Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Banyan At Montclair during CMS and state inspections, most recent first.
The facility failed to follow infection control practices during resident care, including hand hygiene, glove changes, perineal care, and EBP use. Staff were observed providing care to residents with a feeding tube, wound and colostomy needs, and toileting assistance without proper hand hygiene or correct PPE, and one resident’s nebulizer equipment and a urine-filled urinal were left improperly stored near feeding supplies. A maintenance director also entered a room under neutropenic precautions without a face mask or hand hygiene.
Failure to Investigate and Report Fall With Significant Injury: A resident with severe cognitive impairment and multiple comorbidities, including dementia, DM2, HTN, CKD, and spinal stenosis, fell and sustained a left eyebrow laceration requiring sutures and ED transfer. RN documentation noted the resident was found on the floor, but the cause of the injury was not explained, and the DON confirmed the fall with significant injury was not reported and no investigation was completed.
Failure to Prevent Pressure Injury Development: A resident with dementia, CKD, and major mobility dependence developed a heel pressure injury after the facility did not implement documented pressure prevention measures. Records showed only limited monitoring and shoe changes, while turning/repositioning and heel-floating were not entered into the care plan or orders. Observations found the resident’s heels flat on the mattress, and the pressure redistribution mattress was placed in the wrong direction, with staff confirming they had not been educated on proper placement.
Significant Medication Errors: Two residents received meds contrary to provider hold parameters. One resident with dementia, CKD, and HTN was given Hydralazine when SBP was below the ordered threshold. Another resident with HTN, cardiomyopathy, AFib, and hypotension received Metoprolol when HR and SBP were below hold limits and Midodrine when BP was above the ordered hold parameter. An LPN and RN confirmed the doses should not have been given and identified each as a medication error.
A resident with Alzheimer’s disease and CKD experienced progressive, significant weight loss over several months, during which multiple new treatments were initiated, including a nutritional supplement, KCL for hypokalemia, metformin for prediabetes, mirtazapine for dementia with depression and weight loss, and orders for prealbumin labs, weekly weights, and a renal ultrasound. Although the facility’s policy required notifying the resident’s representative of significant condition changes and new treatments, documentation showed no evidence that the POA was informed of the ongoing weight loss or these new orders, and the POA reported only being told once that the resident would start a supplement and then not hearing more until hospice was discussed.
A resident with Alzheimer’s disease and CKD stage 3 experienced progressive weight loss despite being on a mechanical soft diet, med pass supplement, and snacks as requested, and being care planned for significant weight loss. Facility policy required weekly weights for residents with weight loss, but weekly weights were not initiated, resulting in a large gap between recorded weights during which the resident lost over 10% of body weight, followed by an additional significant loss in one week. A prealbumin lab was ordered due to unintended weight loss, but no result for the initial order was found in the record, even though a later prealbumin level was low and could indicate malnutrition. These omissions show that the resident’s nutritional status and weight loss were not adequately monitored after interventions were implemented.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors found multiple food items in kitchen storage areas that were not labeled, dated, sealed, or were past their use-by dates, including items in reach-in fridges, the walk-in refrigerator, and dry storage. They also observed dirty kitchen equipment and storage areas, including ovens, fridge vents, a mixer, a thermometer, freezer floors, carts, prep table drawers, milk cooler surfaces, and ceiling vents; the DM confirmed the items and areas were not clean.
Delayed APS Reporting After Allegation of Potential Abuse: A resident with intact cognition and extensive ADL dependence reported that an NA was rough during brief care and bumped the resident’s head against the bed rail, leaving a raised area on the forehead. RN-D confirmed the allegation was reported to nursing staff but was not immediately escalated, and APS was not contacted until later that morning, beyond the required 2-hour timeframe.
Failure to verify BiPAP settings and oxygen orders for a resident with morbid obesity and alveolar hypoventilation. The resident had an order for nightly BiPAP AUTO with specific settings, and the care plan directed staff to ensure the settings and supplemental O2 were correct each time the device was applied. An RN said the BiPAP came from home and staff did not program or adjust it, and the RNC confirmed the settings had not been verified and no O2 order had been obtained for use with the BiPAP.
Failure to evaluate PTSD triggers and care plan interventions: A resident with chronic PTSD, dementia, bipolar disorder, schizoaffective disorder, depression, and anxiety had no documented trauma history evaluation in the EMR. The care plan did not identify situational triggers or specific interventions to reduce exposure to triggers, and the RNC confirmed the PTSD had not been evaluated.
Blood pressure medications were administered outside ordered hold parameters for two residents. One resident with CAD, HF, HTN, and intact cognition received Metoprolol when pulse and BP were below ordered limits, and another resident with orthostatic hypotension received Hydralazine and later Midodrine despite BP readings outside the prescribed parameters. The DON and Regional Nurse Consultant confirmed the doses should have been held.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 16% med error rate after 4 errors were found in 25 observed meds. An LPN gave Tylenol outside the scheduled window, failed to obtain BP before giving clonidine and amlodipine despite hold parameters, and administered valproic acid from another resident’s pharmacy-dispensed bottle to a resident via PEG-tube.
Failure to Follow Ordered Renal Diet: A resident with ESRD and dialysis dependence had an order for a renal diet, but meal observations showed regular menu items being served instead of the renal diet substitutions listed on the tray ticket. The RD stated that diet modifications automatically print on the tray ticket, and the Dietary Manager confirmed the resident should have received the renal diet items.
Infection control failures were observed when staff carried unbagged clean linens against their clothing, a resident’s nebulizer kit was repeatedly left uncleaned with residual medication and facial oils on the mask, and another resident’s bed linens were repeatedly found heavily soiled with a dried urine ring and odor. An RN confirmed the neb kit should have been cleaned after each treatment, and staff confirmed the soiled sheets needed to be changed.
Surveyors found that carpets in multiple resident rooms and hallways were stained and retained strong urine odors, with additional issues such as a section of carpet pulled up near a vending machine and handrails with accumulated debris. Facility staff confirmed that cleaning efforts were unsuccessful and that the carpets needed replacement, affecting several residents in the impacted areas.
The facility did not provide required written notifications to residents and their representatives regarding the reasons for hospital transfers, appeal rights, or bed-hold policies for five sampled residents. Documentation and interviews confirmed that, despite facility policy, no transfer forms or written notifications were completed or given at the time of transfer, regardless of the residents' cognitive status or medical condition.
Staff failed to maintain required refrigerator temperatures for a resident's personal refrigerator and did not follow proper procedures for handling dishware during meal service. Dietary staff and management were observed touching the rims of glasses and the interior of bowls with bare hands while serving food and drinks, and no hand sanitizer was used during the process.
Staff did not consistently follow infection prevention protocols, including failing to use gowns and maintain sterile fields during a PICC line dressing change for a resident with a central line and wound, neglecting hand hygiene between glove changes and when switching medication routes, and placing nebulizer machines and tubing on the floor for two residents. These actions were contrary to facility policies and recognized infection control standards.
A resident with multiple psychiatric and neurological diagnoses did not receive a prescribed medication for an extended period due to insurance and pharmacy issues. Facility staff documented the medication's unavailability but did not notify the provider or obtain alternative orders as required by policy until several days after the last dose was given.
A resident with moderately impaired cognition and dementia had personal belongings reported missing by a family member. Although facility records indicated the items were found and sent for labeling, ongoing interviews and observations confirmed the specific pajama pants remained missing. The family member did not receive a written summary of the grievance resolution, as required by facility policy, and remained dissatisfied with the outcome.
A resident with a history of stroke and cognitive intactness was physically kicked by another cognitively intact resident who had exhibited escalating agitation, verbal outbursts, and aggressive behaviors. Despite multiple documented incidents of disruptive behavior, staff did not increase supervision or update interventions to address the risk, resulting in a physical altercation in the hallway.
A resident with a history of falls and cognitive impairment experienced a fall resulting in surgery and hospitalization. Although the LPN assessed the situation and involved the DON and Administrator, the required notification to the State Agency was not made within the facility's specified timeframe, as the DON did not learn of the surgery and hospital admission until the next day and reported it to Adult Protective Services only then.
A quarterly MDS assessment for a resident was not completed and signed within the required 14-day timeframe from the assessment reference date. The MDS Coordinator, who was new to the role, indicated that regional MDS support was responsible for signing the assessment, but it was not completed by the deadline.
A resident with multiple diagnoses, including dementia and major depressive disorder, was incorrectly documented on the MDS as having received antipsychotic medications during the look-back period, despite the MAR showing none were administered. The MDS Coordinator confirmed the error, resulting in an inaccurate assessment.
A resident admitted with complex needs, including a renal diet, fluid restriction, and scheduled dialysis, did not have a Baseline Care Plan completed within 48 hours that addressed these requirements. Staff interviews confirmed the initial care plan omitted dialysis and medication information, and the MDSC was unaware of the resident's dialysis status until after admission.
A resident with a history of falls and mental health conditions experienced a decline in ADLs after a fall and surgery, requiring increased assistance with daily tasks. Despite staff providing this assistance and updated MDS assessments reflecting the change, the comprehensive care plan was not revised to document the resident's new needs.
Three residents with conditions requiring restorative nursing interventions did not have care plans specifying the frequency of ROM and mobility exercises. Although therapy recommendations and care plans described the types of interventions, they lacked directions on how often to perform them, resulting in inconsistent delivery of restorative services. Both staff and residents or their families confirmed the absence of specified frequencies, contrary to facility policy.
Facility staff did not assess a resident's ability to smoke safely, leading to burns when the resident set their hair and beard on fire. Another resident, with severe cognitive and physical impairments and a care plan requiring a fall mat, was observed without a fall mat at bedside on multiple occasions. In both cases, required safety interventions were not implemented as outlined in the facility's policies and care plans.
A resident with moderate cognitive impairment and multiple medical conditions was not evaluated or placed on a toileting program, despite being aware of toileting needs and able to request assistance. The facility failed to complete required quarterly bowel and bladder assessments, and staff confirmed the resident was not on a toileting program, contrary to facility policy.
A resident with cognitive impairment and mobility issues was using bilateral bed assist bars, but the facility failed to complete required quarterly assessments and did not accurately document the use of these devices in the resident's MDS and evaluations, as confirmed by staff interviews and record reviews.
Staff failed to maintain a medication error rate below 5% when a resident received oral medications that were crushed despite 'Do Not Crush' instructions and had eye drops administered incorrectly. The errors were confirmed by both the medication aide and an RN, and were not in accordance with facility policy or manufacturer guidelines.
Four residents experienced deficiencies in pressure ulcer prevention and care, including delayed wound treatment, lack of weekly skin and wound assessments, failure to implement physician-ordered interventions such as pressure-relieving devices, and improper wound dressing application. These failures resulted in the development and worsening of pressure ulcers, with staff and nursing leadership confirming lapses in required monitoring and care.
A deficiency occurred when the facility failed to maintain safe and comfortable room temperatures, with many resident rooms and common areas falling below 71°F, some as low as 49°F. Staff did not consistently follow protocols for monitoring and reporting temperatures, and communication lapses led to delays in addressing cold conditions. Residents were observed bundled in extra blankets, and some heating equipment was found to be malfunctioning or turned off, resulting in an unsafe environment.
Facility administration failed to manage resources effectively, resulting in unmaintained temperatures in resident rooms and common areas. This led to an Immediate Jeopardy situation, and review confirmed that the abatement plan to address the deficiency was not fully implemented, as acknowledged by the DON.
The facility's QAPI program failed to address ongoing issues related to deficiencies such as room temperatures, handrails, and infection control. Staff interviews revealed a lack of awareness about the QAPI committee's activities, contributing to repeated deficiencies in areas like practitioner notification, order management, and pressure ulcer prevention.
The facility failed to maintain appropriate temperatures in the 200 hallway, affecting residents' comfort, with temperatures recorded as low as 63 F. A resident reported feeling cold, and the furnace was not functioning correctly. Additionally, the handrails in the 300/400 hallways were worn, the smoking area door was damaged, and a baseboard heater guard was missing, indicating a lack of timely maintenance and repair actions.
A resident with cerebrovascular disease and dysphagia experienced significant weight loss, but the facility failed to notify the medical provider. Despite a care plan to monitor nutritional intake, the resident lost 14.4 pounds in one month. A dietary note recommended increased supplements and provider notification, but no documentation confirmed the provider was informed. This was acknowledged by the Assistant DON, highlighting a deficiency in communication and care management.
A resident with a malignant carcinoid tumor and secondary neoplasms was discharged to a psychiatric care unit due to aggressive behaviors. The facility failed to evaluate the resident for readmission after hospitalization and did not provide the required discharge notice to the resident, their representative, or the Ombudsman.
The facility failed to follow medical orders for three residents, leading to deficiencies in care. A resident with heart failure and kidney disease did not have daily weights recorded as ordered. Another resident with diabetes had an unclear order regarding a chest port, which was not accessed by staff. Additionally, a resident with chronic pain had an order to discontinue as-needed acetaminophen that was not transcribed, resulting in continued availability of the medication.
A resident developed a Stage II pressure ulcer due to the facility staff's failure to implement necessary interventions as outlined in the care plan. Despite being at mild risk, the resident was frequently observed in positions that increased pressure on their buttocks and heels without repositioning or protective measures. The facility's Pressure Injury Prevention Guidelines were not followed, leading to the development of a preventable pressure ulcer.
A registered nurse failed to follow infection prevention protocols while caring for a resident on Enhanced Barrier Precautions. The nurse did not change gloves, wash hands, or wear a gown during the tube feeding process, despite handling various items and changing the G-tube dressing. The resident had severe cognitive impairment and was on 1-1 observation to prevent G-tube removal.
A resident with multiple chronic conditions had significant clinical events and provider communications documented only in a staff communication app, not in the official EHR. The DON confirmed that required documentation was missing from the medical record, resulting in an incomplete and inaccurate record that did not reflect the resident's care or condition.
Staff did not consistently use required infection control measures, such as wearing gowns and performing proper hand hygiene, during catheter care and while implementing Enhanced Barrier Precautions for two residents with indwelling urinary catheters. Observations showed that staff failed to follow facility policy for cleaning catheter sites and did not always use appropriate personal protective equipment, despite signage and available supplies. Supervisory staff confirmed these lapses in protocol.
A resident, severely cognitively impaired, was unable to receive visits from their family member due to a ban imposed by the facility after an incident involving aggressive behavior. Despite the resident's desire for visits and the family member's attempts to resolve the issue, the facility did not arrange a meeting to address the situation, resulting in a prolonged visitation ban.
A facility failed to resolve a grievance regarding missing clothing for a resident with severe cognitive impairment. The resident's family member, also the POA, reported the issue and made multiple unanswered calls. Despite a care conference discussion and an investigation by the Social Services Director, the grievance remained unresolved, and no written decision was provided, violating the facility's grievance policy.
The facility's kitchen staff failed to follow proper food safety protocols, leading to potential foodborne illness risks. Observations revealed multiple trays of food in the refrigerator that were unlabeled, undated, or past their labeled dates. Additionally, chicken was improperly thawed in a sink without running water. Interviews with staff indicated a lack of awareness regarding food labeling, dating, and thawing procedures.
The facility failed to provide sufficient staff to answer call lights promptly, with delays ranging from 13 to 39 minutes. Staff interviews indicated a reasonable response time should be 5-10 minutes, but the facility lacked an established standard. Residents reported waiting up to 2 hours, highlighting significant delays in assistance.
A resident with a complex medical history did not receive prescribed medications due to a significant error in entering hospital discharge orders into the facility's electronic health record system. The oversight occurred when a corporate employee took the orders home and missed pages containing new medication instructions, leading to the resident's increased confusion and hospital admission for hepatic encephalopathy.
Facility staff failed to properly label and manage insulin injector pens, leading to deficiencies. A Victoza pen lacked an opened-on and expiration date, a Lantus pen was expired without an opened-on date, and an unidentified FLASP pen lacked a resident name and opened-on date. The facility's policy requires clear labeling and discarding of expired pens, which was not followed.
A resident with Type 2 Diabetes Mellitus did not receive prescribed sliding scale Lispro insulin due to a transcription error in the MAR. Despite monitoring, the omission was identified as a medication error, though no immediate negative outcomes were reported.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to implement infection prevention and control practices during resident care, including hand hygiene, glove use, and perineal care. During observation of care for a resident who was cognitively intact, incontinent of bowel, and required total assistance with toileting and transfers, a nursing assistant performed perineal care while wearing soiled gloves, did not perform hand hygiene between glove changes, and cleansed the resident from back to front rather than front to back. The nursing assistant confirmed the hand hygiene was not completed between glove changes and confirmed the wiping direction was incorrect. A licensed practical nurse also confirmed that perineal care should be completed front to back because back-to-front cleansing introduces bacteria to the urinary tract. The facility also failed to follow Enhanced Barrier Precautions for two residents. One resident had a feeding tube and was ordered to receive EBP due to PEG tube placement. During tube feeding and g-tube site care, the LPN washed hands and donned gloves but did not don a gown for the feeding, used a syringe plunger to force formula and flushes through the tube when gravity flow did not work, exceeded the ordered flush amount, and changed gloves without hand hygiene during site care. The LPN confirmed the resident was on EBP, confirmed a gown should have been worn, and confirmed hand hygiene was not performed between glove changes or when exiting the room. Another resident had a wound and colostomy care needs; staff changed gloves without hand hygiene, handled the resident’s clothing and body without gloves at points during care, and the EBP sign was not posted in the room until after the wound was identified. The infection preventionist confirmed the sign was not posted until after the new wound was reported. Additional infection control failures involved equipment storage and isolation precautions. A nebulizer mask and tubing ordered to be stored in a dated plastic bag were observed lying on the resident’s bedside table on two occasions, and a urinal full of urine was observed beside the graduated cylinder and syringe used for tube feeding. Staff confirmed the nebulizer equipment should have been stored in a dated plastic bag and that the urinal beside feeding equipment was an infection control issue. In another room under neutropenic precautions, a maintenance director entered, exited, and re-entered the room without a face mask and without performing hand hygiene. The infection preventionist confirmed the maintenance director should not have entered without a face mask and hand hygiene.
Failure to Investigate and Report Fall With Significant Injury
Penalty
Summary
The facility failed to investigate and report a fall with significant injury for one resident. The resident was admitted with multiple diagnoses including vascular dementia, essential hypertension, chronic kidney disease stage 3, pain, type 2 diabetes, peripheral vascular disease, obstructive sleep apnea, spinal stenosis, major depressive disorder, and morbid obesity. The resident’s MDS dated 4/5/2026 showed a BIMS score of 5, indicating severe cognitive impairment. The care plan identified the resident as at risk for falls related to type 2 diabetes, hypertension, spinal stenosis, weakness, and decreased mobility. A progress note by RN L documented that the resident fell on 5/2/2026 and sustained a laceration to the left eyebrow that required sutures. The note stated the resident was found on the floor and did not explain how the laceration occurred. The resident was transferred to the ED for treatment. During an interview on 5/12/26 at 1:45 PM, the DON confirmed the facility did not report the fall with significant injury and did not perform an investigation.
Failure to Prevent Pressure Injury Development
Penalty
Summary
The facility failed to implement interventions to prevent pressure injuries for a resident who was at risk for skin breakdown and had significant mobility limitations. The resident had diagnoses including unspecified dementia, stage III chronic kidney disease, polymyalgia rheumatica, and osteoarthritis of the left knee. The resident’s MDS showed severe cognitive impairment, dependence or substantial assistance for many activities of daily living, and need for substantial to total assistance with bed mobility and transfers. The resident was identified as being at risk for pressure injury and did not have a pressure ulcer at the time of the assessment. The resident developed a right heel wound that was first identified as an abrasion and later documented by the NP as a new stage 3 pressure ulcer/injury acquired in the facility. Progress notes showed the heel area was initially noted, treated with betadine, and later marked healed on the wound tracker, but the wound reopened. The NP documented that the wound had been thought healed but was found reopened, and noted the wound had been initially caused by Crocs and friction on the resident’s heel. The resident later had proper fitting shoes, but the record did not show pressure injury prevention orders in the order summary, MAR/TAR, or care plan beyond weekly skin checks. The record and observations showed the resident remained in bed with heels flat on the mattress, and no pillow was placed under the lower legs during observations. The wound care nurse confirmed that staff were told to float the resident’s heels, but no order was entered and it was not on the care plan. The wound care nurse also confirmed turning and repositioning should have been completed per standards of practice and facility protocol. Although the facility used a pressure redistribution mattress, the mattress on the resident’s bed was placed with the foot end at the head of the bed, leaving the heel slope on the upper body portion rather than under the heels. The maintenance director confirmed staff applied the mattress without attention to its required direction and that staff had not been educated on the mattress placement. The administrator confirmed staff had not had a competency on placement of the mattress.
Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors. The cited deficiency involved 2 of 5 sampled residents, with record review and staff interview showing that medications were administered contrary to provider orders. The facility’s medication error policy defined a significant medication error as one that causes discomfort or jeopardizes a resident’s health and safety, and the medication administration policy stated medications were to be given as ordered by the physician and in accordance with professional standards of practice. For one resident with diagnoses including unspecified dementia, stage III chronic kidney disease, an infrarenal abdominal aortic aneurysm, a cardiac murmur, and essential hypertension, the order for Hydralazine HCL 25 mg three times daily required the medication to be held if systolic blood pressure was less than 115 mmHg. Review of the MAR showed Hydralazine was administered on multiple occasions when the resident’s systolic blood pressure was below that hold parameter, including readings of 113, 109, 114, 112, 113, 104, 112, 112, and 102 mmHg. During interview, the LPN confirmed the medication had been given when it should have been held and agreed each instance was a medication error. For the second resident, who had diagnoses including essential hypertension, cardiomyopathy, paroxysmal atrial fibrillation, and hypotension, the orders included Metoprolol Tartrate 12.5 mg twice daily to be held if HR was less than 60 or SBP was less than 90, and Midodrine HCl 5 mg three times daily to be held if SBP was greater than 120 when sitting. MAR review showed Metoprolol was administered on days when the resident’s HR was 58, 58, 58, 43, and 56 bpm, and on days when SBP was 72/40, 81/29, 78/56, and 88/58 mmHg. The MAR also showed Midodrine was given at 2:00 PM on several dates when the resident’s BP was 131/81, 128/60, 125/85, 133/84, 125/81, and 132/76. An RN confirmed the medications should not have been given under those conditions and identified each instance as a medication error.
Failure to Notify Resident Representative of Significant Weight Loss and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal representative of significant changes in condition and treatment, as required by facility policy and state licensure regulations. The facility’s written policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there were accidents, significant changes in physical, mental, or psychosocial condition, or circumstances requiring alteration of treatment, including new treatments. Resident 3 was admitted with Alzheimer’s disease with late onset and stage 3 chronic kidney disease, and the admission record identified a family member as POA. The POA reported being told months earlier at a care conference that the resident was losing weight and would start a supplement, but reported receiving no further information about the resident’s weight loss until the resident was placed on hospice. The social service note for that care conference did not document weight loss as a concern. Weight records showed a progressive and significant weight loss over several months, with multiple documented 5–10% or greater changes from prior comparison weights. During this period, several new clinical interventions and orders were initiated in response to the resident’s condition, including starting a nutritional supplement (med pass 60 cc three times daily) for slow weight loss, potassium chloride for hypokalemia, metformin for prediabetes, and mirtazapine for dementia with depression and weight loss, as well as orders for a prealbumin lab, weekly weights, and a renal ultrasound due to a history of mass and significant weight loss. A handwritten note indicated the family declined the ultrasound. However, a review of progress notes and medical professional notes between late October and early January did not show documentation that the POA was notified of the resident’s weight changes or the new orders for potassium chloride, metformin, mirtazapine, or the prealbumin lab. The registered dietitian confirmed not speaking with the family about the weight loss, and the ADON confirmed that nurses are expected to notify the POA of changes in condition, including weight loss and medication changes, and that no additional documentation of POA notification could be found.
Failure to Monitor Nutritional Status and Weight Loss After Interventions
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and follow up on a resident’s nutritional status and weight loss after nutritional interventions were implemented. Facility policy required that residents with weight loss be monitored with weekly weights and that interventions be identified, implemented, monitored, and modified as appropriate. The resident, who had Alzheimer’s disease with late onset and stage 3 chronic kidney disease, was care planned for significant weight loss and was receiving a mechanical soft diet, med pass supplement, and snacks as requested. Dietary notes documented progressive weight loss, including a 3.5% loss in 30 days and an 8.9% loss in 90 days, with plans for the RD to monitor oral intake, diet status, weight trends, and skin integrity. Despite these interventions and plans, the facility did not obtain weekly weights as required for a resident with weight loss, as confirmed by the RD. The weight and vital summary showed a weight of 134.8 lbs. on one date and then no further recorded weight until a later date when the resident’s weight had dropped to 121 lbs., reflecting a 10.2% loss over that period, followed by another recorded weight of 114 lbs. one week later, a 5.79% loss in that week. Additionally, a prealbumin lab was ordered due to unintended weight loss, but no result was found in the record for that order, and the regional nurse consultant confirmed that no result could be located. A later prealbumin result showed a level of 14, which could indicate malnutrition. These gaps in weight monitoring and lack of documented follow-up on the initial prealbumin order occurred despite the resident being identified with significant weight loss and having nutritional interventions in place.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food stored in the kitchen was labeled, sealed, and dated, and failed to discard food that was past its use-by date. During observation of the kitchen, surveyors found a bag of green leafy substance in the True 2-door reach-in refrigerator that was not labeled or dated, a plastic bag of brown patties in the refrigerator by the double ovens that was not labeled or dated, and a 1-gallon container of mayonnaise that had been opened with no open date. The walk-in refrigerator contained a personal can of Pepsi and a 5-pound container of low fat cottage cheese with a best if used by date of 11/22/25. Three 6.5-pound cans of Country Style Gravy with a Best Buy date of September 14, 2025 were also found on the dry storage rack, along with a large opened bag of all-purpose flour that was not sealed or dated. The Dietary Manager confirmed these items were not labeled, dated, sealed, or were past their use-by date and should have been discarded. The facility also failed to ensure kitchen equipment and storage areas were clean and sanitized. Surveyors observed black crust in the bottoms of the double oven, food splatters and debris on the vents of both True 2-door reach-in refrigerators, food debris and splatters on the large commercial mixer and stand, a black slimy substance on the internal thermometer in the walk-in refrigerator, food debris and corn kernels scattered on the walk-in freezer floor, food debris on a black cart by the walk-in freezer, and food debris in the drawers on the prep table by the walk-in refrigerator and freezers. The top and front of the milk cooler by the back door had food splatters, and ceiling vents by the back door and in the dry storage area had a thick gray fuzzy substance. The Dietary Manager confirmed these items and areas were not clean and should have been.
Delayed APS Reporting After Allegation of Potential Abuse
Penalty
Summary
The facility failed to ensure Adult Protective Services (APS) was notified within 2 hours of an allegation of potential abuse involving one resident. The facility’s Abuse, Neglect, and Exploitation policy stated that alleged violations involving abuse or serious bodily injury were to be reported immediately, but no later than 2 hours after the allegation was made. In this case, the resident had a BIMS score of 15, indicating cognitive awareness, and required supervision or touching assistance with eating, oral hygiene, and personal hygiene, while being dependent on staff for all other activities of daily living and mobility. On 12/10/2025, the resident reported that a nursing assistant had been rough during brief care and had bumped the resident’s head against the bed rail. The resident stated the staff member rolled the resident toward the window, the resident hit the forehead on the rail, and the resident felt afraid or humiliated by the interaction. An observation later that morning showed the resident in bed appearing upset, and another observation showed a dime-sized raised area on the right side of the forehead. RN-D confirmed the resident reported that a staff member had bumped the resident’s face into the bed rail and that RN-D had not reported the incident to anyone at the time. RN-D later told the DON about the situation during a phone call, and the DON initially understood the report differently, believing the resident had bumped a hand on the bedside table and that no injury was seen. The facility’s investigation form showed APS was contacted at 12:20 PM, while RN-D stated the allegation was reported to RN-D at about 8:46 AM. The DON later confirmed that APS should have been contacted within 2 hours of the allegation being reported to staff.
Failure to Verify BiPAP Settings and Oxygen Orders
Penalty
Summary
The facility failed to ensure oxygen and BiPAP orders were obtained and followed for one resident. The resident had morbid obesity with alveolar hypoventilation, was cognitively intact with a BIMS score of 15, and had a noninvasive mechanical ventilator noted on the MDS. The resident’s AVS included an order for BiPAP AUTO to be used every night as directed with settings of 14/6 and a backup rate of 16. The care plan identified impaired respiratory status and directed staff to use BiPAP per order and to ensure the settings and supplementary oxygen were correct each time the device was applied. An observation found the resident’s BiPAP machine on the bedside table. The resident stated that staff attach supplementary oxygen to the BiPAP when it is used. An RN stated the BiPAP machine was brought from home and that facility staff do not program or adjust BiPAP settings, relying instead on the machine arriving with settings already programmed or on the respiratory company to set it up. When the RN checked the BiPAP, the settings could not be verified. The RNC confirmed the resident’s BiPAP settings had not been verified by the facility’s respiratory company and that the facility had not obtained orders for supplementary oxygen to be used with the BiPAP.
Failure to Evaluate PTSD Triggers and Care Plan Interventions
Penalty
Summary
The facility failed to evaluate and identify situational triggers for PTSD for 1 resident reviewed. The facility policy on Trauma Informed Care stated that residents with trauma histories should be assessed for triggers, that trigger-specific interventions should be added to the care plan, and that the facility should evaluate whether those interventions reduce the impact of identified triggers. The policy also stated that the facility would use multiple sources, including resident interview and screening tools, to identify trauma history and cultural preferences. Resident 12 was admitted with diagnoses that included chronic PTSD, unspecified dementia, bipolar disorder, schizoaffective disorder, major depressive disorder, and anxiety disorder. The most recent MDS showed short- and long-term memory problems, modified independence with decision making, no mood concerns, and no behaviors. The resident was receiving antipsychotic, antidepressant, and antianxiety medications daily. Review of the EMR, including progress notes, clinical assessments, and the comprehensive care plan, showed no completed evaluation for PTSD. The EMR and care plan did not identify situational triggers or specific interventions to decrease the resident’s exposure to triggers that could re-traumatize the resident. During interview, the Regional Nurse Consultant confirmed that the resident had a diagnosis of PTSD, that no history of trauma had been identified in the EMR, and that PTSD had not been evaluated. The Regional Nurse Consultant also confirmed that the care plan did not identify situational triggers or specific interventions to reduce exposure to triggers.
Blood Pressure Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to hold blood pressure medications according to prescribed parameters for 2 of 5 sampled residents. The medication administration policy required vital signs to be obtained and medications to be held when values were outside physician-prescribed parameters, and the unnecessary drugs policy required monitoring parameters to be incorporated into the resident’s care plan. Despite these requirements, Resident 3, who had coronary artery disease, heart failure, hypertension, and intact cognition with a BIMS score of 15, received Metoprolol Tartrate 12.5 mg twice daily on multiple occasions when pulse and/or blood pressure were below the ordered hold parameters. The MAR showed administrations outside parameters on several dates in November and December 2025, and the DON confirmed these doses should not have been given. Resident 1, who had orthostatic hypotension, a BIMS score of 15, and required supervision with eating, bathing, toileting, and transfers, had a care plan addressing hypotension and orders for blood pressure monitoring. The resident’s MAR showed Hydralazine 25 mg three times daily for SBP greater than 160 or DBP greater than 90, yet the medication was administered on multiple occasions when blood pressure readings were below those parameters. After Midodrine 5 mg three times daily was ordered for hypotension with instructions to hold if SBP was greater than 120 while sitting, the MAR also showed doses given when blood pressure exceeded the hold parameter. The Regional Nurse Consultant confirmed that both Hydralazine and Midodrine were administered outside of the prescribed parameters and should have been held.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 4 errors identified during observation of 25 medications for an error rate of 16%. The deficiency involved Resident 100, whose MAR listed Tylenol Extra Strength 500 mg, clonidine 0.2 mg with a hold parameter for SBP less than 100, amlodipine 5 mg with a hold parameter for SBP less than 130, and valproic acid 250 mg/5 ml via PEG-tube. The facility’s medication administration policy required vital signs to be obtained when applicable or per physician orders and required the six rights of medication administration to be followed. During observation, an LPN dispensed two Tylenol tablets, one clonidine tablet, and one amlodipine tablet into a pouch, crushed them, and dumped them into a medication cup before administering them through the PEG-tube. The LPN did not obtain a blood pressure before giving clonidine or amlodipine, gave Tylenol 1 hour and 22 minutes after the scheduled time, and administered valproic acid after obtaining it from another resident’s pharmacy-dispensed medication bottle. In interview, the LPN confirmed that another resident’s valproic acid was given to Resident 100, that Tylenol was administered outside the administration window, and that blood pressure should have been obtained for amlodipine and clonidine.
Failure to Follow Ordered Renal Diet
Penalty
Summary
The facility failed to ensure that a physician-ordered renal diet was followed for one resident who was admitted with dependence on renal dialysis and end stage renal disease. The resident had an order dated 12/3/25 for a renal diet with regular texture and thin liquids, and the care plan included providing and serving the diet as ordered. Observation of the resident’s lunch tray on 12/11/25 showed chicken, cornbread, macaroni and cheese, Brussel sprouts, and pumpkin pie, even though the facility menu and tray ticket for residents on a renal diet called for buttered macaroni noodles instead of macaroni and cheese and butterscotch pudding instead of pumpkin pie. Observation of the resident’s breakfast tray on 12/15/25 showed French toast casserole, bacon, oatmeal, and chocolate milk, although the menu and tray ticket for a renal diet called for 2 slices of French toast instead of French toast casserole and 1/4 cup scrambled eggs instead of bacon. The Registered Dietitian stated that menu modifications from the regular diet automatically print on the tray ticket, and the Dietary Manager confirmed the resident should have received the renal diet items and that the renal diet needed to be followed.
Infection Control Lapses With Linen Handling, Nebulizer Cleaning, and Soiled Bed Linens
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff transported clean linens in a manner that could allow cross contamination, a resident’s clean sheets were not used, and a resident’s nebulizer administration kit was not cleaned after use. On 12/15/2025, a Medication Aide was observed walking from the laundry room to a resident room with unbagged clean bedding draped over the left arm and against the aide’s hand and clothing, and later a Nurse Aide was observed carrying unbagged clean linens between the left arm and chest against clothing while moving into resident care areas. The Regional Director of Operations confirmed staff should not have carried clean linens against their body or clothing. Resident 1 had an order for sodium chloride inhalation nebulization solution 3% four times daily, and the MAR showed it was administered multiple times each day from 12/09/2025 through 12/15/2025. However, observations on 12/10/2025, 12/11/2025, and 12/15/2025 showed the nebulizer kit left on a table or ledge with residual medication in the kit and facial oils on the mask. RN-F confirmed the nebulizer kit was supposed to be cleaned after each treatment and had not been. In addition, Resident 70, whose MDS identified diagnoses of non-Alzheimer’s dementia and psychotic disorder and who was occasionally incontinent of urine, was observed on multiple dates with bed sheets heavily soiled by a large dried yellow-brown substance resembling a urine ring, and staff confirmed the sheets smelled of urine and needed to be changed.
Failure to Maintain Clean and Odor-Free Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and homelike environment for residents, specifically regarding the condition of carpets and cleanliness in resident rooms and hallways. During environmental tours, stained carpets and strong urine odors were noted in 13 resident rooms and throughout the 100, 200, 300, and 400 hallways on the north side of the building. Additionally, a section of carpet was found pulled up and folded near a vending machine, and handrails along the 100 hallway had accumulated dust, dead bugs, food particles, and trash. These issues were confirmed by the Housekeeping Director and Maintenance Director during interviews, who acknowledged the presence of stains, persistent odors, and inadequate cleaning results. The Housekeeping Director further confirmed that despite attempts to clean the carpets, the stains and odors remained, indicating that the carpets retained urine odors and required replacement. The environmental concerns affected 17 residents residing in the impacted rooms, with a total facility census of 110 residents. The observations and interviews documented that the facility did not uphold the required standards for cleanliness and environmental maintenance in resident-use areas.
Failure to Provide Written Notification for Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for hospital transfers, as well as information about appeal rights and bed-hold policies, for five sampled residents. According to the facility's own policy, staff are required to obtain physician orders stating the reason for emergency transfers, ensure transfer forms and advance directives accompany the resident, and provide written notice of transfer and the facility's bed-hold policy to both the resident and their representative. However, record reviews and staff interviews confirmed that these steps were not completed for the sampled residents. For each of the five residents, documentation in the medical records, including progress notes, practitioner orders, and care plans, did not include the reason for transfer or evidence that a written notification was provided. This included residents with varying cognitive statuses, such as those with severe impairment and those who were cognitively intact. In several cases, the residents were transferred to the hospital for acute medical issues, but there was no indication that the required written notifications were completed or given to the residents or their representatives at the time of transfer. Interviews with the Regional Nurse Consultant confirmed the absence of transfer forms and written notifications for each incident. The lack of documentation and notification was consistent across all five cases reviewed, regardless of the residents' cognitive abilities or the circumstances of their transfers. The findings indicate a systemic failure to comply with both facility policy and regulatory requirements regarding resident notification during transfers to acute care settings.
Deficient Food Storage and Improper Dishware Handling During Meal Service
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, resulting in deficiencies related to food safety. Review of the facility's policy for resident in-room refrigerators indicated that residents are responsible for recording refrigerator temperatures weekly, with required temperatures at or below 41 degrees Fahrenheit. However, observation and record review revealed that one resident's personal refrigerator consistently recorded temperatures above the required range, with several days showing temperatures between 43 and 51 degrees Fahrenheit. The Maintenance Director confirmed these out-of-range temperatures, and the issue was reported to the maintenance department. Additionally, the facility did not adhere to professional standards for handling dishware during meal service. Multiple observations during dining services showed dietary staff and the dietary manager handling glasses and bowls by the rim or interior surfaces, contrary to facility policy, which prohibits touching eating surfaces. Staff were observed serving drinks and salads while touching the rims of glasses and the inside of bowls with bare fingers, and no hand sanitizer use was observed during meal service. These actions were confirmed by interviews with the dietary manager and administrator, who acknowledged that such practices were not in line with facility policy.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to implement proper infection prevention and control practices in several observed instances. During a peripherally inserted central catheter (PICC) line dressing change for a resident with acute osteomyelitis, ESBL infection, and diabetes, the MDS Coordinator placed soiled gloves in the sterile field and did not wear a gown as required by Enhanced Barrier Precautions (EBP). The resident's care plan and physician orders specified the use of EBP due to the presence of a central line and wound, but these precautions were not followed during the procedure. Hand hygiene protocols were not consistently observed during medication administration and tube feeding. A medication aide failed to perform hand hygiene between glove changes and when switching between different routes of medication administration for a resident. Similarly, an LPN did not perform hand hygiene between glove changes or before handling equipment and did not wear a gown while administering tube feeding to a resident on EBP, despite signage indicating the requirement for a gown. Additionally, nebulizer machines and tubing were repeatedly observed placed directly on the floor in the rooms of two residents. Both staff and residents confirmed that this was a common practice, and staff interviews acknowledged that this created an infection control risk. These observations demonstrate multiple lapses in infection prevention practices, including improper use of personal protective equipment, failure to maintain sterile fields, and inadequate hand hygiene.
Failure to Timely Notify Provider of Unavailable Medication
Penalty
Summary
Facility staff failed to notify a resident's provider in a timely manner when a prescribed medication, tetrabenazine, became unavailable. The facility's policy requires immediate action and provider notification when a medication cannot be obtained, including obtaining alternative treatment orders or specific monitoring instructions. For one resident with diagnoses including bipolar disorder, schizoaffective disorder, anxiety, and vascular dementia, the medication was not administered from early April through late May, with documentation showing the pharmacy and insurance issues were known by staff. Progress notes indicated awareness of the unavailability, but there was no documentation that the provider was notified until eight days after the last dose was given. The resident was cognitively intact and had active orders for antipsychotic, antianxiety, and anticonvulsant medications. Despite multiple entries in the medical record about the medication's unavailability, there was no evidence that the provider was promptly informed or that alternative orders were sought as required by facility policy. The Assistant Director of Nursing confirmed the delay in provider notification and the absence of documentation regarding the hold order or provider communication during the period the medication was not available.
Failure to Resolve Grievance and Provide Written Decision Regarding Missing Resident Belongings
Penalty
Summary
The facility failed to resolve an ongoing grievance regarding missing personal belongings for a resident with moderately impaired cognition and a diagnosis of non-Alzheimer's dementia. The resident's family member reported missing items, specifically a shirt and four pairs of sleep bottoms, through a grievance form. Although the facility documented that the items were located and sent to laundry for labeling, subsequent interviews and observations revealed that the specific pajama pants remained missing. The family member continued to report the items as missing, and observations confirmed that the pants were not found in the resident's room, laundry, or among the resident's belongings. Despite the facility's policy requiring a written decision to be provided to the resident or their representative at the conclusion of a grievance investigation, the family member reported not receiving a written summary of the resolution. The facility's documentation indicated the grievance was marked as resolved, but the family member expressed dissatisfaction and confirmed that the missing items had not been returned or accounted for, and no written decision was provided as required by policy.
Failure to Prevent Resident-to-Resident Physical Abuse Amid Escalating Behaviors
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was cognitively intact and had a history of stroke with paralysis on one side, was kicked in the shin by another cognitively intact resident while waiting in the hallway for a cigarette. The incident did not result in pain, injury, or mental anguish for the victim, but it was a physical altercation that was reported to staff. Prior to the incident, the resident who committed the abuse exhibited escalating behavioral issues, including increased agitation, verbal outbursts, refusal of medications, and disruptive actions such as throwing items and making threats. Documentation in the progress notes indicated that these behaviors were observed and recorded by staff over the course of at least two days, with specific episodes of agitation, wandering, and aggression noted. Despite these documented behaviors, there was no evidence in the electronic health record that interventions were changed or increased to address the resident's escalating behavior or to prevent potential harm to others. The facility's own policy required ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, including the implementation of appropriate interventions to prevent abuse. However, interviews and record reviews confirmed that the facility did not increase supervision or modify interventions for the resident exhibiting aggressive behaviors, even after multiple incidents and the physical altercation occurred.
Failure to Timely Report Significant Injury to State Agency
Penalty
Summary
The facility failed to notify the required State Agency of a significant injury within the required time frame for one resident. The resident, who had a history of falling, schizoaffective disorder, bipolar type, violent behavior, traumatic subdural hemorrhage, and chronic pain, experienced a fall that resulted in surgery and a subsequent hospital stay. The resident was assessed by an LPN, who determined that an emergency room visit was necessary and called 911. The DON and Administrator were made aware of the situation at the time of the incident. Despite being aware of the resident's transfer to the emergency room, the DON did not become aware of the need for surgery and hospital admission until the following day. The facility's policy requires immediate reporting, but Adult Protective Services was not notified until the morning after the surgery and hospitalization. This delay in reporting did not meet the facility's policy or regulatory requirements for timely notification of significant injuries.
Quarterly MDS Assessment Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to complete and sign the federally mandated Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, the quarterly MDS must be completed and signed no later than 14 days from the assessment reference date. Record review showed that for one resident, the quarterly MDS with a reference date of 6/10/25 was not signed as completed as of 6/26/25, which was two days past the required deadline. During an interview, the MDS Coordinator, who had recently started in the role, stated that regional MDS support was responsible for signing the MDS as completed, but confirmed that the assessment had not been signed by the required date.
Inaccurate MDS Assessment for Medication Administration
Penalty
Summary
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS dated 04/25/25 indicated that the resident had received antipsychotic medications during the 7-day look-back period, as marked in Section N0415A1. However, a review of the resident's Medication Administration Record (MAR) for the same period showed that no antipsychotic medications were administered. The resident involved had a history of stroke, dementia, insomnia, and major depressive disorder. The MDS Coordinator confirmed during an interview that the resident did not receive antipsychotic medications during the specified period and acknowledged that the MDS was incorrectly coded as if the medications had been given. This discrepancy resulted in the MDS not accurately reflecting the resident's medication administration during the assessment period.
Failure to Complete Baseline Care Plan for New Admission with Dialysis Needs
Penalty
Summary
Facility staff failed to complete a Baseline Care Plan within 48 hours of admission for a resident who was admitted with complex medical needs, including a renal diet, fluid restriction, and scheduled dialysis treatments. Record review showed that the resident's hospital discharge orders included specific instructions for a renal diet, a 1500 ml daily fluid restriction, and dialysis three times a week via a hemodialysis catheter. However, the Baseline Care Plan initially created did not address these critical care needs, including dialysis and medication information. Interviews with facility staff, including an LPN and the MDS Coordinator, confirmed that the Baseline Care Plan only included information on code status, behavioral issues, and pressure ulcer management, but omitted essential details related to the resident's dialysis and other immediate care requirements. The MDS Coordinator was unaware of the resident's dialysis status at the time the Baseline Care Plan was developed, and additional care areas were only added later after the omission was discovered.
Failure to Update Care Plan After Resident Decline in ADLs
Penalty
Summary
The facility failed to revise the comprehensive care plan (CCP) for one resident following a significant change in their condition. The resident, who had a history of falling, schizoaffective disorder, bipolar type, violent behavior, and chronic pain, was admitted to the facility and initially assessed as independent in activities of daily living (ADLs) such as eating, toileting, ambulation, dressing, and personal hygiene. However, after experiencing a fall that resulted in surgery and a subsequent hospital stay, the resident returned to the facility with a documented decline in ADLs, as evidenced by a Minimum Data Set (MDS) assessment and staff observations. Despite the updated MDS Section GG indicating the resident now required varying levels of assistance with oral hygiene, toileting, dressing, and personal hygiene, the CCP was not updated to reflect these changes. Staff interviews confirmed that the resident was receiving assistance with these ADLs, but the care plan continued to list the resident as independent. This failure to update the care plan was confirmed by the MDS Coordinator, indicating a lapse in the required review and revision process following a change in the resident's condition.
Failure to Specify Frequency in Restorative Nursing Programs
Penalty
Summary
The facility failed to establish and implement restorative nursing programs with specified frequencies for range of motion (ROM) and mobility interventions for three residents. For one resident with bilateral osteoarthritis of the knee and moderate cognitive impairment, the care plan and therapy recommendations included active range of motion (AROM) exercises but did not specify how often these exercises should be performed. Documentation showed that restorative services were provided inconsistently, and both the resident and the Director of Nursing (DON) confirmed the absence of a defined frequency in the care plan. Another resident, who had a history of stroke with paralysis on one side and was cognitively intact, was assessed as needing restorative ROM and ambulation. The care plan and therapy recommendations listed the types of exercises and ambulation support required but again omitted the frequency for these interventions. Review of the electronic health record indicated that restorative services were provided only once during the review period, and both the resident and the DON acknowledged the lack of a specified frequency for these modalities. A third resident with dementia and total dependence for activities of daily living was also receiving restorative ROM and transfer training. The therapy recommendations described the exercises and transfer activities but did not include directions on how often they should be performed. Documentation showed sporadic provision of these services, and interviews with a family member and the DON confirmed that the frequency was not specified in the care plan. The facility's policy required that restorative nursing plans include the frequency of activities, but this was not followed for these residents.
Failure to Assess Smoking Safety and Implement Fall Prevention Measures
Penalty
Summary
Facility staff failed to assess a resident's ability to smoke safely, resulting in a physical injury. The resident, who had severe cognitive impairment, a history of stroke with hemiplegia and aphasia, limited range of motion, and was non-ambulatory, was allowed to smoke in the courtyard without a prior safe smoking evaluation. During this unsupervised activity, the resident set their beard and hair on fire, causing burns to the anterior neck, right chest, and left fingertips. No safe smoking evaluation had been conducted for this resident before the incident occurred. Additionally, the facility failed to implement a fall mat for another resident who was at high risk for falls. This resident had osteoporosis, epilepsy, a left hip fracture, severe cognitive impairment, and required extensive to total assistance with daily activities and mobility. The resident's care plan specifically included the use of a fall mat at the bedside when occupied, but observations on two separate occasions revealed the absence of a fall mat. A nursing assistant incorrectly stated that the resident was independent and did not need a fall mat, and the fall mat was not moved with the resident when they changed rooms. The facility's own policy required the identification and implementation of interventions to prevent avoidable accidents, including the use of assistive devices and supervision based on individual risk assessments. In both cases, the facility did not follow its policy or the residents' care plans, resulting in a failure to provide an environment free from accident hazards and adequate supervision to prevent accidents.
Failure to Evaluate and Implement Toileting Program for Incontinent Resident
Penalty
Summary
Facility staff failed to evaluate and implement a toileting program for a resident who was frequently incontinent of bowel and bladder. The resident, who had diagnoses including type 2 diabetes mellitus, chronic constipation, benign prostatic hyperplasia, polyuria, and bilateral osteoarthritis of the knee, was assessed as having moderate cognitive impairment but retained awareness of the urge to void and defecate, could find the toilet, understood reminders, and was motivated to be continent. Despite these abilities and the facility's policy requiring appropriate treatment and services for incontinence, the resident was not placed on a toileting program. Record review showed that the resident's last bowel and bladder evaluation was completed in October of the previous year, with no updated assessment since then, even though quarterly evaluations were required and the most recent was overdue. Observations and interviews confirmed that the resident was not on a toileting program, despite being able to request assistance and sometimes remaining continent when helped. Facility leadership acknowledged that the system for triggering bowel and bladder evaluations had failed, resulting in the missed assessment and lack of a toileting program for the resident.
Failure to Assess and Document Bed Assist Bar Use
Penalty
Summary
The facility failed to properly assess the use of bed assist bars for a resident with multiple diagnoses, including stroke, dementia, epilepsy, weakness, and reduced mobility. Despite physician orders and care plan documentation indicating the use of bed assist bars for assistance with repositioning and mobility, the resident's Minimum Data Set (MDS) and Quarterly Evaluation did not reflect the use of these devices. Observations confirmed the presence of bilateral bed assist bars in use, and interviews with facility staff revealed that the required quarterly assessment for bed assist bar appropriateness had not been completed since the previous evaluation. The Assistant Director of Nursing and the MDS Coordinator both confirmed that the resident had not been evaluated for bed assist bar use as required, and that the documentation did not accurately reflect the current interventions in place. The lack of timely and accurate assessment and documentation for the use of bed assist bars constituted a failure to comply with regulatory requirements for resident safety and individualized care planning.
Medication Error Rate Exceeds Regulatory Limit Due to Improper Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by regulation. During observation of 35 medication administrations, three errors were identified, resulting in an error rate of 8.57%. The errors were associated with one resident who had physician orders for potassium, divalproex, and artificial tears. The medication administration record and medication packaging for potassium and divalproex clearly indicated 'Do Not Crush,' yet the medication aide crushed all of the resident's oral medications before administration. The aide stated that they had been instructed to always crush this resident's medications, despite the explicit instructions not to do so. Additionally, the medication aide administered eye drops incorrectly by pulling up the resident's upper eyelid and placing the drop directly onto the eye, rather than forming a pouch in the lower eyelid as required by facility policy. Both the medication aide and a registered nurse confirmed that crushing medications labeled 'Do Not Crush' and improper eye drop administration constituted medication errors. Facility policies reviewed specified adherence to the six rights of medication administration, compliance with manufacturer specifications, and correct technique for administering eye drops, all of which were not followed in these instances.
Failure to Provide Timely and Appropriate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and care for four out of five sampled residents. For one resident, staff identified an open wound to the buttock but did not obtain or implement wound treatment orders until two weeks after the wound was first noted. Additionally, there was a lack of ongoing wound monitoring, as measurements and staging were not consistently documented. The Director of Nursing confirmed that the wound was not properly monitored or treated in a timely manner. Another resident, who was at risk for pressure ulcers due to immobility and a recent hip fracture, did not receive weekly skin checks as required by facility policy. This resident developed a deep tissue injury (DTI) to the heel, and interventions to offload pressure were not initiated until after the injury was identified. The DON confirmed that the DTI was acquired in the facility and that required weekly skin evaluations were not performed during the relevant period. A third resident, who was readmitted with a stage 3 pressure ulcer and assessed as high risk for further skin breakdown, did not receive weekly skin or wound assessments for nearly a month. The resident subsequently developed a new DTI to the ankle, and the existing sacral wound worsened. For a fourth resident with a stage 3 pressure ulcer to the heel, staff failed to provide an ordered alternating air mattress for several days after a room change, and wound care was not performed according to physician orders. The DON confirmed that the correct dressing was not used and the air mattress was not in place as ordered.
Failure to Maintain Safe Room Temperatures and Inadequate Staff Response
Penalty
Summary
The facility failed to maintain safe and comfortable temperatures in 59 of 76 occupied resident rooms and common areas, affecting all 119 residents. Multiple temperature logs and direct observations revealed that room and hallway temperatures frequently fell below 71°F, with some readings as low as 49°F to 70°F. The low temperatures were attributed to tripped electrical breakers caused by the use of multiple portable heaters, and the facility's heating system was unable to maintain adequate warmth throughout the building. Staff interviews confirmed that the issue was ongoing, with residents being offered extra blankets and some rooms being closed for the winter, but these measures were insufficient to maintain required temperatures. Staff did not consistently follow the facility's own abatement plan or policy for loss of heating. Temperature checks of resident rooms were not performed hourly as directed, and there was a lack of timely communication with the Maintenance Director regarding cold rooms and malfunctioning portable heaters. Some staff were unaware of the procedures for monitoring and reporting room temperatures, and there were discrepancies in the frequency and documentation of temperature checks. Additionally, equipment used to measure temperatures was sometimes inaccurate, further complicating efforts to monitor conditions. Residents were observed to be bundled in multiple blankets, and frost was noted on windows in several rooms. In the memory care unit, one of the portable heaters was turned off because it was blowing cold air, and staff reported difficulty keeping residents warm. The facility's failure to maintain adequate heating and to ensure staff followed established protocols resulted in an environment that did not meet regulatory requirements for resident safety and comfort.
Removal Plan
- Every resident will have their temperature taken every two hours to assess for hypothermia. If the resident temperature drops, or the resident shows signs of hypothermia, appropriate medical treatment will be provided, beginning with moving the resident to a warmer environment.
- Every occupied room temperature will be taken every hour to assure they maintain their temperature.
- If the temperature drops or there are problems with the portable heaters, maintenance will be notified immediately.
- If a resident is cold in their room, another room will be offered. If no other warmer rooms are available, residents will be moved to an area in the dining room for warmth.
- Education will be provided to nursing staff of the temperature process and schedule.
- Education will be provided to staff on the signs of hypothermia.
- A portable whole building heating unit was obtained from Nebraska Machinery. The heater will be operational.
- If the room temperature falls by more than 1 degree or there are problems with the portable heaters, maintenance will be notified immediately.
- Staff were re-educated on taking room temperatures every hour, residents temperatures every 2 hours, and when to call maintenance. Education will be provided every shift by DON or designee, until all staff have been educated and are able to verbalize understanding of the temperature process.
- DON or designee will verify that temperature procedures are being followed, and all heating units are functioning properly every two hours.
- The doors to the memory care unit will be opened to allow heat to flow through. A staff member will be stationed at each memory care unit entrance continuously to ensure no resident leaves the unit unattended.
- Velcro door signs will be added to each unit doorway as a visual reminder for residents. We will re-evaluate temperatures to determine if this needs to continue.
- Three additional large heating units have been obtained and are en route to the building.
- Heating company called to check heating system to ensure current system is working properly.
- Maintenance are working to patch large portable units into wall ventilation system so that we are not dependent on hallway heater. If maintenance unable to connect heating units to ventilation system, we will blow heat directly into the building through a door opening or window opening. Hourly monitoring to continue until comfortable temperatures are maintained.
- Staff will be educated on the carbon monoxide detectors on each unit and what to do if they alarm.
Failure to Maintain Resident Room Temperatures and Implement Abatement Plan
Penalty
Summary
Facility administration staff failed to ensure effective management of resources, resulting in the inability to maintain appropriate temperatures in resident rooms and common areas. Survey history showed a previous citation for this issue, specifically on the 200 hallway, where temperatures were not maintained. This failure led to an Immediate Jeopardy situation, as defined by CMS, due to the risk of serious harm to residents. Observations and record reviews confirmed that the facility had not implemented the complete abatement plan intended to address the temperature control deficiency. During an interview, the DON confirmed that the original abatement plan had not been followed.
QAPI Program Fails to Address Repeated Deficiencies
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program failed to identify and address ongoing issues related to several deficiencies, including F584, F623, F580, F684, F686, and F880. The QAPI program did not implement effective plans of action to correct these deficiencies, which have been repeated across multiple surveys since March 2024. Specific issues included problems with room temperatures, handrails, exit doors, failure to evaluate a resident for readmission, failure to notify practitioners of weight loss, failure to follow practitioner orders, failure to discontinue orders, failure to obtain ordered weights, and failure to implement interventions to prevent pressure ulcers. Additionally, the facility failed to ensure respiratory equipment was clean and stored properly and did not adhere to Enhanced Barrier Precautions (EBP) for infection control. Interviews with facility staff, including nursing assistants and licensed practical nurses, revealed a lack of awareness regarding the QAPI committee's activities and objectives. Staff members reported not knowing what the QAPI committee was working on, indicating a disconnect between the committee's efforts and the staff's understanding of quality improvement initiatives. This lack of communication and engagement with the QAPI program contributed to the facility's inability to address and maintain corrections for the identified deficiencies.
Environmental and Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain appropriate environmental conditions and safety measures, impacting the residents' right to a safe and comfortable living environment. Observations revealed that the temperature in the 200 hallway was consistently below the expected level, with readings ranging from 63 F to 70 F over several days. A resident reported feeling cold, and the temperature in their room was recorded at 62.8 F. The facility's furnace, replaced earlier in the year, was not functioning correctly, and the maintenance team, along with an external heating and air conditioning company, could not identify the issue despite multiple service calls. Additionally, the facility did not maintain the physical environment in good repair. The handrails in the 300/400 hallways had worn-off finishes, and no work order had been made to address this. The door to the smoking area was damaged, allowing daylight to be seen through the frame, and the replacement had not been approved. Furthermore, a guard was missing from a baseboard heater in a resident's room, posing a potential safety risk. These deficiencies indicate a lack of timely maintenance and repair actions, affecting the safety and comfort of the residents.
Failure to Notify Provider of Resident's Weight Loss
Penalty
Summary
The facility failed to notify the medical provider of a significant weight loss experienced by a resident, which is a deficiency in communication and care management. The resident, who was admitted with cerebrovascular disease and dysphagia, had a care plan that included monitoring nutritional intake and weight. Despite these measures, the resident experienced a weight loss of 14.4 pounds, or 10.57%, over one month, as recorded in the electronic medical record. A dietary note also documented a 9% weight loss over 30 days and recommended increasing nutritional supplements and notifying the medical doctor. However, a review of the resident's progress notes revealed no documentation that the medical provider was informed of this weight loss. This oversight was confirmed in an interview with the Assistant Director of Nursing, who acknowledged the lack of evidence that the provider had been notified. This failure to communicate critical health information to the resident's medical provider constitutes a deficiency in the facility's care practices.
Failure to Evaluate Readmission After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's condition was evaluated for readmission following hospitalization. Resident 119, who was admitted with a malignant carcinoid tumor of the bronchus and lung, and secondary malignant neoplasms of the adrenal glands, was discharged to a psychiatric care unit due to aggressive and destructive behaviors. The discharge was agreed upon by hospice and the family, and the resident was sent home with family members along with all medications and belongings. However, the facility did not provide a separate discharge notice to the resident or their representative, nor did they send a copy to the State Long-Term Care Ombudsman as required. The facility's policy on transfers and discharges states that residents should be allowed to return to the facility after hospitalization unless specific exemptions apply. In this case, the facility denied readmission for Resident 119 due to property destruction while at the facility. The facility's policy also requires that a discharge notice be sent to the resident and their representative, as well as the Ombudsman, before the discharge occurs. The facility did not comply with these requirements, as the only discharge notice provided was the one dated 9/3/24, and there was no evidence of a separate notice being sent to the Ombudsman.
Failure to Follow Medical Orders for Residents
Penalty
Summary
The facility failed to adhere to medical orders for three residents, leading to deficiencies in care. For Resident 34, who has acute on chronic diastolic heart failure and chronic kidney disease, the facility did not consistently record daily weights as ordered by the provider. The absence of weight records on multiple dates from May to November 2024 was confirmed by the Assistant Director of Nursing (ADON), indicating non-compliance with the provider's directive to monitor weight changes critical for managing the resident's conditions. Resident 12, diagnosed with Type 2 diabetes mellitus, had an unclear provider's order regarding the use of a chest port for infection control. The resident reported that the port was not being accessed, and the nursing staff, including a registered nurse and the Director of Nursing (DON), were unaware of the order's existence or its requirements. Additionally, for Resident 7, who suffers from spinal stenosis and chronic pain syndrome, an order to discontinue as-needed acetaminophen was not transcribed, resulting in the medication being available despite a new order for scheduled doses. The DON confirmed the oversight, highlighting a lapse in medication management.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility staff failed to implement necessary interventions to prevent the development of a pressure ulcer for Resident 5, who was identified as having a mild risk of developing pressure ulcers according to their Braden score. Resident 5's comprehensive care plan included interventions such as encouraging good nutrition and hydration, assisting with repositioning, and using positioning pillows. However, observations revealed that Resident 5 was frequently left in a position that increased pressure on their buttocks and heels, without the use of protective devices or repositioning as required. Resident 5 was observed multiple times over several days lying in bed with the head and foot of the bed elevated, causing increased pressure on their lower back, buttocks, and heels. Despite the care plan's directive to reposition the resident and use protective measures, staff interviews confirmed that Resident 5 was not repositioned, and no pressure prevention measures were observed. This lack of action led to the development of a new Stage II pressure ulcer on Resident 5's left buttock, which was confirmed by the facility's wound nurse as being caused by pressure. The facility's Pressure Injury Prevention Guidelines, which include evidence-based interventions such as routine repositioning every two hours and the use of pressure-relieving devices, were not followed. The guidelines also emphasize the importance of documenting interventions and monitoring their effectiveness, which was not evident in Resident 5's care. The failure to adhere to these guidelines and the care plan resulted in the development of a preventable pressure ulcer for Resident 5.
Infection Control Breach During Tube Feeding
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by a registered nurse (RN) while providing care to a resident on Enhanced Barrier Precautions (EBP). The resident, identified as Resident 115, had severe cognitive impairment and was on a 1-1 observation to prevent the removal of their gastrostomy tube. The resident's medical history included anorexia, severe protein-calorie malnutrition, and adult failure to thrive. Despite the presence of a CDC Enhanced Barrier Precautions sign outside the resident's room, which required hand hygiene and the use of gowns and gloves for high-contact care activities, the RN did not adhere to these protocols. During the observation, the RN entered the resident's room wearing gloves but no gown, and failed to change gloves or perform hand hygiene throughout the tube feeding procedure. The RN handled various items, including tube feeding bags, formula, and a stethoscope, without changing gloves or washing hands. The RN also changed the dressing around the G-tube and left the room to collect supplies, all while wearing the same soiled gloves. The RN confirmed in an interview that they did not change gloves, wash hands, or don a gown during the care process, which was a clear violation of the infection control practices required for residents on EBP.
Incomplete Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by professional standards and facility policy. Record review showed that significant clinical events and communications, including a cardiology appointment note, lab results, medication refusals, and changes in the resident's condition, were documented in a communication app used by staff and the primary care provider, but were not entered into the resident's official electronic health record (EHR). The resident, who had chronic kidney disease, diabetes, heart failure, and pressure injuries, experienced several notable events, such as refusal of medications, low oxygen saturation requiring supplemental oxygen, and communication with outside providers, none of which were reflected in the EHR or progress notes. Interviews with the Director of Nursing (DON) confirmed that nurses were using the communication app instead of the EHR to document important clinical information, and that this information was not transferred into the official medical record. The DON also acknowledged that the facility's policy required all assessments, observations, and services to be documented in the medical record before the end of the shift, and that this policy was not followed. As a result, the resident's medical record was incomplete and did not provide an accurate picture of their care and condition during the period in question.
Failure to Follow Infection Control Protocols for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols during the care of residents with indwelling urinary catheters and while implementing Enhanced Barrier Precautions (EBP). Facility policy required that suprapubic catheter stoma care be performed by cleaning outward from the stoma in a circular motion, and that EBP, including the use of gown and gloves, be used during high-contact care activities for residents with indwelling devices. However, observations revealed that staff did not consistently adhere to these protocols. For one resident with multiple sclerosis, quadriplegia, a pressure injury, and a suprapubic catheter, a nursing assistant performed catheter care and emptied the drainage bag without wearing a gown, as required by EBP. The assistant also failed to clean the over-bed table before placing supplies, did not perform hand hygiene when changing gloves, and did not follow the correct cleaning technique for the catheter site. The resident reported a history of urinary tract infections and noted that staff did not wear gowns when emptying the catheter bag. Interviews with staff confirmed a lack of understanding and adherence to EBP and hand hygiene protocols. A second resident with a history of stroke, dementia, and a flaccid neurogenic bladder also had an indwelling catheter and was on EBP. During care, a nursing assistant emptied the catheter bag while wearing gloves but not a gown, despite knowing the requirements of EBP. Interviews with supervisory staff confirmed that gowns should have been worn during these care activities for both residents, and that the observed practices did not align with facility policy or infection control standards.
Failure to Facilitate Resident Visitation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as evidenced by the case of a resident who was unable to have visits from their family member. The resident, who was severely cognitively impaired with a BIMS score of 3, had their family member listed as their responsible party and Power of Attorney. The family member was banned from the facility following an incident where they were reported to have been aggressive and threatening towards a staff member, and subsequently called the police. Despite the family member's attempts to resolve the situation and visit the resident, the facility did not facilitate a meeting to address the issue. Interviews with the resident and staff confirmed that the resident desired visits from their family member and had no other visitors. The facility's administrator acknowledged the situation but had not taken steps to arrange a meeting with the family member to discuss acceptable behavior and resolve the visitation ban. This inaction resulted in the resident being unable to receive visits from their family member for an extended period, contrary to their rights.
Failure to Resolve Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve grievances in a timely manner for Resident 5, who was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3. The resident's family member, who is also the Power of Attorney for health care and financial matters, reported missing clothing and made multiple calls to the facility that went unanswered. During a care conference, the family member discussed the issue with the facility, and the Social Services Director was assigned to investigate. However, the grievance form lacked a resolution date, and the issue remained unresolved as confirmed by the family member and the facility administrator. Interviews with Resident 5 and a Licensed Practical Nurse (LPN) indicated that the resident could communicate through yes or no questions and confirmed the awareness of the missing clothing issue. Despite the facility's grievance policy requiring prompt efforts to resolve grievances and provide a written decision, the facility did not resolve the issue of the missing clothes, and no written decision was issued to the resident or their representative. The facility's failure to address the grievance promptly and effectively led to the deficiency noted in the report.
Improper Food Handling and Labeling in Facility Kitchen
Penalty
Summary
The facility's kitchen staff failed to adhere to proper food safety protocols, which could potentially lead to foodborne illnesses affecting all residents consuming food from the kitchen. During an observation, it was noted that the refrigerator contained multiple trays of food that were either unlabeled, undated, or past their labeled dates. Specifically, there were 35 small containers of unlabeled and undated food, 46 containers of a jello-like substance dated 8/15/2024, and 3 containers dated 8/3/2024. Additionally, there were 11 portions of unlabeled food dated 8/11 and 40 containers of unlabeled food, with 37 dated 8/21/24 and 3 dated 8/13/24. Furthermore, a kitchen sink was observed to contain 8 sealed bags of partially frozen chicken breasts, which were not submerged in water nor under running water, contrary to safe thawing practices. Interviews with the kitchen staff revealed a lack of awareness and understanding of proper food labeling, dating, and thawing procedures. Cook-A admitted to not knowing why the food containers were undated or unlabeled and was unaware of the appropriate time to discard dated food. Dietary Staff C also could not explain the discrepancies in food labeling and dating. The Dietary Manager confirmed the presence of unlabeled and out-of-date food and acknowledged that the chicken in the sink was not being thawed according to policy. The facility's food preparation policy outlines specific methods for thawing frozen items, which were not followed in this instance.
Delayed Response to Call Lights Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient staff were available to answer calls for assistance in a timely manner for several residents. Observations on a specific date revealed that call lights in multiple rooms were left unanswered for extended periods, ranging from approximately 13 to 39 minutes. Interviews with staff, including registered nurses, licensed practical nurses, and nurse aides, indicated that a reasonable response time for call lights should be between 5 to 10 minutes. However, the facility did not have an established acceptable time for answering call lights, and staff were often occupied with other tasks, leading to delays. Interviews with residents further highlighted the issue, with reports of waiting times ranging from 15 minutes to as long as 2 hours for call lights to be answered. Residents generally agreed that a reasonable waiting time should be between 5 to 20 minutes. The Director of Nursing acknowledged the problem, noting that aides could be busy in residents' rooms for extended periods, causing other residents to wait for assistance. This deficiency in staffing and response time was observed in a facility with a census of 123 residents.
Significant Medication Error Due to Missed Orders
Penalty
Summary
The facility failed to ensure that Resident 4 was free from significant medication errors. Resident 4, who was cognitively intact, had a complex medical history including acute on chronic diastolic heart failure, chronic kidney disease, cirrhosis of the liver, and other conditions. After being discharged from the hospital, Resident 4 was prescribed several medications, including levofloxacin, metolazone, potassium chloride SA, rifaximin, and torsemide. However, these medications were not entered into the facility's electronic health record system, Point Click Care (PCC), due to an oversight by a corporate employee who took the discharge orders home and missed pages containing the new medication orders. As a result of this oversight, Resident 4 did not receive the prescribed medications, leading to increased confusion and a subsequent hospital admission for hepatic encephalopathy. The facility's Director of Nursing (DON) confirmed that the error occurred because the employee responsible for entering the orders into the system failed to include the pages with the new medication orders. This significant medication error was reported to the state, and the facility conducted an investigation to determine the cause of the error.
Insulin Pen Labeling and Management Deficiencies
Penalty
Summary
The facility staff failed to ensure proper labeling and management of insulin injector pens for residents, leading to several deficiencies. An observation of a medication cart revealed that a Victoza insulin pen for one resident was labeled with the resident's name but lacked an opened-on date and expiration date. A registered nurse confirmed this labeling deficiency. Additionally, another resident's Lantus insulin pen was found to be expired and lacked an opened-on date, which was confirmed by another registered nurse. Furthermore, an unidentified FLASP insulin pen was found without a resident name or opened-on date, and a licensed practical nurse confirmed that it was unknown who the pen belonged to and that it should be discarded. The facility's Insulin Pen policy requires that insulin pens be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. If a label is missing, the pen should not be used, and a new pen must be ordered from the pharmacy. The policy also mandates checking the expiration date and discarding expired pens. The Director of Nursing confirmed the deficiencies, acknowledging that the insulin injector pens should have been labeled with the date opened, date of expiration, and the residents' names.
Failure to Transcribe Insulin Order Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of insulin. The resident, who was admitted with a diagnosis of Type 2 Diabetes Mellitus, had hospital discharge orders for a sliding scale Lispro insulin to be administered with meals and at night based on blood sugar levels. However, this order was not transcribed into the resident's Medication Administration Record (MAR), resulting in the omission of the prescribed insulin regimen. The Director of Nursing acknowledged that not transcribing the sliding scale Lispro insulin order constituted a medication error. Despite the omission, the resident's blood sugar levels were monitored, showing fluctuations but no immediate negative outcomes. The facility's policy defines a significant medication error as one that causes discomfort or jeopardizes the resident's health and safety. The Director of Nursing did not consider the failure to transcribe the insulin order as a significant error, as the resident did not experience high blood sugars or adverse effects. However, the lack of proper transcription and administration of the prescribed insulin regimen was identified as a deficiency by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Millard Llc | 0.6 mi | ★★★★★ | 10 | 0 |
| Rose Blumkin Jewish Home | 1.4 mi | ★★★★★ | 7 | 0 |
| Brookestone Village | 1.5 mi | ★★★★★ | 10 | 0 |
| Good Samaritan Society - Millard | 2.3 mi | ★★★★★ | 2 | 0 |
| Newport House | 2.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.