The Banyan At Montclair
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 2525 South 135th Avenue, Omaha, Nebraska 68144
- CMS Provider Number
- 285054
- Inspections on file
- 45
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at The Banyan At Montclair during CMS and state inspections, most recent first.
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.
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.
The facility failed to monitor two residents after their procedural appointments, leading to deficiencies in post-procedural care. One resident, severely cognitively impaired, had a dental extraction without proper analgesic orders or site assessment. Another resident, cognitively intact, had an eye procedure without subsequent assessment or documentation. The DON confirmed that critical charting was not initiated for either case.
The facility staff failed to implement interventions to prevent and treat pressure ulcers for a resident identified as at risk. Despite being identified as at risk, the resident's care plan and skin evaluations were not adequately followed, resulting in the development of a stage 3 pressure ulcer. The facility's policy on pressure injury prevention and management was not adhered to, leading to inadequate follow-up and documentation.
The facility kitchen staff failed to follow proper handwashing and gloving techniques during food preparation, and significant sanitation issues were observed in the kitchen. These deficiencies could potentially affect 126 residents who consume food prepared in the facility.
The facility failed to ensure its QAPI program identified and addressed concerns related to deficient practices, including failure to notify family of changes in resident condition, improper use of physical restraints, inadequate reporting of abuse allegations, and poor monitoring for changes in resident conditions. The facility also had repeat deficiencies from previous surveys, affecting all 126 residents.
The facility failed to complete and document competencies for a significant number of its nursing staff, including both facility and agency employees. This deficiency was confirmed through record reviews and interviews, revealing that no competency checks had been documented for the year 2023, potentially affecting all 126 residents.
The facility failed to provide bathing per resident preference for two residents. One resident with severe cognitive impairment did not receive any showers or baths in the last 30 days, while another resident with moderate cognitive impairment received only one shower during their stay, despite a preference for three showers a week. The DON confirmed these deficiencies.
The facility staff failed to implement proper infection control precautions for residents with ESBL and C. Diff, and did not follow appropriate hand hygiene and gloving techniques during wound care and personal care, as confirmed by staff interviews and observations.
The facility staff failed to evaluate the use of a seatbelt as a restraint for a resident with severe cognitive impairment and multiple diagnoses. Observations showed consistent use of the seatbelt without documented medical justification or assessment, violating the facility's policy on a restraint-free environment.
The facility failed to develop and implement a pain management program for a resident following spine surgery, leading to inadequate pain control. Despite multiple active pain medication orders, the baseline care plan did not address pain, and staff were unaware of the resident's pain contract or acceptable pain level. The resident experienced significant pain due to the unavailability of Oxycodone, and non-pharmacological interventions were not utilized.
The facility failed to assess the need for and safety of half-sized side rails for two hospice residents, resulting in potential entrapment risks due to a 3-inch gap between the side rail and the mattress. The Director of Nursing confirmed the lack of safety assessments and the presence of loose bed rails.
The facility failed to identify and monitor specific target behaviors for the use of antipsychotic medications for two residents and did not discontinue an antipsychotic medication per gradual dose reduction order for one resident. Observations and interviews revealed a lack of behavior charting and non-compliance with the facility's policies on psychotropic medication use.
The facility failed to routinely check bed rails for security and maintain documentation of preventative maintenance for 10 resident beds. Observations revealed loose bed rails with a 3-inch gap between the mattress and rail. The DON and DOM confirmed these findings and noted that routine checks had not been completed.
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.
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.
Failure to Monitor Residents Post-Procedure
Penalty
Summary
The facility failed to adequately monitor two residents following their respective procedural appointments, leading to deficiencies in post-procedural care. Resident 1, who was severely cognitively impaired with a BIMS score of 8, underwent a surgical extraction of a failing implant. Despite receiving post-operative instructions and a prescription for analgesics, there were no new orders for analgesics in the resident's record, nor was there any nursing assessment of the surgical site. The Director of Nursing confirmed that critical charting should have been initiated for the extraction site and that the facility did not receive the post-operative report until a month later. Additionally, Resident 1 was started on an antibiotic without proper critical charting or assessment of the oral infection and extraction site. Resident 3, who was cognitively intact, had a procedure involving a temporary tarsorrhaphy of the left eye following a corneal abrasion. Upon returning from the appointment, the facility staff failed to assess the resident's eye, and there was no documentation of the appointment or assessment in the progress notes. The Director of Nursing confirmed that critical charting should have been initiated for Resident 3's eye procedure. The lack of documentation and assessment highlights the facility's failure to monitor and provide appropriate post-procedural care for these residents.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility staff failed to implement interventions to prevent and treat pressure ulcers for a resident identified as at risk. The resident, who had multiple diagnoses including anemia, atrial fibrillation, hypertension, GERD, thyroid disorder, stroke, malnutrition, and hemiplegia, required substantial assistance with daily activities and was frequently incontinent. Despite being identified as at risk for pressure ulcers, the resident's care plan and skin evaluations were not adequately followed. The resident's comprehensive care plan included interventions such as wearing edema wear, encouraging good nutrition and hydration, and using Pravalon boots, but these were not consistently implemented or documented. On 2-28-2024, a skin observation during a shower revealed red and open areas on the resident's left buttock, but there was no follow-up or additional weekly skin evaluations documented. The next documented skin evaluation was on 3-25-2024, during which a dressing change revealed a stage 3 pressure ulcer on the resident's right buttock. The wound nurse confirmed the presence of the ulcer and the correct dressing application. The facility had received orders for wound care on 3-6-2024, but there was no evidence of consistent skin checks or follow-up between 2-28-2024 and 3-7-2024 when the wound care practitioner evaluated the resident. An interview with the Director of Nursing (DON) confirmed that no other skin checks were performed between 2-28-2024 and 3-7-2024, and the only Braden Scale evaluation completed was on admission. The facility's policy on pressure injury prevention and management required systematic assessment and treatment, including weekly skin assessments and Braden Scale evaluations, which were not adhered to in this case. This failure to follow the care plan and policy resulted in the development of a stage 3 pressure ulcer for the resident.
Improper Hand Hygiene and Sanitation Issues in Kitchen
Penalty
Summary
The facility kitchen staff failed to utilize proper handwashing and gloving techniques during food preparation, which could potentially lead to foodborne illness affecting 126 residents. Observations revealed that Cook II and Dietary Aide JJ did not wash their hands for the required 20 seconds before donning new gloves and returning to food preparation tasks. Additionally, Dietary Aide KK did not perform hand hygiene after handling soiled dishes and before touching clean silverware. These actions were confirmed by the Dietary Manager, who acknowledged that the staff did not adhere to the facility's handwashing policy, which mandates a 20-second handwashing procedure before engaging in food preparation and after handling soiled items. Further observations highlighted significant sanitation issues within the kitchen. The walk-in freezer had stained, broken, and missing floor tiles with food particles present. The walk-in refrigerator had corroded shelves with rust and peeling metal coating. The stove and surrounding areas had burnt food spatters, grease, and food particles. The pan drying rack was also corroded, and food transport carts had food and liquid spatters. These sanitation concerns were confirmed by the Dietary Manager, District Manager for Dietary, and the Registered Dietician. Record reviews indicated that cleaning schedules were not adequately followed, as evidenced by the documented cleaning dates not aligning with the observed conditions.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement Program (QAPI) identified and addressed concerns related to deficient practices cited in the current annual survey. These deficiencies included issues such as failure to notify family of changes in resident condition, improper use of physical restraints, inadequate reporting of abuse allegations, insufficient assistance with activities of daily living (ADL) like bathing, and poor monitoring for changes in resident conditions. Additionally, the facility had repeat deficiencies from previous surveys, including issues with pressure ulcer treatments, pain management, bed rail assessments, staff competencies, behavior monitoring for antipsychotic medication use, significant medication errors, and unsanitary kitchen conditions. The facility census was 126 residents, all of whom were potentially affected by these deficiencies. The QAPI plan, which was supposed to track and measure performance, establish goals, identify and prioritize quality deficiencies, and develop corrective actions, was not effectively implemented. Interviews with the facility Administrator confirmed that there were no active Performance Improvement Programs (PIP) in place to address these issues. Observations, record reviews, and interviews during the survey period revealed that the facility's QAPI process had not identified the current deficient practices and had not maintained correction for repeated tags. Specific deficiencies included failure to notify family of changes in resident condition, improper use of physical restraints, inadequate reporting of abuse allegations, insufficient assistance with ADLs, poor monitoring for changes in resident conditions, inadequate pressure ulcer treatments, poor pain management, lack of bed rail assessments, insufficient staff competencies, inadequate behavior monitoring for antipsychotic medication use, significant medication errors, unsanitary kitchen conditions, and poor hand hygiene practices. The facility's failure to maintain an effective QAPI program had the potential to affect all 126 residents in the facility.
Failure to Complete and Document Staff Competencies
Penalty
Summary
The facility failed to complete and document competencies for a significant number of its nursing staff, including both facility and agency employees. Specifically, competencies were not completed for 7 of 34 LPNs, 2 of 36 RNs, and 6 of 122 NAs. This deficiency was identified through record reviews and interviews, revealing that no competency checks had been documented for the year 2023. The Director of Nursing (DON) confirmed the absence of competency checks and stated that attempts to obtain these records from various agencies were unsuccessful. Additionally, no competency checks were conducted for agency staff before they began working in the facility. The Facility Assessment Tool dated 12/20/23 outlined the expected competencies for staff, including activities of daily living, infection control, medication administration, resident assessment, and specialized care. Despite this, the facility did not ensure that these competencies were completed or documented. The DON confirmed that staff members T, Y, C, K, J, and L, who are agency staff, also lacked documented competency checks. This failure had the potential to affect all 126 residents residing in the facility.
Failure to Provide Bathing Per Resident Preference
Penalty
Summary
The facility failed to provide bathing per resident preference for two residents, Resident 78 and Resident 384, out of a sample of 13 residents. Resident 78, who had severe cognitive impairment and was dependent on assistance for showering and personal hygiene, did not receive any showers or baths in the last 30 days as per the facility's records. Observations over several days revealed that Resident 78 had uncombed hair and a strong odor of urine, indicating a lack of proper hygiene care. The Director of Nursing (DON) confirmed that no baths were given by the facility staff during this period, relying instead on hospice aides who also did not provide the necessary care. Resident 384, who had moderate cognitive impairment and required substantial assistance with showering and dressing, was admitted and discharged within a short period. Despite a documented preference for showers three times a week, Resident 384 received only one shower during their stay and went eight days without a shower before discharge. The DON confirmed that Resident 384 did not receive showers according to their preference, highlighting a failure to adhere to the resident's bathing schedule and preferences as documented in their care plan.
Infection Control Deficiencies
Penalty
Summary
The facility staff failed to implement infection control precautions to prevent the spread of infectious disease for Resident 100, who was diagnosed with Extended Spectrum Beta Lactamase Resistance (ESBL). Despite a positive urine culture for ESBL, the RN Infection Preventionist was unaware of the diagnosis, and Resident 100 was not placed in isolation as required. The Director of Nursing confirmed the positive result and acknowledged that the proper procedure would have been to place the resident in an individual room or cohort with another resident with ESBL if a single room was unavailable. For Resident 120, who was on contact precautions for Clostridium Difficile (C. Diff), staff failed to follow proper hand hygiene protocols. Observations revealed that staff used alcohol-based hand rub (ABHR) instead of washing hands with soap and water, which is necessary to prevent the transmission of C. Diff. Interviews with staff confirmed the incorrect use of ABHR and the need for soap and water hand hygiene for C. Diff cases. Resident 41's wound care was compromised due to improper hand hygiene and gloving techniques by LPN T. The LPN did not perform hand hygiene before and during the wound treatment, used soiled gloves to handle clean dressings, and failed to change gloves between different stages of the treatment. Similarly, Resident 80's personal care was inadequately managed by NA K, who did not perform proper hand hygiene between glove changes and contaminated the wipes package with dirty gloves. These actions were confirmed through interviews with the staff involved.
Failure to Evaluate Seatbelt Use as a Restraint
Penalty
Summary
The facility staff failed to evaluate the use of a seatbelt as a restraint for one resident. The facility's policy on a restraint-free environment mandates that any use of restraints must be justified by a specific medical symptom, documented in the medical record, and regularly re-evaluated. However, for Resident 2, who has severe cognitive impairment and multiple diagnoses including aphasia, quadriplegia, and traumatic brain injury, there was no assessment or evaluation for the continued use of a seatbelt. Observations over several days showed that the resident was consistently using a seatbelt while seated in a wheelchair, but there was no documentation in the resident's medical record or care plan regarding the necessity or medical justification for the seatbelt's use. Interviews with the Director of Nursing confirmed that the resident could disconnect the seatbelt without assistance, indicating that it may not function as a restraint. However, the lack of assessment and documentation violated the facility's policy and regulatory requirements. The resident's electronic medical record and comprehensive care plan did not contain any information related to the use of the seatbelt, and no medical reasons for its use were evaluated or documented.
Failure to Implement Pain Management Program
Penalty
Summary
The facility failed to develop and implement a pain management program for Resident 134, who was admitted following spine surgery and required skilled nursing care for surgical wounds and pain management. Despite having multiple active orders for pain medications, including buprenorphine, pregabalin, Oxycodone, extra strength Tylenol, and cyclobenzaprine, the baseline care plan did not identify pain as a concern or establish an acceptable pain level or goal for the resident. The Medication Administration Record (MAR) showed that Oxycodone was used 2-4 times a day, but non-pharmacological interventions were not utilized. On multiple occasions, Resident 134 reported significant pain, rating it as high as 8.5 on a 0-10 scale, and was observed moaning and grimacing. The resident reported being up all night in pain due to the unavailability of Oxycodone, which was confirmed by LPN A. The facility staff, including LPN A and LPN N, were unaware of the resident's pain contract with a pain specialist, the acceptable pain level, or the interventions to alleviate the pain. The Director of Nursing (DON) confirmed that the facility was unaware of the pain contract until the resident ran out of Oxycodone. The facility's undated pain management policy stated that a systematic approach should be used for the recognition, assessment, treatment, and monitoring of pain, involving collaboration with the attending physician, other healthcare professionals, and the resident. However, this policy was not followed, as evidenced by the lack of a comprehensive pain management plan for Resident 134, leading to inadequate pain control and significant discomfort for the resident.
Failure to Assess Bed Rail Safety for Hospice Residents
Penalty
Summary
The facility failed to assess the need for and resident safety regarding the continued use of a half-sized side rail for two residents. Resident 2, who had severe cognitive impairment and was on hospice care, was observed with a half-sized side rail attached to the bed frame, with a 3-inch gap between the side rail and the mattress. The side rail was loose and could be moved back and forth. Record reviews revealed no assessment for the need or safety of the side rail for Resident 2. Similarly, Resident 20, who was moderately cognitively impaired and also on hospice care, was observed with a half-sized side rail with the same 3-inch gap and looseness. No assessment for the need or safety of the side rail was found in Resident 20's records either. The Director of Nursing confirmed the presence of the half-sized bed rails on both residents' beds and acknowledged the 3-inch gap, which could pose a risk for entrapment. The DON also confirmed that no bed rail safety assessments had been completed for either resident and that the beds with the attached side rails were brought in by hospice when the residents were admitted. This lack of assessment and the presence of unsafe bed rails could potentially result in resident injury.
Failure to Monitor and Discontinue Antipsychotic Medications
Penalty
Summary
The facility staff failed to identify and monitor specific target behaviors for the use of an antipsychotic medication for two residents and failed to discontinue an antipsychotic medication per gradual dose reduction order for one resident. Resident 78, who was severely cognitively impaired and admitted to hospice, was prescribed Quetiapine for unspecified dementia without behavioral disturbance. Despite a physician's order to discontinue the medication, Resident 78 continued to receive it daily. Observations revealed no disruptive or negative behaviors, and the Director of Nursing (DON) confirmed that there was no behavior charting for residents on psychotropic medications and that the discontinuation order was not implemented. Resident 78's care plan also lacked targeted behaviors for the antipsychotic medication use. Resident 96, who was severely cognitively impaired and resided on the secured unit, was prescribed Seroquel for psychosis. The resident's medical records indicated no identified target behaviors or behavior monitoring for the use of the antipsychotic medication. Observations of Resident 96 showed no negative behaviors, and the DON confirmed that specific target behaviors had not been identified and no behavior monitoring was completed prior to the survey date. The physician's orders were later updated to include monitoring for specific targeted behaviors related to the use of the antipsychotic medication. The facility's policies on the use of psychotropic medications and gradual dose reduction were not followed, leading to the continued use of antipsychotic medications without proper monitoring and documentation of target behaviors. This failure affected the quality of care provided to the residents and did not comply with the regulatory requirements for the use of psychotropic drugs in long-term care facilities.
Failure to Maintain Bed Rail Safety and Documentation
Penalty
Summary
The facility failed to routinely check bed rails for security and maintain documentation of preventative maintenance for 10 of 134 occupied resident beds. Observations revealed that bed rails on the beds of two residents had a 3-inch gap between the mattress and the rail, and the rails were loose and could be moved back and forth. The Director of Nursing confirmed these findings and noted that the beds with attached rails were brought in by Hospice when the residents were admitted to Hospice care. Further review of the facility's records showed that the beds in rooms 104 A, 107 B, 109 B, 111 A, 309 B, 310 A, 317 B, 403 A, 403 B, and 803 had bed rails present. The Director of Maintenance confirmed that routine checks on these beds and rails had not been completed. The facility's policy on the proper use of bed rails emphasized the importance of ensuring correct installation and regular maintenance, which was not adhered to in these cases.
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Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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