Tiffany Square
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Island, Nebraska.
- Location
- 3119 West Faidley Avenue, Grand Island, Nebraska 68803
- CMS Provider Number
- 285087
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Tiffany Square during CMS and state inspections, most recent first.
A resident with acute on chronic diastolic CHF and on warfarin therapy had a urinalysis that resulted in physician orders to start Macrobid and reduce the warfarin dose by half, but these orders were not implemented. Subsequent documentation showed warfarin dose changes based on INR results, initiation of Paxlovid for COVID without documented pharmacy review of the warfarin–ritonavir interaction, and delayed follow-up on the original urinalysis order. The resident later exhibited nosebleeds, dizziness, lightheadedness, nausea, emesis, and low tympanic temperature, leading to transfer to the ER. The DON reported there was no specific policy for taking or following physician orders and could not explain why the antibiotic order for the positive UTI was not initiated.
The facility failed to follow physician orders for wound care for two residents and did not obtain necessary orders for another. A resident received incorrect wound cleansing, while another had medication applied improperly. Additionally, a resident returned with a pressure ulcer but lacked treatment orders. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to implement Enhanced Barrier Precautions for a resident with hemiplegia during transfers, as staff did not wear gowns or clean the lift between uses. Additionally, improper wound care was provided to another resident with a pressure ulcer, risking cross-contamination. The DON confirmed these deficiencies, acknowledging non-compliance with infection control policies.
The facility failed to manage psychotropic medications appropriately for three residents. Two residents received antidepressants without documented mood or behavior changes, and their care plans lacked specific behaviors for medication use. Additionally, informed consent for one resident's medication was unsigned. Another resident had a PRN psychotropic medication without an end date, and the DON was unaware of this oversight.
The facility failed to serve the correct portion size of beef chili to 50 residents, using a 6-ounce ladle instead of the required 8-ounce portion as per the menu. This discrepancy was confirmed by the dietary staff and the RD, despite the facility's audit indicating that portions should follow the menu specifications.
The facility failed to ensure proper hand hygiene by a staff member delivering laundry, who did not sanitize hands between resident rooms, and did not maintain oxygen equipment per infection control procedures for a resident with COPD. The nasal cannula for the resident's portable oxygen container had not been changed since August, contrary to monthly requirements.
A facility failed to document a recapitulation of a resident's stay as required. The resident, who aimed to return home with their spouse, was involved in discharge planning discussions. However, the medical record lacked a documented summary of the stay. The DON confirmed the absence of a Nursing Discharge Summary and acknowledged the facility's lack of a discharge policy.
A survey revealed a 12% medication error rate in a facility, affecting three residents. Errors included improper administration of Potassium Chloride tablets without a full glass of water for two residents and incorrect inhaler use for another resident, with no waiting period between puffs. These errors were confirmed by the MA-C and DON.
A facility failed to ensure proper labeling of medications, leading to discrepancies between medication labels and physician orders for a resident. An RN identified that the label on a box of Insulin Aspart did not match the physician's order, and a vial of Lantus insulin was mislabeled with an incorrect discard date. The DON confirmed these discrepancies and acknowledged the need for accurate labeling as per facility policy.
Failure to Follow Physician Orders for Anticoagulation and UTI Treatment
Penalty
Summary
Surveyors identified a failure to follow practitioner orders for a resident admitted with acute on chronic diastolic congestive heart failure. The resident’s care plan included interventions to administer medications per MD order and to consult the pharmacist for monthly and PRN medication reviews, including medications with black box warnings. On admission, a future lab order was entered for an INR draw, and on 2/13 a urinalysis was ordered. The hospital lab urinalysis collected on 2/13 and finalized on 2/15 included physician-directed medication changes: initiation of Macrobid 100 mg PO BID for 7 days and a decrease in the resident’s warfarin dose by half while on the antibiotic, with an electronic physician signature. These medication orders were not implemented as directed. Progress notes showed that an INR was drawn on 2/16 and that staff called the physician’s office on 2/17 for recommendations, but there was no documentation of follow-up on the Macrobid order from the 2/15 urinalysis report. On 2/18, the resident tested positive for COVID and was started on Paxlovid. The order recap showed multiple warfarin dose changes over the subsequent days, including a change from 5 mg daily to 4 mg daily, then to 3 mg daily, and an order for vitamin K after an INR of 7.3 was obtained on 2/23, along with instructions to hold warfarin for two days and recheck the INR. The record also showed a delayed urinalysis order on 2/23, despite the original urinalysis order dated 2/13 and the earlier lab results with treatment recommendations. The resident experienced nosebleeds over a weekend and, on 2/23, was documented as feeling dizzy, lightheaded, nauseated, with two episodes of emesis and a tympanic temperature of 95°F, leading to an order to send the resident to the emergency room. There was no documentation of pharmacy review or communication regarding the interaction between Paxlovid and warfarin, despite reference information advising frequent INR checks and anticoagulant dose adjustments when warfarin is co-administered with ritonavir-containing therapy. In an interview, the DON stated there was no facility policy on taking or following physician orders and that the facility relied on general standards of practice. The DON acknowledged not knowing why the Macrobid order from the 2/15 urinalysis result was not followed and could not explain why the antibiotic for the positive UTI was not initiated per physician orders.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide wound care according to physician orders for two residents and did not obtain physician orders for wound care for another resident. Resident 2, who was admitted with hepatic failure, congestive heart failure, and dementia, was observed receiving wound care that did not follow the physician's orders. The Licensed Practical Nurse (LPN) used normal saline instead of soap and water to cleanse the wound, which was contrary to the prescribed treatment plan. This deviation was confirmed by both the LPN and the Director of Nursing (DON). Resident 3, admitted with hemiplegia, type 2 diabetes, and chronic pulmonary disease, was also subject to improper wound care. The Registered Nurse (RN) applied topical antibiotic ointment and viscous lidocaine to the skin surrounding the wound instead of directly to the wound as ordered by the physician. This incorrect application was acknowledged by the RN and confirmed by another LPN and the DON. Resident 1, who had type 2 diabetes and congestive heart failure, returned to the facility with a pressure ulcer on the right buttock. Despite documentation of the wound in progress notes and after-visit summaries, there were no physician orders for treatment of the pressure ulcer. This lack of treatment orders was confirmed by the RN and the DON, indicating a failure to obtain necessary medical directives for wound care management.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for Resident 3, who was admitted with diagnoses including hemiplegia, type 2 diabetes, and chronic pulmonary disease. Despite the facility's policy requiring the use of gowns and gloves during high-contact resident care, Nurse Aide C and Nurse Aide E did not wear gowns while assisting Resident 3 with a transfer using a full body lift. Additionally, the lift was not cleaned between uses, as required by the facility's Mechanical Lift and Transfer Standard policy. Both nurse aides confirmed their failure to adhere to the EBP and lift cleaning protocols during interviews. Resident 2, who was admitted with hepatic failure, congestive heart failure, and dementia, was also subject to deficient care practices. The resident had a pressure ulcer, and the care plan included an order to cleanse the wound with soap and water and apply zinc oxide twice daily. However, during an observation of wound care, LPN-B did not cleanse the wound properly and applied a thick white cream in a manner that could lead to cross-contamination. LPN-B confirmed the improper technique during an interview. The Director of Nursing (DON) confirmed the deficiencies in both cases, acknowledging that the staff failed to follow the facility's infection control policies. The DON verified that Resident 3 required EBP for all direct care, including transfers, and that lifts should be cleansed between each resident use. Similarly, the DON confirmed that the wound care for Resident 2 was not performed in a manner to prevent cross-contamination.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that the medication regimen for two residents was free from unnecessary psychotropic medications. Resident 10, who was admitted with diagnoses of depression and anxiety, had their Lexapro dosage increased without documented evidence of mood or behavior changes that would justify the increase. The facility did not document any specific or targeted behaviors for the use of antidepressant medication in Resident 10's care plan, and there was no evidence of monitoring the resident's mood and behaviors in the weekly risk meetings. Additionally, the Director of Nursing (DON) was unaware of the changes in the resident's antidepressant medication and the lack of documentation to support these changes. Resident 32, diagnosed with Alzheimer's disease and depression, was receiving routine antidepressant medication without a gradual dose reduction or documentation that such a reduction was clinically contraindicated. The care plan for Resident 32 also lacked specific or targeted behaviors for the use of antidepressant medication. Furthermore, the informed consent for the use of psychotropic medications was not signed by the resident or their responsible party, and there was no documentation of mood or behavior changes to support the addition of Zoloft to the resident's medication regimen. The DON confirmed that Resident 32's mood and behaviors were not being monitored in the weekly risk meetings. The facility also failed to implement a stop date for a PRN psychotropic medication for Resident 12, who was admitted with a terminal prognosis related to atrial fibrillation. The resident's care plan included a focus on maintaining comfort levels, but the order for Lorazepam, a psychotropic medication prescribed as needed, did not have an end date. The DON and Administrator were initially unaware of the lack of an end date for the PRN medication, which was later confirmed during the survey.
Deficiency in Serving Correct Food Portion Sizes
Penalty
Summary
The facility failed to ensure that residents were served the required food portion size per the menu to meet nutritional needs for 50 out of 58 residents. The facility's menu specified that the regular portion size for beef chili was 8 ounces. However, during an observation in the facility kitchen, it was noted that a 6-ounce ladle was used to serve the beef chili instead of the required 8-ounce portion. This discrepancy was confirmed by Dietary Cook-A and the Registered Dietitian (RD), who acknowledged that the residents did not receive the 8-ounce serving as required by the menu. The facility's Food Preparation and Dining Service Audit indicated that standardized recipes were available and portions were to be served according to the menu unless otherwise requested by the resident. Despite this, the serving utensils used did not align with the menu specifications, leading to the deficiency. Additionally, a list provided by the facility's RD showed that 15 residents had requested small portions, but this did not account for the 50 residents who were affected by the incorrect portion size of the beef chili.
Infection Control Deficiencies in Hand Hygiene and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by the Laundry and Housekeeping Supervisor (LHS) while delivering laundry to resident rooms. On multiple occasions, the LHS was observed handling clean laundry and potentially contaminated hangers without performing hand sanitization between resident rooms. The LHS did not use alcohol-based hand sanitizer or wash hands with soap and water, despite acknowledging that all employees are expected to do so to prevent cross-contamination and reduce infection risks. Additionally, there was no alcohol-based hand sanitizer available on the laundry cart used by the LHS. The facility also failed to maintain oxygen equipment and supplies according to infection control procedures for a resident with chronic diastolic heart failure and chronic obstructive pulmonary disease (COPD). The resident's care plan required oxygen therapy, and orders were in place for changing oxygen tubing and holders monthly. However, observations revealed that the nasal cannula connected to the portable oxygen container had not been changed since 08/02, indicating non-compliance with the infection control procedures. The Director of Nursing confirmed that the nasal cannula should be changed monthly and tagged with a date and initials. These deficiencies highlight lapses in the facility's infection prevention and control program, specifically in hand hygiene practices and the maintenance of medical equipment. The lack of adherence to established protocols for hand hygiene and equipment maintenance poses a risk of cross-contamination and infection among residents.
Failure to Document Recapitulation of Resident's Stay
Penalty
Summary
The facility failed to ensure that a recapitulation of a resident's stay was completed as required for a resident who was reviewed. The resident, identified as Resident 78, was admitted to the facility and had a goal to return home with their spouse. The Minimum Data Set (MDS) assessments indicated that the resident and their spouse were involved in the assessment and goal-setting process, with the overall goal being to discharge to the community. Progress notes documented ongoing discussions about discharge plans between the resident, their spouse, and the facility. However, upon review of the medical record, it was found that there was no documented recapitulation of the resident's stay. An interview with the Director of Nursing (DON) revealed that the facility lacked a policy or procedure for resident discharge and relied on a Nursing Discharge Summary assessment to document the recapitulation of stay. The DON confirmed that this summary was not completed for the resident, resulting in the deficiency.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 12% during a survey. This deficiency affected three of the eleven sampled residents. The errors were identified during the observation of medication administration by a Medication Aide (MA-C). For Resident 13, the MA-C did not ensure the resident drank a full glass of water with their Potassium Chloride Extended Release tablet, as required by the medication's administration instructions. Similarly, Resident 30 was not provided with a full glass of water for their Potassium Chloride tablets, contrary to the prescribed directions. Additionally, Resident 33's inhaler administration was not conducted according to the prescribed method. The resident was instructed to inhale two puffs of medication with a one-minute interval between puffs, but the MA-C allowed the resident to take both puffs consecutively without the required waiting period. These actions were confirmed as medication errors by both the MA-C and the Director of Nursing (DON) during interviews conducted as part of the survey process.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medications for a resident, leading to discrepancies between medication labels and physician orders. During an observation of insulin administration, a Registered Nurse (RN) identified that the label on a box of Insulin Aspart did not match the physician's order in the electronic medical health record. The label provided a simplified version of the sliding scale instructions, which did not align with the detailed physician order. The RN acknowledged that medication should not be administered if the label and order do not match, indicating a need for clarification before administering the medication. Additionally, the RN discovered a mislabeling issue with a vial of Lantus insulin. The discard date on the vial was incorrectly labeled as 10/29, instead of the correct date of 10/26, which is 28 days from the opening date of 09/29. The Director of Nursing (DON) confirmed these discrepancies and acknowledged that the facility's policy was to use 'use as directed' on labels for complex instructions. The DON also confirmed that the discard date should be accurately calculated and labeled as per the facility's policy.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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