion, a medication cart was found unlocked and unattended on the 100 hall at 7:10 AM. This was confirmed by interviews with a Registered Nurse (RN) and a Medication Assistant (MA), who acknowledged that the cart should not have been left unlocked and out of sight. This oversight had the potential to affect 10 residents identified as self-mobile who resided on the 100 hall. On a second occasion, another medication cart was left unlocked and unsupervised by a Medication Assistant (MA) between 6:12 and 6:18 AM. Additionally, a card of Acetaminophen was left unsecured on top of the cart. The MA confirmed during an interview that the medication card should not have been left on top of the cart and that the cart should have been locked and secured. The facility's medication storage policy, dated August 2018, mandates that all medications and biologicals be stored in locked compartments when not in use or left unattended.
Failure to Follow Pureed Meal Menu
Penalty
Summary
The facility failed to follow the menu to meet the nutritional needs of residents requiring pureed meals, affecting 7 out of 13 residents identified as needing such meals. On a specific day, the menu planned for lunch included a pureed hot dog with bun and gravy, among other items. However, during lunch service, residents on pureed diets were mistakenly served pureed mashed potatoes with gravy instead of the planned pureed hot dog and bun. This error was confirmed by staff interviews, including one with the Registered Dietician, who noted that the residents received less protein and calories than intended due to the menu not being followed.
Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for several residents, leading to potential cross-contamination risks. Observations revealed that staff members did not wear gowns during high-contact care activities for residents on EBP. For instance, a Licensed Practical Nurse (LPN) administered water via a G-tube to a resident without donning a gown, despite the resident being on EBP due to a gastrointestinal tube. Similarly, a Nursing Assistant (NA) emptied a foley catheter bag for another resident without wearing a gown, even though the resident was on EBP due to an indwelling medical device. Further deficiencies were noted with other residents on EBP. A Nursing Assistant provided care to a resident with a Multi-Drug Resistant Organism (MDRO) without wearing a gown, despite the resident being on EBP for having a gastrostomy tube. Another instance involved two Nursing Assistants transferring a resident to a commode without gowns, even though the resident was on EBP due to a gastrostomy tube. Additionally, a Licensed Practical Nurse administered medications through a gastrostomy tube to a resident on EBP without wearing a gown. The facility also failed to maintain proper infection control practices in other areas. An oxygen nasal cannula for a resident was repeatedly observed on the floor, contrary to the facility's policy requiring it to be stored in a plastic bag when not in use. Furthermore, the Laundry Supervisor was observed delivering laundry with clothing and linens touching their body and dragging on the floor, which is against the facility's protocols for preventing cross-contamination.
Privacy Violation of Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical information. Specifically, information regarding a resident's dietary restrictions was posted on the outside of their door, visible to anyone passing by. The resident, identified as having a moderate cognitive impairment with a BIMS score of 9 and a diagnosis of Diabetes Mellitus, had a sign on their door indicating dietary instructions, such as avoiding snacks full of sugar and allowing Glucerna and half a sandwich. This action was confirmed by the Director of Nursing to be a violation of privacy, as it disclosed personal health information publicly.
Failure to Apply Compression Stockings and Prevalon Boots as Ordered
Penalty
Summary
The facility failed to ensure that a resident's compression stockings and Prevalon boots were applied according to the physician's orders. The resident, who had diagnoses of Peripheral Vascular Disease, Cellulitis of the right lower leg, and Unspecified Dementia, was dependent on staff for all activities of daily living and was at risk for developing pressure ulcers. Despite these conditions, the resident's Medication Administration Record and Treatment Administration Record from June to August 2024 did not show that compression stockings or Prevalon boots were applied until late August. Observations on multiple occasions revealed that the resident was not wearing compression stockings or Prevalon boots as prescribed. A Licensed Practical Nurse confirmed that the orders were entered incorrectly into the system, which resulted in the oversight. The nurse also confirmed that the resident would not have refused to wear the compression stockings or Prevalon boots, indicating that the failure was due to administrative error rather than resident non-compliance.
Failure to Implement Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to evaluate and implement a toileting program for a resident who was frequently incontinent of urine and always incontinent of bowel. The resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, expressed awareness of the need to use the toilet and the ability to use a bedpan if provided. Despite this, the resident's care plan did not include an evaluation or implementation of a toileting program, which is a requirement based on the facility's policy and procedure for urinary incontinence. Interviews conducted with the resident and the MDS Coordinator confirmed the absence of a toileting program for the resident. The facility's policy, dated June 2021, outlines the need for assessing urinary continence status upon admission, quarterly, and with any significant change of condition. It also requires developing an incontinence plan of care, particularly for cognitively intact residents who can participate in their care. However, these procedures were not followed for the resident in question, leading to the deficiency noted in the report.
Deficiency in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to provide an indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. For Resident 28, a physician order for Amoxicillin/Augmentin was issued without a documented reason for its administration. The medication was administered for 20 doses over a period of ten days, yet there was no indication in the resident's records, including practitioner orders, progress notes, or laboratory work, to justify the use of the antibiotic. An interview with the Infection Preventionist Coordinator confirmed that the antibiotic use did not meet the criteria set by McGeer's tool for determining the necessity of antibiotic use. Similarly, Resident 144 was prescribed doxycycline without a specified stop date, and there was no documented rationale for the continued use of the antibiotic. The facility's policy requires that when a resident is admitted on an antibiotic, staff must verify the reason for its use and obtain a stop date or rationale from the physician. This was not adhered to in the case of Resident 144, indicating a lapse in the facility's antibiotic stewardship practices. The facility's Infection Control Policy and Procedure Manual outlines the importance of a quality antibiotic stewardship program, emphasizing the need for appropriate use of antimicrobials and minimizing antibiotic overuse and resistance. The policy includes procedures for the interdisciplinary antibiotic stewardship team to ensure antibiotics are used appropriately, with proper follow-up on cultures and sensitivities. However, the failure to document the indication for antibiotic use for both residents highlights a significant deficiency in adhering to these established protocols.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to prevent potential COVID-19 infection by not offering, providing education, or documenting the opportunity for two residents, Resident 15 and Resident 25, to accept or decline the updated COVID-19 vaccination for 2024-2025. The facility's policy, dated May 2021, mandates that all residents should be educated about the COVID-19 vaccine, including its risks and benefits, and be given the opportunity to be vaccinated. However, the Electronic Health Records (EHR) for both residents did not show any documentation of education, the vaccine being offered, or any opportunity for the residents to decline or accept the updated vaccination. Resident 15 had a history of receiving COVID-19 vaccines on three occasions in 2021, while Resident 25 had a history of receiving vaccines on five occasions between 2020 and 2022. Despite these histories, there was no documentation in the EHR for the 2024-2025 vaccination. An interview with the Director of Nursing confirmed that these residents were not offered the updated COVID-19 vaccination, nor were they provided with the necessary education. This oversight is a direct violation of the facility's policy and the CDC's recommendations for COVID-19 vaccination.
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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