Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wildflower Court during CMS and state inspections, most recent first.
Food storage, labeling, and sanitation practices were not followed in the kitchen. Sanitizer buckets tested outside the manufacturer range, numerous prepared and packaged foods were found unlabeled, missing open or use-by dates, or expired across multiple storage areas, and a cook handled raw chicken with contaminated gloves after touching a speaker without removing the gloves or performing hand hygiene.
A facility failed to complete NOMNC forms with the required QIO name and toll-free number for three residents, leaving generic template language and missing Medicare service details on the notices. For one resident, staff used an expired ABN instead of the correct SNFABN, and the DON/Administrator acknowledged the incorrect form was used and that the generic NOMNC template should have been completed before being given to residents.
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Staff failed to honor a resident’s expressed preference to use a mounted doorbell instead of knocking before entering the room. The resident had PTSD and a history of trauma, and knocking was a known trigger. During observation, a CNA knocked, rang the doorbell, and opened the door while the resident was being interviewed, despite a posted sign requesting staff ring the bell and not knock. Interviews confirmed staff knew the resident’s preference and trigger.
Incomplete MDS Mood and Behavior Assessments: A resident with a BKA, HF, and hypothyroidism had annual and quarterly MDS assessments that left Sections D and E as not assessed/no information, despite care plan documentation of depressed mood, little interest in activities, refusal of meds, weights, and cares, and limited engagement noted during survey observations. Nursing notes also showed refusals of VS and meds, while the SW said she had not spoken with the resident and the MDS Coordinator could not verify the accuracy of the completed sections.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
Nursing staff were found to lack required competencies, with several nurses missing current oxygen safety training and a CNA working without a valid CPR certificate. Personnel files and interviews confirmed these deficiencies, despite facility policies mandating annual oxygen safety education and BLS certification for all clinical staff.
Surveyors identified failures in food storage and preparation, including expired and unlabeled food items in kitchen and unit storage areas, as well as inconsistent documentation of cooked food temperatures. Staff interviews revealed confusion about labeling practices and recent changes to temperature recording procedures, resulting in incomplete or missing temperature logs.
Nursing staff did not document pain reassessments within 30 to 60 minutes after administering opioid pain medications to multiple residents with complex medical conditions, despite facility policy and clinical guidelines requiring such follow-up. This deficiency was confirmed through record review and staff interview.
A resident with multiple medical conditions was allowed to self-administer medications, including a controlled substance, without a documented assessment or physician order. Nursing staff left medications at the bedside and did not observe ingestion, contrary to facility policy and without care plan documentation supporting self-administration.
A CNA failed to follow a care plan requiring two-person assistance for a resident with anoxic brain damage and reduced mobility, instead performing transfers and toileting alone and using improper techniques. The resident was left unattended on the toilet, contrary to the care plan and facility policy, as confirmed by staff interviews and record review.
A resident with significant mobility impairments and a care plan requiring two-person assistance for transfers and toileting was assisted by a CNA alone, who used improper transfer techniques and left the resident unattended on the toilet. Additionally, the room's internal doorway was obstructed by a Hoyer lift, potentially impeding access. Staff interviews confirmed the resident's need for two-person assistance and the importance of keeping doorways clear.
A Hoyer lift was left blocking a resident's room entryway, making access difficult and potentially delaying emergency assistance. Additionally, an exit door in the activity room kitchen lacked a wander guard alarm or locking system, allowing a resident with dementia and a history of elopement to move freely and potentially exit the building. Staff confirmed these safety lapses, and facility policies did not address regular security checks for all exit doors.
A medication error rate of 36% was identified when a nurse handed a resident a cup containing nine medications and left the room without observing ingestion, despite no physician order or self-administration assessment. The DON confirmed that nurses are required to observe residents taking medications, and facility policy was not followed.
A CNA was found to be providing direct patient care without a valid CPR certificate, contrary to facility policy requiring all clinical staff to have completed BLS training. The CNA had not completed the required CPR course since hire and was assigned to various units, with the HR Manager confirming the lack of certification and incomplete follow-up by staff development.
The facility's pharmacy services failed to provide accurate dispensing of medications and necessary consultation, leading to multiple medication errors and unaddressed concerns despite repeated attempts by the DON to contact the pharmacy.
The facility failed to complete monthly DRRs by a licensed pharmacist for all residents from November 2023 to January 2024. Additionally, errors in the DRRs for two residents were identified, including an incorrect assessment of an active medication and inappropriate Morphine PRN orders with identical parameters.
The facility failed to submit mandatory PBJ staffing data for FY Quarter 4 2023, potentially denying residents and the public accurate staffing information. The Accounting Officer Controller cited a change of ownership as the reason for missing the deadline, resulting in a one-star staffing rating.
The facility failed to ensure that residents or their representatives were informed of the risks and benefits of psychoactive medications. Two residents had active orders for Diazepam and Lorazepam without documented informed consent forms, as confirmed by the pharmacist and the Director of Nursing.
The facility failed to provide timely SNFABN and NOMNC forms to two Medicare Part A residents, delivering the forms either on the day of or one day before the end of coverage. This did not allow the residents or their families sufficient time to appeal a denial of Medicare coverage.
The facility failed to implement the care plan for a resident with a known eye condition, resulting in unaddressed needs for glasses repair and eye exams. The resident's care plan included actions for specialist referrals and glasses maintenance, but these were not followed through, potentially delaying necessary treatments.
The facility failed to ensure that a new open area on a resident's skin was communicated to the nurse. The resident, who had spinal stenosis and cellulitis, reported soreness and a high pain level. CNAs discovered a small open wound but did not report it, leading to a lack of documentation and treatment. The Director of Nursing confirmed that the CNAs should have reported the wound immediately, as per facility policy.
The facility failed to ensure that a resident who smoked followed the care plan and smoking policy by smoking outside in a wood-framed gazebo lacking safety measures, instead of the designated smoking shed equipped with fire safety measures. This non-compliance posed a potential fire hazard.
A resident experienced significant weight loss, which was not reported to the physician as required. Despite a care plan indicating the need for regular weight monitoring, the facility failed to document interventions or communications regarding the weight loss. Observations and interviews revealed concerns from the resident's family and acknowledgment from staff that proper procedures were not followed.
The facility failed to ensure a resident's medication regimen was free from unnecessary drugs by not providing specific parameters for four different Morphine as-needed orders. The resident, with severe cognitive impairment and on palliative care, had identical parameters for each Morphine order, risking excessive or subtherapeutic administration. Interviews with the DON, ADON, and a pharmacist confirmed the orders were inappropriate.
The facility failed to ensure that two residents were provided with their ordered diets, leading to potential risks for poor health outcomes. Observations revealed discrepancies in meal preparation and serving sizes, and a lack of oversight and training among staff. One resident with dietary restrictions was served inappropriate food items, while another resident with swallowing difficulties did not receive the ordered side of moisture with meals.
A facility failed to ensure staff performed hand hygiene during wound care for a resident with sepsis and a sacral wound. A licensed nurse did not wash hands or change gloves when moving from a dirty to clean task. The infection preventionist confirmed the requirement for hand hygiene in such situations, as per the facility's policy.
Food Storage, Labeling, and Hand Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, and maintain food and food-contact sanitation in accordance with food safety standards. During observations in the main kitchen, two sanitizer buckets were found with sanitizer concentrations that tested at 0 ppm and 100 ppm, which did not match the manufacturer-recommended range posted in the kitchen areas. Follow-up testing later showed one set of buckets at 100 ppm, another at 350 ppm, and then again at 0 ppm on a later observation. Facility leadership gave differing explanations about which sanitizer dispenser should have been used and whether the buckets needed to be tested before use. The facility also had multiple food items in the main kitchen walk-in refrigerator, freezer, dry storage area, nourishment cooler, and unit kitchens that were unlabeled, missing use-by dates, missing open dates, or expired. Observations included prepared foods such as pancakes, French toast, pureed meats, vegetables, cheeses, eggs, desserts, breads, sauces, and individual serving cups that were stored without required date markings or with dates that had already passed. Several items in manufacturer packaging were also found without open dates or use-by dates, and some expired items remained in storage, including cereal, bread mix puree, dessert sauces, butter pats, and therapeutic nutrition supplements. During food preparation, a cook handling raw chicken thighs with gloves stopped to touch a speaker while still wearing the same gloves, then returned to handling the raw chicken without removing the gloves or performing hand hygiene. The DCNS stated the cook should have removed the gloves, washed hands, and put on clean gloves before returning to food preparation. The report also notes that the facility’s policy required handwashing before preparing food, after contamination, when returning to a workstation, and when switching between raw and ready-to-eat foods.
Incomplete Medicare Non-Coverage Notices and Use of an Expired ABN
Penalty
Summary
The facility failed to ensure that the CMS Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the required Quality Improvement Organization (QIO) name and toll-free telephone number before it was issued to three residents reviewed for beneficiary notifications. For each of the three residents, the NOMNC forms retained generic template language, including the placeholder for the type of Medicare-covered services, and did not include the facility’s QIO name or toll-free contact number. The forms were signed by the residents, and the notices stated that Medicare-covered services would end after the listed date, but the required specific information was not entered on the forms. The facility also failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form CMS-10055, for one resident. Instead, an expired ABN, Form CMS-R-131, was signed by that resident even though the form had been retired from use by CMS before the signature date. During interview, the Administrator acknowledged that the resident should have received the correct form and stated there was no knowledge that staff attempted to correct the error or provide the appropriate form. The Administrator also acknowledged that the facility used a generic CMS-10123 template and that it should have been completed with the correct information before residents received it.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Staff Failed to Honor Resident’s Doorbell Preference
Penalty
Summary
The facility failed to ensure staff treated Resident #39 with dignity and respect by honoring the resident’s expressed preference for how staff announced themselves before entering the room. Resident #39 was admitted with diagnoses that included PTSD and frontal lobe and executive function deficit, and stated during interview that knocking on the door was a known trigger related to a history of trauma. The resident preferred that staff use the mounted doorbell instead of knocking when the door was shut for privacy. During observation, CNA #2 approached the resident’s room, knocked on the door, rang the mounted doorbell, and then opened the door while surveyors were interviewing the resident. The resident responded, “Not now, I’m busy,” and the CNA closed the door. A sign posted outside the room stated, “Pls. Ring the Bell, Don’t Knock! STOP,” and a doorbell was mounted next to the sign. Interviews with the ADON and CNA #9 confirmed staff were aware of the resident’s preference and that knocking was a known trigger, yet the observed practice did not follow the resident’s stated wishes.
Incomplete MDS Mood and Behavior Assessments
Penalty
Summary
The facility failed to complete all required sections of the Resident Assessment Instrument 3.0 Minimum Data Set for one resident, specifically Sections D (Mood) and E (Behavior), on both an annual comprehensive assessment and a quarterly assessment. Both assessments were documented as “Not assessed/no information,” even though the resident’s record contained information about mood concerns, refusal behaviors, and resident preferences that should have been reflected in the assessment. Resident #33 was admitted with diagnoses including a below-the-knee right leg amputation, heart failure, and hypothyroidism. The resident’s care plan, dated 3/9/26, identified potential depressed mood, impaired psychosocial well-being with little interest or pleasure in doing things, and impaired behavior related to refusal of cares to reduce skin breakdown risk, refusal of medications, refusal of weights, and refusal to get out of bed. The continuity of care document also included a goal for the resident to show a decrease in behavior episodes by the next review date. Surveyors observed the resident lying in bed in a hospital gown with flat facial expressions and limited engagement in conversation, and random observations showed the resident remained in bed, slept, and had minimal interactions with staff. Nursing notes documented refusal of vital signs and refusal of medications, with the provider notified of frequent medication refusal. During interviews, the MDS Coordinator stated the Social Worker completed Sections C, D, E, and Q, but she could not verify the accuracy of those sections, and the Social Worker stated she had not spoken with the resident and that the assessment dates may have been missed.
Incomplete Fall Prevention Care Planning
Penalty
Summary
The facility failed to develop, implement, and revise the comprehensive person-centered care plan for one resident with a history of falls. The resident was admitted with diagnoses including osteoarthritis, spinal stenosis, neurosarcoidosis, obstructive sleep apnea, macular degeneration, and restless leg syndrome. The resident’s care plan, initiated after a fall risk assessment, identified the resident as at risk for falls and fall-related injury due to generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision, and it included floor mats to the sides of the bed per orders. Record review showed the resident experienced three falls over a little more than one month, including one fall that resulted in shoulder pain and prompted diagnostic imaging. During interview, the resident stated that fall mats were not currently in place but would be liked. The ADON stated fall mats were identified in the care plan but could not locate fall mat orders in the EMR. A CNA stated staff were told by the DON or unit nurse when to place the mats and that staff first started using fall mats on the night of 6/10/26. The Administrator stated the facility was aware of the resident’s increased falls, had discussed the falls with the resident, and had recently ordered additional mats because the facility did not have enough. The resident’s record also showed use of multiple high-risk medications with fall-related side effects, including diazepam, escitalopram, gabapentin, and oxycodone. Review of the care plan showed no interventions addressing medication-related fall risk despite the resident’s falls and the presence of these medications. Facility policies stated that staff, with physician input, would implement a resident-centered fall prevention plan based on specific risk factors and modify care plans when goals and objectives were not achieved.
Failure to Ensure Staff Competency in Oxygen Safety and CPR Certification
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required competencies and certifications necessary to provide safe and appropriate care to residents. Specifically, six licensed nurses did not have current training in safe oxygen handling, as evidenced by personnel file reviews and interviews with the Human Resources Manager and Assistant Director of Nursing. Some of these nurses, including a traveler nurse, had not completed the required annual oxygen safety education until after the survey began. Observations confirmed the presence of compressed gas cylinders in a unit, and the ADON acknowledged that oxygen tanks were stored for resident use. Additionally, one certified nurse aide was found to be working without a valid CPR certificate, as confirmed by a review of personnel files and interviews with the HR Manager. The aide had been hired without completing the required CPR course, and there was no documentation of certification in the personnel file. Facility policy required all clinical staff providing direct patient care to have completed Basic Life Support (BLS) training, but this requirement was not met for the aide in question.
Deficient Food Storage, Labeling, and Temperature Documentation
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During observations in the main kitchen and unit kitchens, surveyors found multiple instances of expired food items not being discarded, including expired pork loin chops, smoked sausage, and instant oatmeal. Additionally, several food containers and bags were not labeled with expiration or best-by dates, and some containers held unidentified or improperly stored food items, such as brown bread placed on top of brown sugar. The Director of Nutrition Services (DNS) confirmed that some labeling practices were based on when items were placed in containers, and that dry goods were rotated every two weeks, but this did not ensure proper tracking or removal of expired items. In the walk-in cooler, a large bag of shredded mozzarella cheese was found without an expiration date, and the DNS was unable to provide this information. Unlabeled and undated containers of prepared food were also observed. Review of facility policies and position descriptions indicated that all stored food should be labeled and dated, and that staff are responsible for following health department guidelines for safe food handling and storage. However, these procedures were not consistently followed, as evidenced by the presence of expired and unlabeled food items in storage areas. The facility also failed to consistently record the temperatures of cooked potentially hazardous foods after cooking. While staff took temperatures of foods such as chicken after cooking, they did not document these temperatures, following a recent management directive to only record temperatures before food was transported to dining units. Temperature logs were incomplete or missing for several days, and some logs were found discarded in the garbage. Staff interviews confirmed that temperature documentation practices had changed and that there was confusion about where and when to record food temperatures. Facility policies required that potentially hazardous foods be cooked to appropriate temperatures and that these temperatures be documented, but these requirements were not met.
Failure to Reassess Pain After Opioid Administration
Penalty
Summary
The facility failed to ensure that residents who received opioid pain medications were re-evaluated for pain within 30 to 60 minutes following administration, as required by facility policy. Record reviews and interviews revealed that for 11 residents with various complex medical conditions—including cerebral palsy, hemiplegia, anxiety disorder, PTSD, neurogenic bladder, heart failure, depression, renal insufficiency, anemia, peripheral vascular disease, multiple sclerosis, dementia, schizophrenia, seizure disorder, cellulitis, chronic pain, arthritis, and paraplegia—there was no documentation of pain reassessment after opioid administration. The number of missed reassessments ranged from two to 62 instances per resident during the review period. The residents involved were prescribed and administered different opioid medications such as hydrocodone-acetaminophen, Norco, oxycodone, Tylenol-Codeine #3, Percocet, Endocet, and Dilaudid, all on an as-needed basis for pain management. Despite the administration of these medications, the clinical records and electronic medication administration records (eMAR) lacked evidence that nursing staff performed or documented pain reassessments within the specified timeframe after each dose. During an interview, the DON confirmed that the facility's policy required nurses to perform pain reassessments within 30 to 60 minutes after administering pain medications. The facility's written policy and referenced clinical guidelines also supported this requirement. However, the documentation review showed consistent noncompliance with this standard for the identified residents.
Failure to Assess and Document Safe Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including cellulitis, chronic pain, and arthritis was observed to have medications, including Tylenol and a controlled substance (oxycodone), left at the bedside without direct supervision or confirmation of ingestion by nursing staff. The resident reported that nurses routinely left medications in the room, allowing the resident to take them at their discretion. Observations confirmed that a licensed nurse handed the resident a cup containing multiple medications, including a controlled substance and other critical medications, and then exited the room without verifying that the medications were taken. Record review revealed there was no documented assessment for the resident's ability to safely self-administer medications, nor was there a physician's order authorizing self-administration. The resident's care plan did not address self-administration of medications, and facility policy required physician and interdisciplinary team determination of a resident's capacity to self-administer. The Director of Nursing confirmed that nurses should not leave medications with residents and should observe ingestion, but this was not followed in the case of this resident.
Failure to Follow Two-Person Assist Care Plan for Resident Transfers and Toileting
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required the use of ankle-foot orthoses (AFOs) and a two-person assist for transfers and toileting. The care plan specifically stated that two staff members were needed to assist with all transfers and toileting, using a Sara Steady device and providing extensive assistance. However, during observation, only one CNA was present and assisted the resident out of bed and to the toilet. The CNA used improper technique by pulling the resident by the wrists and allowing the resident to lower themselves onto the toilet without assistance. Further, the CNA left the resident unattended on the toilet while leaving the room to make the bed, despite the care plan's requirement for two-person assistance. Interviews with the Director of Nursing and another CNA confirmed that the resident was always to be assisted by two staff members for transfers and toileting. The facility's policy on safe patient movement and handling also emphasized the responsibility of staff to ensure patient safety during handling activities. These actions and inactions resulted in the care plan not being implemented as required for the resident's basic care needs.
Failure to Follow Two-Person Assist and Safe Transfer Protocols
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required two-person assistance for transfers and toileting. During an observed transfer, the CNA assisted the resident alone, using improper technique by pulling the resident by the wrists and allowing the resident to twist toward the bed's edge, with the resident's face briefly resting on the side rail. The resident, who wore ankle-foot orthoses (AFOs), was then assisted to stand using a Sara Steady device and transported to the bathroom, where the CNA again provided assistance without a second staff member present, contrary to the care plan instructions. Additionally, the internal doorway to the resident's room was obstructed by a Hoyer lift, which could have impeded access to the room. The CNA left the resident unattended on the toilet and exited the room, relying on the resident to use the call light when finished. Interviews with the Director of Nursing and other staff confirmed that the resident was always to be assisted by two people for transfers and toileting, and that doorways should remain clear for safety. Facility policy required staff to ensure safe patient handling and clear access during care activities.
Obstructed Room Entry and Unsecured Exit Door Create Safety Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two key areas: obstruction of a resident's room entryway and inadequate security of an exit door for residents at risk of elopement. In one instance, a Hoyer lift was left positioned directly behind the door of a resident's room, preventing the door from opening fully. This required individuals entering the room to step over the lift's legs and squeeze through a narrow space, despite there being other available areas in the room to store the lift. Staff interviews confirmed that doorways should remain clear to ensure timely assistance in emergencies, and facility policy emphasized the importance of safety during patient handling activities. Additionally, the facility did not ensure that all exit doors were secured to prevent elopement among residents identified as at risk for wandering. One resident with dementia and a history of elopement was observed moving freely throughout the facility, including approaching an exit door in the activity room kitchen that lacked both a wander guard alarm and a locking system. Staff confirmed that this door could be opened from the inside, providing direct access to the outside, and acknowledged that a resident with a wander guard could exit through it. The facility's policy on wandering and elopements did not include procedures for checking the security of all exit doors. These deficiencies were identified through record review, observation, and staff interviews, and involved residents with significant mobility and cognitive impairments. The lack of clear entryways and unsecured exits placed residents at risk for delayed emergency response and potential elopement, as evidenced by a prior incident where a resident exited the facility through a door with a locking failure.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 36% based on 9 errors out of 25 observed medication administration opportunities. During medication administration, a licensed nurse prepared and handed a resident a cup containing nine different medications, including Entresto, Eliquis, Allopurinol, Florastor, Metoprolol, Jardiance, Eplerenone, Torsemide, and Oxycodone. The nurse asked the resident to rate their pain level and then left the room without observing the resident ingest the medications. There was no documentation of a physician's order or a self-administration assessment authorizing the resident to self-administer or be left with medications. Interviews with facility staff revealed that the nurse believed the resident was independent and routinely took medications without supervision, but the Director of Nursing confirmed that nurses should not leave medications with residents and must observe ingestion. Review of the resident's medication record showed discrepancies in administration times, and facility policies required documentation of medication administration and an interdisciplinary team determination for self-administration. The facility was unable to provide evidence of compliance with these requirements for the resident involved.
CNA Provided Direct Care Without Required CPR Certification
Penalty
Summary
A Certified Nurse Aide (CNA) was found to be providing direct patient care without having a valid Cardiopulmonary Resuscitation (CPR) certificate, as required by facility policy. Review of the CNA's personnel file confirmed the absence of a CPR certificate since the date of hire. The Human Resources (HR) Manager acknowledged that the CNA had been enrolled in a CPR class but did not complete it, and that the Staff Development Office should have followed up on the completion. The HR Manager did not answer when asked if the CNA was allowed to work on the floor without the required certification. Facility policy mandates that all clinical staff providing direct patient care must have completed Basic Life Support (BLS) training, which includes CPR. The CNA in question was assigned to various units, including during the orientation period, and could be assigned to any unit as needed. Documentation of the CNA's specific unit assignments and corresponding unit census was requested but not provided by the end of the survey. This lapse in ensuring required certification was identified through personnel file review and staff interviews.
Pharmacy Services Deficiency
Penalty
Summary
The facility's pharmacy services failed to meet the obligations of its contract agreement, specifically in providing accurate pharmaceutical services and consultation. The contract stipulated that a pharmacist would be available for consultation and that medications would be supplied in unit dose sizes. However, an observation revealed a dispensing error in a bubble pack card of Warfarin for a resident, where one dose contained half a tablet instead of a whole tablet. This error was part of a pattern of issues identified by the Director of Nursing (DON), who reported multiple instances of incorrect medications being sent and difficulties in contacting the pharmacy for resolution. The DON provided an account of several attempts to contact the pharmacy about these issues, including wrong doses, discontinued medications being sent, and a lack of response from the pharmacy owner. Despite multiple messages and texts, the pharmacy owner failed to address the concerns or provide the necessary consultation. The facility's policy on accepting delivery of medications requires notifying the dispensing pharmacy and returning incorrect medications, but the ongoing issues indicate that these steps were not effectively resolving the problems.
Failure to Complete and Accurately Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility's pharmacy services failed to complete monthly drug regimen reviews (DRRs) by a licensed pharmacist for all residents from November 2023 to January 2024. This failure was due to the resignation of the pharmacist responsible for these reviews, and the pharmacy did not provide a replacement despite repeated requests from the facility. As a result, no DRRs were completed for any residents during this period, placing all residents at risk for unnecessary medications, medication errors, and adverse reactions. During the survey, a pharmacist from the hospital that acquired the facility completed the overdue DRRs for November and December 2023. For Resident #2, the DRRs contained an error indicating that Diazepam had been discontinued, although the medication order remained active. This error persisted in the DRRs from June to October 2023 and was not corrected in the December 2023 review by the new pharmacist. The pharmacist acknowledged that the medication should have been assessed as an active order. For Resident #35, who was on palliative care with severe cognitive impairment, the DRRs failed to identify inappropriate Morphine PRN orders. The orders had identical parameters for different doses, which lacked clear instructions on when each dose should be administered. Both the DON and ADON confirmed the inappropriateness of these orders, and the pharmacist admitted that this concern should have been documented in the DRR.
Failure to Submit PBJ Data for FY Quarter 4 2023
Penalty
Summary
The facility failed to ensure the mandatory submission of staffing information based on Payroll-Based Journal (PBJ) data for Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30, 2023). This failure potentially denied residents and/or their representatives, as well as the public, accurate staffing data when accessing the Nursing Home Compare website. The review of the facility's PBJ Staffing Data Report revealed that the facility did not submit the required data for the specified quarter, resulting in a one-star staffing rating. During an interview, the Accounting Officer Controller stated that the facility missed the deadline due to a change of ownership. The facility's policy on reporting direct care staffing information specifies that data must be submitted no less frequently than quarterly, with a submission deadline for Fiscal Quarter 4 being November 14.
Failure to Document Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of the risks and benefits of psychoactive medications. Specifically, for Resident #2, who was admitted with depressive disorder and restless leg syndrome, there was an active order for Diazepam that had been in place for over thirteen months without an informed consent form documented in the medical record. Both the pharmacist and the Director of Nursing confirmed the absence of the informed consent form for Diazepam during interviews. Similarly, Resident #35, who had diagnoses of dementia and anxiety and a resident representative through Power of Attorney, had active orders for Lorazepam without an informed consent form documented. The medication orders for Lorazepam were not officially discontinued, and the absence of the informed consent form was confirmed by both the pharmacist and the Director of Nursing. The facility's policy on Resident Rights, which guarantees the right to be informed of and participate in care planning and treatment, was not adhered to in these cases.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure the timely delivery of the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) to two Medicare Part A residents or their representatives. Specifically, the forms were delivered either on the day of or one day before the end of Medicare Part A coverage. This practice did not provide the residents or their families with a timely opportunity to appeal a denial of Medicare coverage. For Resident #44, the Medicare Part A Skilled Services Episode started on 10/9/23 and ended on 10/17/23, with the forms being signed on the last day of coverage. For Resident #66, the Medicare Part A Skilled Services Episode started on 8/17/23 and ended on 9/28/23, with the forms being signed one day before the end of coverage. During an interview, the Social Services Manager stated that the facility aimed to present the SNFABN and NOMNC forms at least two days before the end of Medicare Part A coverage, but this did not always occur. The facility's policy, dated 11/16/23, also indicated that the notice should be provided at least two days before the end of a Medicare-covered Part A stay. The failure to adhere to this policy denied the residents or their families a timely opportunity to make decisions regarding their care and financial responsibilities.
Failure to Implement Comprehensive Care Plan for Resident's Eye Condition
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident with a known eye condition. The resident, who was admitted in 2005 with diagnoses including traumatic brain injury, seizures, and 3rd nerve palsy of the left eye, was observed wearing glasses with tape over the right hinge. There was no documentation indicating that the resident's glasses needed repair or that an eye appointment had been scheduled during the year. The care plan identified the resident's visual function problem and included actions such as arranging for specialist referrals and checking the glasses for cleanliness and repair needs, but these actions were not followed through. Interviews with the Director of Nursing and the Resident Care Coordinator revealed that the facility was unaware of the need for glasses repair and could not determine the last time the resident had an eye exam. The facility's policies on care plan goals and comprehensive person-centered care plans emphasize the importance of measurable objectives and timetables to meet the resident's needs, but these were not implemented in this case. This failure had the potential to delay treatments to improve the resident's eyesight and affect their ability to maintain their highest practicable physical, mental, and psychological well-being.
Failure to Communicate New Skin Wound
Penalty
Summary
The facility failed to ensure that information about a new open area on the skin of Resident #34 was communicated to the nurse. Resident #34, who was admitted with diagnoses including spinal stenosis, weakness, and cellulitis, reported soreness in the sacral area and had a pain level of '8' out of 10. During an observation, CNAs discovered a red area with a small open wound on the resident's sacral area but did not report this to the nurse, leading to a lack of documentation and treatment initiation for the wound. Interviews with the licensed nurses revealed that they were unaware of the open area as it had not been mentioned in the morning report. Upon being informed, the nurse assessed the wound, cleaned it, and applied Calmoseptine. The wound was described as a fissure with bleeding, approximately 1/4 to 1/2 inch long. The resident's care plan indicated a potential for skin breakdown, but the CNAs did not report the new open area because they did not consider it a pressure ulcer. The Director of Nursing confirmed that the CNAs should have communicated the discovery of the open area to the nursing staff immediately. The facility's policies on the prevention of pressure injuries and skin assessment require CNAs to report any new or changed skin conditions to the charge nurse as quickly as possible. This failure to communicate placed the resident at risk for further skin breakdown and infection.
Failure to Enforce Smoking Policy and Designated Smoking Area
Penalty
Summary
The facility failed to ensure that the sole resident who smoked followed the care plan and smoking policy. Specifically, the resident was observed smoking outside in a wood-framed gazebo near the main entrance, which had a wood floor and lacked safety measures to prevent or address fire accidents. This was contrary to the care plan and facility policy, which stipulated that the resident should only smoke in the designated smoking shed equipped with safety measures such as a fire extinguisher, smoking apron, smoking blanket, and a metal trash can with a fire-resistant liner. Interviews with staff confirmed that the resident had scheduled smoking times and that smoking materials were stored in the nurse's medication room, but the resident was not adhering to the designated smoking area as required by the care plan and policy. Record reviews revealed that the resident had been evaluated as safe to smoke independently and was grandfathered in to continue smoking as they were admitted before the facility's smoking policy change in 2012. Despite these evaluations, the resident's non-compliance with the designated smoking area posed a potential fire hazard. The facility's policy clearly stated that residents admitted before the policy change were allowed to smoke only in designated areas, and staff were responsible for ensuring safe smoking practices. The failure to enforce this policy and ensure the resident smoked in the designated area introduced avoidable fire risks, potentially affecting all residents in the facility.
Failure to Report Significant Weight Loss to Physician
Penalty
Summary
The facility failed to ensure significant weight loss was reported to the physician for one resident. The resident, who was admitted with diagnoses including stroke and seizures, experienced a 16.59% weight loss from admission to early February. Despite the recorded weight loss, there were no interventions or communications documented for the significant weight loss observed on February 1st. The resident's weight history showed a consistent decline, and the care plan indicated the need for regular weight monitoring and nutritional assessments, which were not adequately followed. During observations and interviews, it was noted that the resident's family member was concerned about the weight loss and mentioned that the resident did not like the facility's food. The Registered Dietician acknowledged that the resident should have been reweighed, and the Director of Nursing confirmed that the physician should have been contacted regarding the weight loss. The facility's policies on nutrition and change in condition were not adhered to, leading to the deficiency in care for the resident's nutritional needs.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure the medication regimen for one resident was free from unnecessary medication. Specifically, the facility did not provide specific parameters for four different Morphine as-needed medication orders for a resident with severe cognitive impairment and on palliative care. Each Morphine order had identical parameters, which could lead to excessive or subtherapeutic medication administration and potential adverse reactions. Record review revealed that the resident had a BIMS score indicating severe cognitive impairment and was on palliative care for dementia and anxiety. Interviews with the DON, ADON, and a pharmacist confirmed that the Morphine orders were inappropriate as written, lacking clear parameters to indicate which dose to administer and when. The facility's policy required medication orders to include the clinical condition or symptoms for which the medication is prescribed, which was not followed in this case.
Failure to Provide Ordered Diets and Adequate Oversight
Penalty
Summary
The facility failed to ensure that two residents were provided with their ordered diets, leading to potential risks for poor health outcomes. During a resident council meeting, multiple residents expressed concerns about the food served, specifically mentioning excessive sugar and carbohydrates and the lack of diabetic diets. One resident noted that meal cards were sometimes inaccurate. Observations revealed that a Home Attendant (HA) was not following the correct menu extension sheet and served inappropriate food items to a resident on an 1800 calorie consistent carbohydrate (CCHO) diet. The Registered Dietitian (RD) and nursing staff did not provide adequate training or oversight to ensure the correct diets were served, leading to discrepancies in meal preparation and serving sizes. Additionally, the facility's policy on food and nutrition services was not followed, as the food trays were not inspected to ensure the correct meals were provided to each resident. Another resident with multiple sclerosis and a history of stroke, who had significant weight loss and trouble swallowing, was not provided with the ordered side of moisture with meals. Despite the physician's order for a side of moisture, the resident had to request it from the staff, indicating a lack of adherence to dietary orders. Interviews with the staff, including the RD, Licensed Nurses (LNs), and the Director of Nursing (DON), revealed a lack of clarity and responsibility regarding oversight and training for meal preparation and serving, contributing to the deficiencies observed in the residents' dietary care.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene according to accepted professional practices during wound care for one resident. Specifically, a licensed nurse did not perform hand hygiene or change gloves when moving from a dirty to clean task while treating a resident's sacral wound. The resident was admitted with sepsis due to a urinary tract infection and had a sacral wound/tear. The infection preventionist consultant confirmed that hand hygiene was required during wound care when moving from a contaminated to a clean task. The facility's hand hygiene policy also mandated hand washing or disinfection when moving from a contaminated body site to a clean body site during patient care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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