Wauneta Care And Therapy Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wauneta, Nebraska.
- Location
- 427 Legion Street, Wauneta, Nebraska 69045
- CMS Provider Number
- 285220
- Inspections on file
- 15
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wauneta Care And Therapy Center during CMS and state inspections, most recent first.
A nurse aide did not complete the required 12 hours of annual continuing education, instead receiving only 2.85 hours during the relevant period, as confirmed by facility records and the Facility Administrator.
The facility did not ensure that residents received required visits from a physician during initial and subsequent recertification periods, instead relying on PAs and APRNs to perform these visits. Multiple residents with complex medical conditions were only seen by non-physician practitioners, and in some cases, there was no evidence of any physician evaluation during their stay. The DON confirmed that physicians were not routinely involved in resident care as required.
A resident was admitted with admission orders written and signed only by a physician assistant, without a physician's co-signature or recommendation for nursing home placement. The DON confirmed that the resident was not followed by a physician and that no physician documentation was present in the medical record, despite the resident having multiple complex medical conditions.
A resident with dementia, anxiety, and other conditions was prescribed multiple psychotropic medications, but the facility did not attempt a gradual dose reduction (GDR) or document a physician rationale for not doing so. Review of records and interviews with the DON confirmed the absence of GDR attempts or related documentation.
Two residents received acetaminophen outside the prescribed administration times, with one dose given early and another given late by an LPN. These timing errors resulted in a medication error rate of 6.5%, exceeding the allowable 5% threshold as confirmed by the DON and facility policy.
The facility failed to identify and treat a resident's pain, who had dementia and exhibited non-verbal indicators of pain. Staff misinterpreted the resident's behaviors as agitation or anxiety, and did not use appropriate pain assessment tools. The resident's care plan did not specifically address their potential for pain, leading to inadequate pain management.
The facility failed to submit their PBJ data for Q1 2024, covering 10/1/2023 through 12/31/2023. An AA responsible for the submission was locked out of the system after entering an incorrect password too many times on the due date, affecting all 32 residents.
The facility failed to ensure that a Nurse Aide completed the required 12 hours of ongoing training per year. A review of the aide's training records revealed only 2.85 hours of training in the past 12 months, confirmed by the Administrative Assistant. This deficiency had the potential to affect all 32 residents in the facility.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Residents with conditions such as dementia, heart failure, COPD, diabetes, and pressure ulcers had care plans that did not adequately address their specific needs, as confirmed by interviews with the DON and MDS Nurse.
The facility failed to follow infection control protocols, including the use of PPE and hand hygiene. A nurse aide did not wear a gown during catheter care for a resident requiring enhanced barrier precautions. Additionally, a medication aide did not perform hand hygiene between residents and handled medication with bare hands.
The facility failed to ensure that PRN psychotropic medications were reviewed and reordered every 14 days for a resident receiving telemedicine psychiatric care. Despite improvements in the resident's mental health, the PRN order for Clonazepam was not renewed as required by the facility's policy, leading to a significant deficiency in medication management.
The facility failed to ensure that medications that should not be crushed were not crushed, resulting in a medication error rate of 16.67%. A Medication Aide crushed multiple medications for a resident without proper instructions or awareness, despite the facility's policy and guidelines indicating these medications should not be crushed.
Failure to Provide Required Continuing Education for Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide received the required minimum of 12 hours of continuing education within the annual period based on the aide's employment date. According to facility policy, nurse aides must complete at least 12 hours of in-service training annually, calculated from their hire date. Record review showed that one nurse aide, hired on 2/1/22, completed only 2.85 hours of continuing education during the period from 2/1/24 to 2/1/25. This was confirmed by the Facility Administrator, who acknowledged that the nurse aide did not meet the required training hours for the specified period.
Failure to Ensure Required Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician during the required initial 30-day visit and at a minimum of every other visit, as mandated. Record reviews and interviews revealed that for six residents, physician visits were either not conducted or were substituted with visits by physician assistants (PAs) or advanced practice registered nurses (APRNs), who are not physicians. The Director of Nursing (DON) confirmed a misunderstanding regarding the requirements, believing that PAs or APRNs could perform all 60-day certifications and that the terms 'primary care physician' and 'primary care practitioner' were used interchangeably in the facility, despite acknowledging that they are not the same. For several residents, including those with complex medical histories such as chronic obstructive pulmonary disease, congestive heart failure, Alzheimer's disease, chronic kidney disease, and recent surgeries, medical records showed that recertification and routine visits were consistently performed by non-physician practitioners. In some cases, there was no evidence that a physician had evaluated the resident at any point during their stay. For example, one resident with multiple chronic conditions was only seen by a PA for all recertification visits, and another resident with Alzheimer's and chronic kidney disease had no record of ever being evaluated by a physician while in the facility. Additionally, documentation for other residents indicated that initial and subsequent required visits were completed by APRNs, with no physician involvement documented. In some instances, the facility's electronic health records incorrectly listed non-physician practitioners as the resident's physician. Interviews with the DON confirmed that these practices were routine and that physicians did not routinely see residents as required, resulting in non-compliance with federal regulations regarding physician oversight and resident care.
Failure to Obtain Physician Admission Orders for Resident
Penalty
Summary
The facility failed to ensure that all residents admitted had a written recommendation or written orders from a physician, as required by licensure regulations. Specifically, for one resident who was admitted, the admission orders were written and signed solely by a physician assistant (PA), without a co-signature or involvement from a physician (MD). Review of the resident's medical record confirmed that there was no documentation from a physician recommending nursing home placement or signing the admission orders. Interviews with the Director of Nursing (DON) confirmed that the resident's primary care provider was the PA, and that the resident was not followed by a physician. The DON acknowledged that after reviewing the medical records, there was no evidence of physician involvement in the admission process. The resident in question had multiple complex medical diagnoses, including status post left hip replacement with complications, chronic right hip hardware infection, long-term antibiotic use, hypertension, history of blood clots, anticoagulation, muscle weakness, anxiety, and overactive bladder.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) were attempted for a resident receiving psychotropic medications. Record review showed that the resident, who had diagnoses including renal insufficiency, Alzheimer's dementia, anxiety disorder, and adjustment disorder, was prescribed multiple psychotropic medications such as buspirone, mirtazapine, and sertraline. The resident exhibited behaviors such as delusions, verbal and physical outbursts, rejection of care, wandering, and urinary incontinence, and was unable to participate in a Brief Interview for Mental Status exam. Despite these conditions and ongoing use of psychotropic medications, there was no evidence in the medical record that a GDR had been attempted in the past year. Additionally, there were no physician orders or documented rationales indicating that a GDR was contraindicated for this resident. Interviews with the DON confirmed that no documentation of a GDR or physician rationale for not attempting a GDR could be found for this resident.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. Out of 31 observed medication administration opportunities, there were 2 medication errors, resulting in an error rate of 6.5%. The errors involved two residents. In the first instance, a resident was administered acetaminophen earlier than the scheduled time of 9:00 AM, as per their preference, rather than at the time ordered. In the second instance, another resident received acetaminophen later than the scheduled administration time of 7:00 AM. Both errors were confirmed through observation and staff interviews. Facility policy requires adherence to the Five Rights of Medication Administration, which include giving the right drug to the right resident, in the right amount, at the right time, and by the right route. The Director of Nursing confirmed that medications must be administered within one hour before or after the scheduled time, and deviations from this window are considered medication errors. The observed errors occurred outside of this acceptable time frame, directly contributing to the facility's medication error rate exceeding the regulatory threshold.
Failure to Identify and Treat Resident's Pain
Penalty
Summary
The facility failed to identify and treat the pain of Resident 19, who had a history of dementia and exhibited non-verbal indicators of pain. Despite the facility's policy to observe for non-verbal indicators and use appropriate pain assessment tools, the staff did not adequately assess or address the resident's pain. The resident's care plan did not specifically address their potential for pain, and the staff frequently misinterpreted the resident's behaviors as agitation or anxiety rather than potential pain indicators. Observations revealed that Resident 19 exhibited signs of pain, such as facial grimacing, repetitive distressed vocalizations, and holding their forehead. Despite these clear indicators, staff members did not ask the resident about their pain or use an appropriate pain assessment tool. Instead, the staff focused on managing the resident's agitation with psychotropic medications and non-medication interventions like providing a quieter environment and playing soft music. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN)-G confirmed that the facility used the FACES pain scale or a 0-10 pain rating scale, which were not suitable for residents with cognitive impairments like Resident 19. The facility did not have an alternative pain assessment tool for cognitively impaired residents, leading to inadequate pain management for Resident 19. The DON acknowledged that the resident's behavioral symptoms persisted despite frequent use of psychotropic medications, indicating that the root cause of the resident's distress, likely pain, was not being addressed.
Failure to Submit PBJ Data for Q1 2024
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data for the first quarter of fiscal year 2024, covering the period from 10/1/2023 through 12/31/2023. This deficiency was identified through a record review of the PBJ report from CMS, which revealed no direct care nursing staff data was submitted for the specified period. An interview with the Administrative Assistant (AA) confirmed that the AA, who was responsible for submitting the PBJ data, did not submit the data due to being locked out of the system after entering an incorrect password too many times on the evening of the due date. This failure had the potential to affect all 32 residents residing within the facility.
Failure to Ensure Required Ongoing Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA)-H completed the required 12 hours of ongoing training per year. A review of NA-H's training records on the Relias online training program revealed that NA-H had only completed 2.85 hours of training in the past 12 months. This included two 0.5-hour courses and five courses totaling 1.85 hours, all completed on a single day. An interview with the Administrative Assistant confirmed that NA-H had not attended any in-person facility in-services over the last twelve months. This deficiency had the potential to affect all 32 residents in the facility.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident 19, who had dementia and cognitive impairments, exhibited non-verbal signs of pain, but the care plan did not include interventions for pain management. Despite receiving multiple psychotropic medications and PRN pain medication, the resident's behavioral symptoms persisted, indicating that the root cause of the problem was not addressed. Interviews with the DON and an LPN confirmed the lack of appropriate pain assessment tools for cognitively impaired residents and the inadequacy of the care plan in addressing the resident's pain management needs. Resident 23, admitted with heart failure, COPD, hypertension, and edema, had a care plan that did not address these medical conditions or the use of anticoagulants and diuretics. The MDS Nurse confirmed that the care plan was not comprehensive and failed to address the resident's medical conditions. Similarly, Resident 26, who had severe cognitive impairment and Type 1 Diabetes, had a care plan that did not focus on diabetes management or insulin use. The MDS Nurse acknowledged that all care plans needed improvement to be comprehensive. Resident 32, admitted with pressure ulcers and arterial stasis ulcers, had a care plan that did not address these conditions. The MDS Nurse and DON confirmed that the care plan lacked information regarding the resident's pressure ulcers and arterial stasis ulcers. The failure to include these critical medical conditions in the care plans highlights the facility's deficiency in developing and implementing comprehensive care plans for its residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) and hand hygiene. During an observation, a nurse aide did not don a gown while providing catheter care to a resident who required enhanced barrier precautions. The resident had a left hip fracture and hydronephrosis and required maximal assistance with toileting hygiene. Despite a sign on the resident's door indicating the need for enhanced barrier precautions, the nurse aide only wore gloves and not a gown, which was confirmed during an interview with the aide. Additionally, the facility failed to ensure proper hand hygiene and medication handling during medication passes. A medication aide did not perform hand hygiene before starting a medication pass for another resident and used bare hands to handle medication without gloves. The aide also touched their hair and did not perform hand hygiene before continuing with the medication pass. These actions were observed and confirmed during an interview with the medication aide, who acknowledged the lapses in hand hygiene and proper medication handling procedures.
Failure to Review and Reorder PRN Psychotropic Medications Every 14 Days
Penalty
Summary
The facility failed to ensure that all psychotropic medications given on a PRN basis were reviewed and reordered every 14 days for Resident 32. Resident 32, who was admitted to the facility after being discharged from the hospital, was receiving telemedicine psychiatric care every two weeks. Despite the improvement in Resident 32's mental health, the facility did not adhere to the policy requiring a 14-day renewal order for PRN psychotropic medications. Specifically, the medication Clonazepam, prescribed for anxiety, was not reviewed and reordered every 14 days as required by the facility's policy and procedure for the use of psychotropic medications. Interviews with various staff members, including the Social Services Director, Minimum Data Set Nurse, Infection Control Nurse, and Director of Nurses, confirmed that Resident 32 was receiving psychiatric care via telemedicine and had shown significant improvement. However, the record reviews revealed that the PRN order for Clonazepam, which started on 1/09/2024, did not have a stop date and was not renewed every 14 days. The medication administration records for February and March 2024 showed multiple instances where Resident 32 received Clonazepam without the required 14-day renewal order. The facility's policy dated 1/24/2024 clearly states that all psychotropic drugs used on a PRN basis must be documented with a specific condition, limited to 14 days, and require the prescribing practitioner to document the rationale and duration in the medical record. Despite this policy, the facility failed to ensure compliance, as evidenced by the lack of 14-day renewal orders for Clonazepam in Resident 32's records. This oversight was identified through multiple telemedicine visit records and medication administration records, highlighting a significant deficiency in the facility's medication management practices.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications that should not be crushed were not crushed for one of the sampled residents, leading to a medication error rate of 16.67%, which is significantly higher than the acceptable threshold of 5%. Specifically, Resident 16, who was admitted with diagnoses including atrial fibrillation, heart failure, hypertension, gastro-esophageal reflux disease, iron deficiency, and overactive bladder, had multiple medications crushed by a Medication Aide (MA)-B. These medications included ferrous sulfate, pantoprazole, potassium chloride, solifenacin, and carvedilol, all of which were listed as medications that should not be crushed according to the Institute for Safe Medication Practices document. The facility's policy on medication administration, last revised on 9/13/2023, also explicitly stated that slow-release or enteric-coated medications should not be crushed, yet this policy was not adhered to in this instance. An observation on 5/14/2024 revealed that MA-B crushed Resident 16's medications without proper instructions or awareness of which medications could not be crushed. During interviews, MA-B confirmed the lack of specific instructions in the computer system and admitted to being unaware of the medications that should not be crushed. This oversight and lack of proper training or information led to the medication error, highlighting a significant lapse in the facility's medication administration process and adherence to established policies and guidelines.
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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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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