Wayne Countryview Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, Nebraska.
- Location
- 811 East 14th Street, Wayne, Nebraska 68787
- CMS Provider Number
- 285135
- Inspections on file
- 24
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Wayne Countryview Care And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to employ a qualified Dietary Manager, as the current DM had not completed the required training or education. This deficiency was confirmed through interviews with the DM and the facility Administrator, highlighting a potential impact on the quality of nutritional services provided to residents.
The facility failed to maintain kitchen cleanliness and proper food temperatures, risking foodborne illness for residents. Observations revealed dirty floors, caked-on food, and improper food temperatures. The ice machine was also inadequately maintained, with the last cleaning occurring three months prior. Interviews confirmed lapses in daily cleaning and temperature recording.
The facility failed to implement required PPE during care for residents with infections, did not have a waterborne illness mitigation plan, and neglected proper hand hygiene during medication administration and meal delivery. A resident with VRE and another with a surgical wound did not receive care with appropriate PPE. Additionally, staff did not follow hand hygiene protocols, risking cross-contamination.
The facility was found to have multiple deficiencies in maintaining a clean and homelike environment, including stained ceiling tiles, chipped drywall, soiled carpets, and chipped paint. Additionally, issues such as unsecured floor drain caps, dust-coated filters, and damaged flooring were observed. The facility Administrator confirmed these concerns required repair, noting that the previous Maintenance Supervisor had removed work orders without completing repairs.
A facility failed to maintain a pest-free environment, with tiny black bugs found in a resident's bathroom and dead spiders in the kitchen. Despite having a pest control policy and contract, observations confirmed unclean conditions, and staff interviews revealed that kitchen windows and screens had not been cleaned. The administrator acknowledged the issue, leading to the relocation of the affected resident.
A resident with multiple health conditions and moderate cognitive impairment was found with Tums antacid tablets in their bathroom without a physician's order or an assessment for self-administration competency. The facility failed to follow its policy and state regulations regarding the evaluation and documentation of self-administration of medications.
A resident with severe cognitive impairment and incontinence was not provided timely toileting assistance, contrary to the facility's policy requiring checks every 2-3 hours. Observations showed the resident with strong odors of feces and urine, and staff confirmed a delay of over four hours in providing necessary care.
A facility failed to follow a physician's order for a resident's fluid restriction, as there was no documentation of monitoring intake and output. Observations showed the resident had access to a full water pitcher, contrary to the order. The DON confirmed the oversight and the responsibility of Charge Nurses to document intake and output.
A facility failed to monitor a dialysis access site for a resident requiring dialysis services. The facility's policy requires checking the access site for condition, bruit, and thrill every shift, and notifying a physician of any complications. Despite the resident's orders for dialysis three times a week, there was no evidence in the medical records that the nursing staff monitored the access site. An LPN confirmed the requirement to assess the site but acknowledged the lack of evidence for completed assessments.
The facility failed to label insulin pens with an open date for two residents, as required by their policy. Observations revealed that insulin pens for these residents lacked the necessary documentation, which was confirmed by the RN and acknowledged by the DON and Administrator.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM), which had the potential to affect the food service provided to all residents. The deficiency was identified based on a review of the facility's job description for the DM position and the employee file of the current DM, referred to as DM-H. The job description outlined specific duties and responsibilities for the DM, including directing the dietary department, coordinating services, developing policies, and ensuring compliance with dietary requirements. It also specified educational requirements, such as training in cost control, food management, and diet therapy, and the completion of a Certified Dietary Manager (CDM) course within the first year of employment if not already qualified. Upon review, it was found that DM-H had not completed the required training or education for the DM position. This was confirmed during interviews with DM-H and the facility Administrator, both of whom acknowledged that the necessary training and classes had not been undertaken. The lack of a qualified DM had the potential to impact the quality of nutritional services provided to the residents, as the DM plays a crucial role in ensuring dietary compliance and the overall operation of the dietary department.
Deficiencies in Kitchen Sanitation and Food Temperature Maintenance
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as well as to maintain proper food temperatures, which could potentially lead to foodborne illnesses affecting all residents. Observations and audits revealed multiple cleanliness issues, including dirty floors, spills on the steam table, and crumbs on serving carts and shelves. The kitchen floor was noted to have dark, dried splatter spots with a slimy appearance, and the stove and prep areas had dried, caked-on food. Interviews with the Dietary Manager and Cook confirmed that the kitchen floors were not mopped daily as required. The facility also failed to adhere to food temperature guidelines, as documented in the October 2024 Meal Temperature Form. The dietary staff did not record food temperatures for several evening meals, and some recorded temperatures were below the recommended levels. For instance, pancakes, grilled cheese sandwiches, and various entrees were served at temperatures below 140 degrees Fahrenheit, and potato salad was served at 58 degrees Fahrenheit instead of the required 41 degrees Fahrenheit or less. Interviews with dietary staff confirmed these discrepancies. Additionally, the facility did not properly maintain the ice machine, which was last cleaned three months prior to the survey. Observations showed that the ice machine was placed on an uncleanable surface, with a floor drain partially covered and a drainage tube discolored. The filter on the machine was coated with dust and debris. The Administrator was unsure of the last cleaning date and when the next maintenance was due, indicating a lack of proper maintenance oversight.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement the required Personal Protective Equipment (PPE) during the provision of care for several residents, including Residents 12 and 235. Resident 12, who had a history of Vancomycin Resistant Enterococci (VRE), required staff to wear gloves and a gown during high-contact care activities. However, during an observation, a nurse aide assisted the resident with various tasks such as toileting and dressing without wearing the necessary PPE. Similarly, Resident 235, who was on Enhanced Barrier Precautions (EBP) due to a surgical wound, was observed receiving wound care from a Licensed Practical Nurse (LPN) who only wore gloves and not a gown, contrary to the facility's policy. The facility also failed to implement a mitigation plan to prevent potential waterborne illnesses. The Maintenance Supervisor confirmed that there was no consistent plan for flushing unused water systems to prevent water stagnation and the potential growth of pathogens like Legionella. This lack of a water management mitigation plan was acknowledged during interviews with the facility staff. Additionally, the facility did not adhere to proper hand hygiene protocols during medication administration and meal delivery. For instance, a Registered Nurse (RN) was observed handling medications for Resident 21 without performing hand hygiene or using a protective barrier on the bedside table. Similarly, a Dietary Aide (DA) failed to perform hand hygiene while delivering room trays to multiple residents. These actions were in violation of the facility's hand hygiene policy, which emphasizes the importance of hand hygiene before and after resident contact and when handling medications.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as observed during a survey conducted from October 9 to October 16, 2024. Multiple deficiencies were noted, including stained and sagging ceiling tiles, chipped and pitted drywall, and soiled carpets with stains in various rooms. Additionally, door frames throughout the facility had chipped and missing paint, and the floors around these areas were caked with dirt and debris. The alcove outside the laundry area was heavily dusted, and the threshold of the double door entry to the 300 hallway was taped with industrial tape that was scuffed and peeling. Further observations included chipping paint on hallway walls, unsecured floor drain caps with a slimy substance beneath the ice machine, and a heavily dust-coated filter on the ice machine. A resident's fall mat had multiple tears and split seams, and a room's linoleum had a significant tear sticking up in front of a recliner. During a tour and interview with the facility Administrator, it was confirmed that these issues required repair and maintenance. It was revealed that the previous Maintenance Supervisor had been removing work orders without completing repairs, and a new Maintenance Supervisor had been employed.
Pest Control Deficiency in Resident Room and Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of tiny black bugs in the bathroom of a resident's room and dead spiders, dust, and spider webs in the facility kitchen. The facility had a pest control policy in place since 2007 and a contract with a pest control company for monthly inspections. However, during an interview, a resident reported seeing tiny black bugs in the bathroom basin, which was confirmed by observations on two separate occasions. Additionally, observations in the kitchen revealed dead spiders and unclean conditions around the windows, with a removed screen left on the window ledge. Interviews with facility staff, including a cook and the dietary manager, confirmed that the kitchen windows and screens had not been cleaned, and the presence of dead spiders and dust was evident. The pest control service summary indicated that interior rodent traps had little to no catches, suggesting a lack of effective pest control measures. The facility administrator acknowledged the issue, noting that bugs had been observed in other areas of the building as well, leading to the relocation of the affected resident to another room.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility staff failed to evaluate a resident for the ability to self-administer medications and ensure the security of medications. The facility's policy, revised in May, outlines procedures for self-administration of medications, including informing alert residents of their rights, assessing their ability, and documenting this in their medical records. However, the facility did not follow these procedures for a resident with multiple diagnoses, including cancer, coronary artery disease, and anxiety, who was moderately cognitively impaired. During observations, the resident was found with a container of Tums antacid tablets in their bathroom, which lacked a medication label and a physician's order. The resident's electronic medical record showed no evidence of an assessment for self-administration competency or a physician's order for the Tums. An LPN confirmed that the resident had not been evaluated for self-administration and did not have an order for the Tums, indicating a failure to adhere to the facility's policy and state regulations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate toileting assistance and incontinence management for a resident who required assistance with activities of daily living. The facility's policy on incontinent care, dated May 2007, required residents to be checked for incontinence every 2-3 hours. However, observations revealed that the resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was not provided with timely assistance. The resident was observed on multiple occasions with a strong odor of feces and urine, indicating a lack of proper incontinence care. On one occasion, the resident was left in a wheelchair in the corridor for over four hours without being offered toileting assistance, despite having a strong urine odor. The resident's Minimum Data Set (MDS) and care plan indicated a dependency on staff for toileting and personal hygiene. Interviews with staff confirmed that the resident had not been assisted with toileting since being dressed by the night shift, which was a minimum of four hours before assistance was finally provided. This lack of timely care was contrary to the facility's policy and the resident's care plan requirements.
Failure to Follow Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to a physician's order regarding a fluid restriction for a resident, identified as Resident 85. The facility's policy, revised in 2007, required nursing staff to notify the dietary department of fluid restriction parameters, document intake and output on the Medication Administration Record (MAR), and ensure that water pitchers were not provided at the resident's bedside. However, from October 8 to October 10, there was no documentation indicating that the facility monitored the resident's fluid intake and output to ensure compliance with the physician's order. Observations revealed that the resident had access to a full water pitcher containing 600 ml of water on two separate occasions, despite the fluid restriction. The Director of Nursing confirmed that the resident had a physician order for a 2000 ml fluid restriction and acknowledged that a full water pitcher should not have been provided in the resident's room. The Charge Nurses were responsible for documenting the resident's intake and output for each shift on the MAR to ensure compliance with the fluid restriction, but this was not done.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to monitor the dialysis access site for a resident requiring dialysis services. The facility's policy on renal dialysis care, revised in June 2009, mandates that the access site be checked for condition, bruit, and thrill every shift, and that the physician be notified of any complications. Additionally, blood pressures and venous punctures should not be performed on the extremity with the access site, and staff are responsible for preventing, identifying, and managing potential complications. The resident's admission orders indicated that they were to receive renal dialysis three times a week. However, a review of the resident's medical records, including Nursing Progress notes, Treatment Administration Record, and Medication Administration Form, revealed no evidence that the facility's nursing staff were monitoring the dialysis access site. An LPN confirmed that staff were required to assess the dialysis access site for signs of complications after treatment and to check for bruit and thrill each shift, but acknowledged that there was no evidence of these assessments being completed.
Failure to Label Insulin Pens with Open Date
Penalty
Summary
The facility failed to ensure that insulin pens were properly labeled with an open date for two residents, as required by their policy on Proper Insulin Pen Administration. During observations, it was noted that insulin pens for Residents 5 and 21 did not have an open date documented. This was confirmed during interviews with the Registered Nurse (RN) responsible for administering the insulin, who acknowledged that the pens should have been labeled with an open date. The facility's policy mandates that staff document an open date on insulin pens to ensure proper tracking and usage. However, during the survey, it was observed that the insulin pens for both residents lacked this crucial information. The Director of Nursing and the Administrator confirmed that the insulin pens should have been labeled with an open date, indicating a lapse in adherence to the facility's medication management protocols.
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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