Wakefield Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wakefield, Nebraska.
- Location
- 306 Ash Street, Wakefield, Nebraska 68784
- CMS Provider Number
- 285209
- Inspections on file
- 19
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Wakefield Health Care Center during CMS and state inspections, most recent first.
The facility did not attempt or document required Gradual Dose Reductions (GDRs) for antipsychotic medications in two residents with dementia and behavioral disturbances, and allowed as-needed Haldol to be administered to another resident beyond the 14-day limit without proper evaluation. These actions were not in accordance with facility policy or federal regulations regarding psychotropic medication use.
Staff failed to secure medications by leaving them unattended on the medication cart, leaving the cart unlocked, and leaving the narcotic key in the lock without supervision. Additionally, medication aides did not properly supervise two residents during medication administration, relying only on verbal confirmation that medications were taken. The DON confirmed these practices were not in line with facility policy.
The facility did not perform or document required neurological assessments after unwitnessed falls for two residents, including one with severe cognitive impairment and on anticoagulant therapy. Despite facility policy mandating specific post-fall neurological checks and documentation, multiple assessments were missed or incomplete following several incidents. Interviews with staff and the DON confirmed that the established protocol was not followed.
Two residents with dementia, depression, and anxiety were prescribed multiple psychoactive medications, including Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone, without any documented attempts or consideration of Gradual Dose Reductions (GDRs) over the past year. Facility policy and federal regulations required GDRs to be attempted unless clinically contraindicated, but the DON confirmed that no such actions were taken or documented.
The facility failed to manage psychotropic medications properly for several residents. A resident received PRN antipsychotic medication beyond the 14-day limit without physician review. Another resident's gradual dose reduction for Clonazepam was delayed by 57 days despite a recommendation. Additionally, a resident continued to receive PRN Lorazepam without a clinical rationale for over three months.
The facility failed to implement enhanced barrier precautions for a resident with non-healing pressure ulcers and did not adhere to standard precautions for hand hygiene and glove use. Staff did not wash hands or change gloves appropriately, and reusable equipment was not cleaned between uses. The Director of Nursing and Administrator confirmed these deficiencies.
The facility failed to provide two residents with the required Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are necessary to inform them of the discontinuation of Medicare Part A coverage and their right to appeal. There was no documented evidence that these notices were given in a timely manner, nor were there records of the residents' decisions regarding appeals or financial responsibility. Interviews confirmed the notices were not received before the services ended.
The facility failed to protect residents from potential abuse, as a staff member accused of abuse was allowed to continue working their shift, contrary to policy. Two residents with cognitive impairments were involved, with one case reported to Adult Protective Services. The facility's response did not align with their policy, potentially compromising resident safety.
The facility failed to timely report and investigate two incidents involving residents. One resident with severe cognitive impairment eloped, and the report was delayed beyond the required timeframe. Another resident with Alzheimer's dementia fell, sustaining a head injury, but no written investigation was completed or submitted. Interviews confirmed these deficiencies.
A facility failed to ensure appropriate use of antibiotics for a resident, who was on long-term Bactrim for chronic UTIs without a specified duration or supporting documentation. The resident's care plan lacked an indication for the antibiotic, and the DON confirmed the order was for palliative care without a stop date.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received omeprazole nearly two hours late, after breakfast, contrary to the prescribed time. Another resident's insulin was administered without expelling air from the pen, risking an inaccurate dose. Both errors were confirmed by the RN involved.
A resident's insulin medication was incorrectly labeled, indicating a dosage of 11 units instead of the prescribed 7 units. The facility's policy requires proper labeling and verification before administration, but the label lacked a pink sticker to indicate a change in dosage, which had been in effect for over two months. An RN confirmed the discrepancy during an observation.
The facility failed to conduct required state Nurse Aide registry checks for two employees, Housekeeper-M and Transportation Aide-L, before their employment, violating policy and state regulations. This oversight, confirmed by a business office staff member, had the potential to affect all 33 residents, as it could allow individuals with a history of misconduct to work in the facility.
Failure to Ensure Gradual Dose Reductions and Timely Review of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by both facility policy and federal regulations. For two residents with dementia and behavioral disturbances, the facility did not attempt or document Gradual Dose Reductions (GDRs) for their prescribed Seroquel, despite these residents having been on the medication since admission. The care plans and medication administration records for these residents showed ongoing use of antipsychotic medication without evidence of GDRs being addressed or attempted over the previous year. The Director of Nursing confirmed that no GDRs had been attempted or documented for these residents during this period. Additionally, another resident with severe cognitive impairment and multiple diagnoses, including dementia, heart disease, anxiety, and depression, was prescribed Haldol as needed for agitation, aggression, or restlessness. The as-needed order for Haldol was continued and administered beyond the 14-day limit without documented evaluation by the primary care provider for appropriateness, as required by facility policy. The Director of Nursing confirmed that the medication was administered past the 14-day limit. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and review of psychotropic medications.
Failure to Secure Medications and Supervise Administration
Penalty
Summary
Facility staff failed to ensure the safe storage and supervision of medications in accordance with professional standards and facility policy. Observations revealed that medications were left unattended on top of the medication cart, and the cart itself was left unlocked and unsupervised in multiple instances. The key to the narcotic lock box was left in the lock with no nurse present, and staff were observed walking away from the cart while it remained accessible to others. These actions were in direct violation of the facility's own policies, which require all drugs and biologicals to be stored in locked compartments and not left unattended. Additionally, staff did not properly supervise residents during medication administration. On several occasions, medication aides placed medication cups in front of residents and walked away without ensuring the medications were taken, relying solely on verbal confirmation from the residents. Interviews with staff confirmed that residents were not supervised during medication administration, and the Director of Nursing acknowledged that medications should be locked and residents should not receive medications without staff supervision. These failures were observed among a sample of 19 residents, with a facility census of 31.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments as required by its own policy following unwitnessed falls for two residents. The policy, last revised in October 2010, mandates neurological checks after unwitnessed falls, falls with suspected head injury, or when indicated by resident condition. These checks include assessments of orientation, speech, vital signs, pupil reactions, and motor ability, and must be documented in the resident's medical record with specific timing and details. Staff interviews confirmed that the protocol was not followed, and the Director of Nursing acknowledged the lapses. One resident with severe cognitive impairment, multiple diagnoses including heart disease and dementia, and on anticoagulant therapy, experienced several unwitnessed falls. For each incident, required neurological assessments at specified intervals (every 15 minutes, 30 minutes, hourly, and per shift) were missing from the documentation. The resident's care plan identified them as high risk for falls and in need of extensive assistance, yet the facility failed to document or perform the required post-fall neurological checks on multiple occasions. Another resident, cognitively intact but with multiple medical conditions and at risk for falls, also experienced unwitnessed falls. After these incidents, the facility failed to complete and document neurological assessments and vital signs as required. Incident reports and post-fall assessment forms showed missing or incomplete documentation for the required checks. The DON confirmed that staff did not follow the facility's neurological assessment protocol after these falls.
Failure to Attempt Gradual Dose Reductions for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not attempting or addressing Gradual Dose Reductions (GDRs) for their psychoactive medications. Facility policy required that behavior interventions be evaluated before using psychotropic medications, and that GDRs be attempted unless clinically contraindicated, in accordance with federal regulations. For both residents, who had diagnoses including dementia with behavioral disturbances, depression, and anxiety, there was no evidence in their medical records that GDRs were attempted or considered over the previous year for medications such as Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone. Record reviews showed that one resident was receiving Mirtazapine, Zoloft, and Lorazepam, while another was on Lexapro, Lorazepam, and Trazadone, with no documentation of GDRs being addressed. The Director of Nursing confirmed during interview that no GDRs had been attempted or addressed for these residents' psychoactive medications in the past year, which was inconsistent with both facility policy and regulatory requirements.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the administration and management of psychotropic medications for several residents. For Resident 12, the facility did not ensure that an as-needed (PRN) antipsychotic medication order was limited to 14 days in duration. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and depression, received Haloperidol without a stop date, and the medication was administered on multiple occasions beyond the 14-day limit without a physician's review. Resident 18, diagnosed with anxiety disorder, depression, manic depression, schizophrenia, and diabetes, was prescribed Clonazepam for anxiety. Despite a recommendation from a Nurse Practitioner to reduce the dosage due to potential tolerance, the facility did not implement the new order for a gradual dose reduction until 57 days later. This delay occurred even though the Primary Care Provider had signed off on the recommendation. For Resident 25, who had severe cognitive impairment and diagnoses including Alzheimer's disease and depression, the facility failed to provide a clinical rationale for the continued use of PRN Lorazepam. Despite recommendations from the Consultant Pharmacist to re-evaluate the medication and determine a duration date, the facility continued to administer the medication without documented justification for over three months.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with non-healing pressure ulcers, as required by their policy. Despite the resident's ongoing pressure ulcers, there was no signage or additional personal protective equipment (PPE) available in the resident's room to indicate EBP was in place. A nursing assistant confirmed that the resident had not been placed on EBP, and the Director of Nursing and Administrator acknowledged that the resident should have been on EBP due to the non-healing pressure ulcers. Additionally, the facility did not adhere to standard precautions regarding hand hygiene and glove use. Observations revealed that staff did not wash hands or change gloves at appropriate intervals during resident care, leading to potential cross-contamination. For instance, a medication assistant handled soiled linens without proper bagging and transported them through the facility, and another staff member used the same gloves for multiple tasks without changing them, including handling clean items after touching soiled ones. The facility also failed to properly clean reusable equipment between resident uses. A Hoyer lift was used on multiple residents without being cleaned in between, as confirmed by staff interviews. The Director of Nursing and Administrator confirmed that soiled linens should be bagged, and equipment like the Hoyer lift should be cleaned between uses to prevent cross-contamination.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide two residents, identified as Resident 5 and Resident 18, with the necessary Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are required by the Centers for Medicare & Medicaid Services (CMS) regulations. These notices are crucial for informing residents or their representatives about the discontinuation of Medicare Part A coverage, potential financial responsibilities, and their right to appeal the decision. The facility's policy mandates that the ABN be given at least 48 hours in advance of any services likely to be denied by Medicare, and it must include specific details such as the resident's name, service description, reason for denial, estimated costs, and options for the resident to choose regarding the services. However, there was no documented evidence that these notices were provided to the residents or their representatives in a timely manner, nor was there any record of their decision to appeal or accept financial responsibility. For Resident 5, the skilled care services were no longer covered beginning on April 27, 2024, but there was no evidence of the resident or representative's decision regarding the appeal or billing options, nor was there a signature indicating receipt of the notice. Similarly, for Resident 18, the skilled care services ended on February 20, 2024, without documented evidence of the resident or representative's receipt and acknowledgment of the notice. Interviews with the representatives of both residents confirmed that they did not receive the necessary forms before the services ended. Additionally, a Business Office staff member confirmed that there was no verification of the notices being provided to the representatives before the service end dates, and no documented evidence of the residents' choices regarding continued services or appeals.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse, as evidenced by an incident involving two residents and an allegation of staff-to-resident abuse. The facility's policy on abuse, neglect, and misappropriation outlines procedures for handling such allegations, including immediate removal of the accused staff from the facility and ensuring the resident's protection. However, in this case, the accused staff member was allowed to continue working for the remainder of their shift, although they were restricted from entering the rooms of the residents who made the accusations. This decision was confirmed by both the LPN and the Administrator, indicating a failure to adhere to the facility's policy and adequately protect all residents. Resident 2, who had moderate cognitive impairment and required extensive assistance with daily activities, was involved in the incident, but there was no documentation in their progress notes regarding the alleged incident. Resident 5, who had severe cognitive impairment and required substantial assistance, was the subject of a verbal abuse allegation reported to Adult Protective Services. Despite the serious nature of these allegations, the facility's response did not align with their policy, as the accused staff member was not immediately removed from the facility, potentially compromising the safety of all residents.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to complete and submit timely investigations for two separate incidents involving residents. In the first case, a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease and dementia, eloped from the facility. The incident occurred on 8/27/24, but the report was not submitted to the State Agency until 9/5/24, missing the required five working days deadline. The Director of Nursing confirmed the delay in reporting during an interview. In the second incident, another resident with Alzheimer's dementia and severe cognitive impairment experienced a fall with injury. The resident fell backward, striking their head on a dresser, resulting in profuse bleeding and requiring emergency room evaluation. Although Adult Protective Services were notified, the facility did not complete or submit a written investigation to the State Agency. Interviews with the Director of Nursing and the Administrator confirmed the lack of a written investigation for this incident.
Failure to Ensure Appropriate Use of Antibiotics
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, specifically concerning the long-term use of an antibiotic for one resident. The facility's policy on Antibiotic Stewardship, reviewed in June 2024, aimed to monitor and promote the appropriate use of antibiotics, requiring prescribers to provide complete orders including drug name, dose, frequency, duration, route, and indications of use. However, for Resident 18, there was an order for Bactrim Double Strength to be taken daily for chronic urinary tract infections without a specified duration or supporting documentation for clinical use based on laboratory results. Resident 18's Minimum Data Set (MDS) indicated multiple diagnoses, including anxiety, depression, diabetes, manic depression, and schizophrenia, and the resident was receiving several medications, including an antibiotic, daily. The resident's care plan did not reflect an active or chronic infection or an indication for the long-term use of the antibiotic. During an interview, the Director of Nursing confirmed that the resident was on a prophylactic antibiotic, ordered by Hospice for palliative care, but there was no specified stop date or duration for its continued use.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations, record reviews, and interviews. During the administration of 28 medications, two errors were identified, resulting in a medication error rate of 7.14%. These errors affected two of the four sampled residents. The first error involved Resident 4, who was prescribed omeprazole 40 mg to be taken 60 minutes before meals at 7:30 AM. However, the medication was administered by RN-B at 9:25 AM, nearly two hours after the prescribed time, and after the resident had already eaten breakfast. The second error involved Resident 23, who was prescribed Novolog FlexPen insulin, 7 units subcutaneously, to be administered three times a day with meals. RN-B failed to follow the manufacturer's instructions for preparing the insulin pen, which required expelling 2 units of air before administering the dose. Instead, RN-B directly administered the 7 units without expelling air, potentially leading to an inaccurate dose. Both errors were confirmed through interviews with RN-B, who acknowledged the deviations from the prescribed procedures.
Incorrect Insulin Labeling for a Resident
Penalty
Summary
The facility failed to ensure that an insulin medication was labeled correctly for one of the sampled residents. The facility's policy on the storage of medications, which was reviewed in April 2024, mandates that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storage. Additionally, the policy on administering medications requires the individual administering the medication to check the label three times to verify the right resident, medication, dosage, time, and route of administration before giving the medication. During an observation, a registered nurse (RN) administered insulin to a resident using a Novolog FlexPen. The label on the insulin indicated a dosage of 11 units to be given subcutaneously three times a day, 15 minutes before a meal. However, the RN administered 7 units, as per the physician's order recorded in the Medication Administration Record (MAR), which was correct. The RN confirmed that the label on the medication was incorrect and should have had a pink sticker to alert staff of a change in the medication instruction, which had occurred over two months prior. The absence of this sticker was confirmed during the observation and interview with the RN.
Failure to Conduct Required Nurse Aide Registry Checks
Penalty
Summary
The facility failed to complete the required state Nurse Aide registry checks for two of the five sampled employees, which is a violation of the facility's policy and state regulations. The policy mandates that the facility must not employ individuals who have been found guilty of abuse, neglect, exploitation, or misappropriation of property, and requires background checks to be conducted prior to or at the time of employment. However, upon review, it was found that the facility did not check the state Nurse Aide registry for Housekeeper-M, hired on March 18, 2024, and Transportation Aide-L, hired on May 15, 2024, for any negative findings related to abuse, neglect, exploitation, or misappropriation of property. An interview with a business office staff member confirmed that the state Nurse Aide registry was not checked for these two employees before their start dates, and both had been working in the facility since their respective hire dates. This oversight had the potential to affect all residents, as the facility census was 33 at the time of the report. The failure to conduct these checks is a significant lapse in ensuring the safety and well-being of the residents, as it could allow individuals with a history of misconduct to be employed in the facility.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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