Stanton Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stanton, Nebraska.
- Location
- 301 17th Street, Stanton, Nebraska 68779
- CMS Provider Number
- 285102
- Inspections on file
- 19
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Stanton Health Center during CMS and state inspections, most recent first.
A resident was transferred in a bath chair through a corridor while wearing an open-back hospital gown, leaving their lower back and buttocks exposed and visible to others. The bath aide confirmed the resident should have been fully covered during the transfer.
The facility did not report or investigate incidents involving inappropriate physical contact and potential abuse between two cognitively impaired residents, despite facility policy requiring immediate reporting to the State Agency. Documentation and interviews confirmed that these events were not reported as required.
A resident with multiple medical conditions and cognitive impairments experienced several unwitnessed falls, after which staff failed to complete and document neurological assessments as required by facility policy. Instead, staff often recorded that the resident was sleeping, resulting in missed assessments and vital sign checks at scheduled intervals.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A facility failed to notify a resident's PCP of significant changes in the resident's condition, including fluid buildup, altered mental status, and self-harming behaviors. The resident, with multiple diagnoses, exhibited concerning behaviors and physical symptoms over several days, but the PCP was not informed until later, contrary to facility policy.
A facility failed to complete the required Discharge Summary for a resident at the time of their planned discharge. The facility's policy requires a Discharge Summary to include a recapitulation of the resident's stay, a final summary of their status, medication reconciliation, and a post-discharge care plan. However, a review of the resident's records showed no evidence of this summary, which was confirmed by the DON.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident, with a fluid restriction due to health conditions, was observed with excessive fluids in their room, and staff were unaware of the restriction. Another resident, with multiple diagnoses, had orders for daily weights and as-needed Lasix, but the facility failed to obtain weights on numerous days and did not administer Lasix despite significant weight gains. Interviews confirmed these lapses, resulting in deficiencies in care.
A resident admitted with a stage 1 pressure ulcer did not receive the required weekly assessments, leading to the ulcer's progression to stage 2 without proper documentation. An LPN identified the change during a wound care observation, and the DON confirmed the facility's failure to monitor the ulcer effectively.
A facility failed to maintain infection prevention measures during wound and catheter care for two residents. Staff did not properly secure gowns or perform hand hygiene between glove changes, increasing the risk of infection transmission. One resident had chronic wounds and a catheter, while another had self-care deficits and skin issues. The Director of Nursing confirmed the need for proper hand hygiene and gown use during high-contact care activities.
Resident Dignity Not Maintained During Bathhouse Transfer
Penalty
Summary
A resident's right to dignity and privacy was not maintained during a transfer to the bathhouse. Observation revealed that the resident was positioned in a bath chair in the corridor outside their room, with their lower legs and feet uncovered and hanging from the chair. The resident was wearing a hospital gown with the back open, exposing their lower back and buttocks, leaving these areas visible to other residents, staff, and visitors passing through the corridor. The bath aide responsible for the transfer confirmed that the resident should have been covered with no bare skin exposed during the transfer to the bathhouse.
Failure to Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to report, investigate, and submit a completed investigation report to the State Agency within the required timeframe regarding allegations of potential abuse involving two residents. Facility policy mandates immediate reporting of any allegations or suspicions of abuse, neglect, misappropriation, or exploitation to the Administrator, DON, or designee, and requires notification to law enforcement and the State Agency within specified timeframes. Despite this, incidents involving a resident with moderate cognitive impairment and a history of inappropriate sexual comments and touching were documented in progress notes, including one event where the resident pulled another resident's shirt and another where the resident held hands with a different resident and attempted to follow them. These incidents were not reported to the State Agency as required. The residents involved had significant cognitive impairments and required substantial assistance with daily activities. One resident had diagnoses including Alzheimer's Disease, dementia, anxiety, and depression, and a history of inappropriate behaviors. The other resident had severe cognitive impairment, exhibited physical and verbal behaviors, and was dependent on staff for care. Documentation revealed that the incidents were not reflected in the facility's reported incidents log for the past 12 months, and interviews with the Administrator and DON confirmed that the required reporting did not occur.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete required neurological assessments following unwitnessed falls for one resident, as outlined in their policy. According to the policy, after an unwitnessed fall or a fall with a potential head injury, staff are to perform neurological assessments at specific intervals: every 15 minutes for 1 hour, every hour for 4 hours, and every 4 hours for 19 hours. Record reviews showed that after multiple unwitnessed falls, staff did not document or complete neurological assessments and/or vital signs at several required times, often noting that the resident was sleeping instead of performing the assessments. The resident involved had significant medical conditions, including non-traumatic brain dysfunction, heart failure, diabetes, Alzheimer's dementia, anxiety, and depression, and was assessed as having severely impaired memory, decision-making, and balance, as well as being dependent on staff for mobility and personal care. Despite these vulnerabilities, neurological assessments were omitted after several unwitnessed falls, with documentation gaps noted on multiple occasions. An RN confirmed that these assessments should not be skipped unless the resident was out of the building.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide specific details about individual residents, staff actions, or particular infection events.
Failure to Notify PCP of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's Primary Care Physician (PCP) of significant changes in the resident's condition, which included fluid buildup, altered mental status, and behavioral changes. The resident, who had diagnoses of paranoid schizophrenia, diabetes, cerebral palsy, depression, and anxiety, exhibited escalating behaviors such as hearing voices, making strange noises, and being combative and resistive with care. The resident also displayed self-harming behaviors, such as pulling out chunks of hair and wrapping a call light cord around their head, and experienced significant fluid retention in the lower extremities. Despite these concerning changes, the facility did not notify the PCP until several days later, specifically regarding the resident's increased fluid retention and warmth/redness in the lower extremities. The facility's policy required timely notification of the PCP for any significant alterations in a resident's condition, which was not adhered to in this case. The Director of Nursing confirmed that the PCP was only informed via facsimile after the resident's condition had already escalated significantly.
Failure to Complete Required Discharge Summary
Penalty
Summary
The facility failed to complete the required Discharge Summary for a resident, identified as Resident 63, at the time of their planned discharge. The facility's policy on Transfer and Discharge, revised on 5/21/24, mandates that a Discharge Summary must be completed, which includes a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of medications, and a post-discharge plan of care. However, upon review of Resident 63's Admission/Discharge Record and Medical Record, there was no evidence that this summary was completed. The Director of Nursing confirmed the omission of the required Discharge Summary for Resident 63.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. Resident 2, who had a history of coronary artery disease, schizophrenia, diabetes, cerebral palsy, depression, and anxiety, was on a fluid restriction due to the risk of weight fluctuations related to fluid retention. Despite this, observations revealed that the resident had access to excessive fluids, including a large amount of soda and other beverages, far exceeding the prescribed 1500 cc fluid restriction. The dietary aide was unaware of the fluid restriction, and the Director of Nursing confirmed that the resident was non-compliant with the restriction, yet the facility allowed unlimited fluids in the resident's room. Resident 3, diagnosed with non-traumatic brain dysfunction, Alzheimer's disease, anemia, coronary artery disease, heart failure, non-Alzheimer's dementia, malnutrition, depression, and Parkinson's disease, had orders for daily weights and as-needed Lasix for weight gain of 2 pounds or more in one day. However, the facility failed to obtain daily weights on multiple occasions, missing 21 out of 40 days reviewed. Additionally, despite documented weight gains of 4 pounds and 3 pounds on specific days, the as-needed Lasix was not administered as ordered. Interviews with the Director of Nursing confirmed the lapses in following physician orders for both residents. The facility's failure to comply with these orders resulted in deficiencies in the care provided to the residents, as the necessary monitoring and medication administration were not conducted as required.
Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
The facility failed to provide adequate assessment and monitoring of a resident's pressure ulcer, leading to a deficiency in care. The resident, who was admitted with a stage 1 pressure ulcer on the coccyx, did not receive the required weekly assessments to monitor the ulcer's progression. The facility's policy mandated that a licensed nurse conduct a full body assessment at admission and weekly thereafter, with findings documented in the medical record. However, there was no evidence that the stage 1 pressure ulcer was assessed or documented, and the resident's electronic medical record lacked an assessment of the buttocks/coccyx area. The deficiency was further highlighted during an observation where an LPN identified the ulcer had progressed to a stage 2 pressure ulcer, measuring approximately 1.5 cm by 0.2 cm. The LPN confirmed that the facility had been treating the ulcer since admission but was uncertain when the ulcer changed stages. The Director of Nursing also acknowledged the failure to assess and monitor the pressure ulcer, resulting in the progression from stage 1 to stage 2 without proper documentation or intervention.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain infection prevention measures for Enhanced Barrier Precautions (EBP) during the provision of wound care and catheter care for two residents. The facility's policy on EBP, revised on 3/27/24, required the use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms. However, during an observation, a Medication Aide (MA-C) did not fully secure a gown while assisting a resident with a catheter, and the gown was not worn at all during wound care for another resident. Additionally, hand hygiene was not performed at appropriate intervals, such as between glove changes, which is a critical step in preventing the spread of infections. Resident 52, who had a terminal condition and was dependent on staff for toileting and hygiene needs, was observed during care provision. The resident had chronic wounds and a catheter, necessitating the use of EBP. However, during the care, the MA-C did not secure the gown properly and lifted the catheter drainage bag above the resident's bladder, which could lead to potential infections. Furthermore, during wound care, the RN did not wear a gown and failed to perform hand hygiene between glove changes, increasing the risk of infection transmission. Resident 22, who had self-care deficits and a history of skin issues, was also observed during wound care. The RN did not perform hand hygiene between glove changes and wound sites, which is essential to prevent the spread of infection. The Director of Nursing confirmed that staff should perform hand hygiene between glove changes and when changing dressings, as these are high-contact care activities requiring adherence to EBP.
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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