Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Jamestown Nursing And Rehab, Llc during CMS and state inspections, most recent first.
A resident with a history of morbid obesity, mood disorder, and chronic pain, who was admitted with a stage IV pressure ulcer, consistently refused care, including wound care and personal hygiene. The facility failed to implement and modify care interventions to meet the resident's needs, resulting in severe neglect and the presence of maggots in the wound. The lack of specific policies for wound care and urinary catheters, along with inadequate execution of the care plan, contributed to the resident's decline and eventual death.
A resident with a history of chronic pain and anxiety was admitted with a stage 4 pressure ulcer and refused care due to pain. The facility failed to offer effective interventions such as surgical interventions under anesthesia, intravenous pain medication, or anti-anxiety medication. The Medical Director was not involved, and the Administrator did not participate in resident communications. The lack of effective communication and coordination among staff contributed to the deficiency, resulting in Immediate Jeopardy.
A facility failed to provide adequate care to a resident with a stage IV pressure ulcer and mental health issues, leading to a deterioration in the resident's condition. Despite being cognitively intact, the resident frequently refused care, including wound treatment and repositioning, which were critical for their health. The facility lacked a specific policy for wound care and failed to implement effective interventions to address the resident's refusal of care, resulting in an Immediate Jeopardy situation.
A resident with a mood disorder and chronic pain exhibited significant behavioral changes, including daily care refusal and wound infestation, which were not properly assessed by the facility. The resident's care plan noted agitation and distress, but interventions were limited to activities and medication without counseling. Despite consistent care refusal and worsening condition, the facility did not identify these behaviors as significant, leading to a failure in addressing the resident's mental instability.
The facility failed to maintain adequate staffing levels, leading to deficiencies in resident care. Staffing shortages resulted in extended work hours for staff and unmet staffing guidelines, affecting the quality of care. Incidents included residents experiencing falls and injuries, with inadequate investigation and reporting. Additionally, medication administration was delayed due to insufficient staff, impacting resident care and safety.
The facility failed to maintain accurate records and timely administration of controlled substances for several residents. A resident with multiple diagnoses did not receive medications on time, and the SSDN confirmed late administration due to staffing issues without documenting provider notification. Two other residents also experienced medication delays, and discrepancies in controlled drug records were noted, indicating a failure in maintaining accurate records.
A facility failed to secure medications properly, as observed when an RN left a medication cart unlocked and unattended with a resident's antifungal medication exposed. The RN admitted the cart should be locked to prevent unauthorized access. The issue was reported to the Administrator for further action.
The facility failed to ensure proper hand hygiene during meal service in one dining room. A NA and a CNA did not sanitize their hands between serving meal trays to residents, and the CNA improperly opened a milk carton with their finger. Interviews confirmed that staff were aware of the importance of hand hygiene to prevent infection spread.
Expired food items were found in the storage and freezer areas of a facility, posing a potential risk of foodborne illness to 92 residents. Observations revealed expired vinegar, cocktail sauce, Italian seasoning, corn chips, fried chicken patties, pork fritters, and uncooked chicken thighs. The Dietary Manager acknowledged the oversight and removed the items.
A resident with severe cognitive impairment was not treated with dignity during meal service, as a CNA/Unit Manager stood over them while assisting with feeding. Facility policy requires staff to sit at eye level with residents to ensure they do not feel inferior, which was not followed in this instance.
A facility failed to maintain resident privacy when a surveyor observed unattended medication carts with open computer screens displaying sensitive information. A nurse admitted to routinely leaving screens open, assuming they would turn off automatically. The DON confirmed this practice violated HIPAA regulations.
The facility failed to maintain a safe environment by leaving hazardous items like ointments, wipes, and razor blades accessible to residents, including those with cognitive impairments. Additionally, a smoking assessment was not conducted for a resident identified as a smoker, contrary to facility policy. Staff interviews confirmed these items should be secured to prevent harm.
The facility failed to properly document the receipt of Ativan oral concentrate, a controlled narcotic, from the pharmacy. This oversight was discovered during a survey, where it was noted that the medication was not recorded in the narcotic book as required. The Director of Nursing confirmed that staff are expected to document such medications immediately upon receipt, but this procedure was not followed, affecting several residents with Ativan prescriptions.
The facility failed to properly store medications, leaving items like collagen wound dressing and iodine swabs unattended in a resident's room. A narcotic box containing Ativan was found unlocked, and medications were left in rooms of residents, increasing the risk of unauthorized access. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain a safe environment due to missing night light covers and inadequately maintained vinyl flooring, creating potential fall hazards. Staff interviews revealed that the process for reporting maintenance issues was not followed, as neither a CNA nor an LPN reported the flooring problems. The Maintenance Supervisor confirmed the unreported issues and identified them as trip hazards.
A resident with cognitive intactness and physical limitations due to arthritis and pneumonia was left in soiled linens after being incontinent of urine. Despite a care plan requiring staff to clean the perineal area after each episode, the resident reported calling for assistance without timely response. A CNA later confirmed the presence of dried urine on the sheets and acknowledged the need for regular rounding to prevent skin issues. The DON confirmed the expectation for staff to check on residents every two hours, but the policy provided did not apply to the incident.
The facility failed to ensure proper hand hygiene and glove changes during meal service, medication administration, and incontinence care for residents with cognitive impairments. A CNA/Unit Manager did not perform hand hygiene after disposing of an item from the floor before assisting a resident with eating. An RN did not wash hands during medication administration for two residents, and CNAs did not change gloves or wash hands during incontinence care, leading to potential cross-contamination and infection risks.
A facility failed to coordinate with the state office for a PASARR evaluation for a resident with schizophrenia and depressive disorders. The Admission Coordinator did not notify the state office upon the resident's admission, and the LTC MDS Coordinator was unaware of PASARR requirements, relying on personal notes instead of the RAI Manual. This resulted in a deficiency in the admission process and care planning.
A facility failed to include necessary parameters in oxygen orders for a resident with heart failure, chronic kidney disease, and type 2 diabetes mellitus. The resident was observed receiving oxygen at 1.5 liters via nasal cannula without specific parameters in the physician's order, despite the DON acknowledging the importance of such parameters. The facility's oxygen safety policy did not address this requirement.
Failure to Implement Care Interventions Leads to Resident's Decline
Penalty
Summary
The facility failed to implement and modify physical and psychosocial care interventions to meet a resident's activities of daily living needs, resulting in the deterioration of the resident's physical status and eventual death. The resident, who was admitted with a history of morbid obesity, mood disorder, chronic pain, and a stage IV pressure ulcer, consistently refused care, including wound care, repositioning, and personal hygiene. Despite being cognitively intact, the resident's refusal of care was not adequately addressed by the facility, leading to severe neglect. The facility's policies on resident rights and abuse prevention were not effectively implemented, as evidenced by the resident's continued refusal of care and the lack of appropriate interventions to address the resident's needs. The resident was placed on contact isolation due to wound myiasis, yet continued to refuse care, resulting in the presence of maggots in the wound. The facility's failure to exhaust all available remedies and provide necessary care and supervision contributed to the resident's decline. The facility lacked specific policies for wound care and urinary catheters, which further compounded the issue. The resident's care plan included interventions for chronic pain, pressure ulcers, and resistance to care, but these were not effectively executed. The facility's non-compliance with federal regulations on abuse, neglect, and exploitation led to an Immediate Jeopardy situation, highlighting significant deficiencies in the care provided to the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of new pressure ulcers and promote the healing of existing ones for a resident. The resident, who had a history of chronic pain, anxiety, and depression, was admitted with a stage 4 pressure ulcer and refused wound and incontinence care due to pain. Despite the resident's refusal, the facility did not offer effective interventions such as surgical interventions under anesthesia, intravenous pain medication, or anti-anxiety medication. The Medical Director was not involved in the care, and the Administrator did not participate in resident communications or bedside care plan meetings. The facility's policies and procedures were inadequate, as there was no specific policy for wound care, and the Medical Director's role was not clearly defined. The resident's care plan included interventions for pain management and self-care deficits, but these were not effectively implemented. The resident continued to refuse care, and the facility did not explore alternative interventions or consult with specialists to address the resident's pain and anxiety. The lack of effective communication and coordination among the facility's staff, including the Director of Nursing, Assistant Director of Nursing, and Charge Nurse, contributed to the deficiency. The facility's failure to address the resident's needs and refusal of care resulted in a situation of Immediate Jeopardy, as the non-compliance with care requirements was likely to cause serious harm to the resident. The facility did not adequately assess the resident's mental capacity or provide counseling or therapy sessions to address the resident's behavioral health needs. The lack of involvement from the Medical Director and Administrator, along with the absence of a comprehensive care plan, further exacerbated the situation, leading to the deficiency.
Failure to Provide Adequate Care for Resident with Pressure Ulcer and Mental Health Issues
Penalty
Summary
The facility failed to provide appropriate treatment and services to a newly admitted resident who refused activities of daily living (ADL) care, assistance, and wound care. The resident, who had a history of mental disorder and psychosocial adjustment difficulties, was not adequately assessed or treated for pressure wounds, leading to a deterioration in their mental and psychosocial health. The facility's non-compliance with participation requirements was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The resident was admitted with multiple diagnoses, including a stage IV pressure ulcer, morbid obesity, mood affective disorder, and chronic pain. Despite being cognitively intact, the resident frequently refused care, including wound treatment, turning, and repositioning, which were critical for their health. The facility lacked a specific policy for wound care and failed to implement effective interventions to address the resident's refusal of care and the associated risks. The facility's staff, including the Administrator, Director of Nursing, and other nursing staff, did not adequately address the resident's needs or provide necessary interventions to prevent further decline. The resident's care plan included various interventions, but these were not effectively implemented or adjusted in response to the resident's refusal of care. The facility's failure to provide adequate care and services resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's management and oversight of resident care.
Failure to Identify and Assess Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to accurately identify and assess a resident's verbal, physical, or other self-directed behavior symptoms as potential indicators of mental instability. The resident, admitted with diagnoses including unspecified mood disorder, chronic pain, and treatment refusal, exhibited a significant change in behavior that was not properly assessed. The Minimum Data Set (MDS) assessment did not identify any potential indicators for psychosis or behavioral symptoms, despite the resident's daily rejection of care behaviors and worsening behavior status. The resident's care plan, last modified in October 2024, noted agitation and distress due to pain, with interventions aimed at boosting self-esteem through activities. However, the resident refused various care interventions, including wound care, skin assessments, and personal hygiene, leading to a wound infestation issue. The Social Services Director (SSD) conducted interviews and reviewed notes but did not identify verbal behavior or other self-directed behaviors as significant, considering them the resident's baseline rather than new behaviors. Progress notes revealed a pattern of care refusal, with the resident consistently rejecting personal care, meals, and medical interventions. The resident's refusal led to a decline in their condition, including a stage IV open wound with maggot infestation. Despite being informed of the risks, the resident continued to refuse care, and the facility's attempts to involve Adult Protective Services and the ombudsman did not result in a resolution. The SSD acknowledged in hindsight that the behaviors should have been assessed as significant, but at the time, they did not trigger further assessment questions.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, as evidenced by not adhering to its own staffing guidelines for 74 of 87 shifts reviewed. The facility's assessment indicated specific staffing needs per shift, which were not met, leading to numerous instances of staff working extended hours and shifts being understaffed. This lack of adequate staffing was observed across various shifts, with significant shortages in RNs, LPNs, CNAs, and other support staff, impacting the quality of care provided to residents. The report highlights several incidents involving residents that underscore the consequences of insufficient staffing. For instance, one resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, resulting in injuries such as a head bruise and a cervical fracture. Another resident, also with cognitive impairments, suffered a fall from a wheelchair, leading to a cervical spine fracture and a forehead laceration. These incidents were not properly investigated or reported to the state agency, as they were not considered injuries of unknown origin by the facility. Additionally, the report details medication administration issues due to staffing shortages. Residents reported delays in receiving their medications, with some medications being administered hours after the scheduled time. This delay in medication administration was attributed to the lack of available staff, as nurses were required to cover multiple halls and manage a high number of residents. The Director of Nursing acknowledged the challenges in managing staff and the potential consequences of delayed medication administration, such as inadequate pain management and risks associated with blood pressure medications being given too close together.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to maintain accurate records and administration of controlled substances for several residents. Specifically, the facility did not maintain an account of all controlled substances on one of the medication carts and failed to keep accurate records for four residents across two medication carts. Additionally, the facility did not ensure that medications were administered within the specified time to maintain therapeutic status for three residents who reported not receiving their medications on time. Resident #26, who was admitted with multiple diagnoses including polyneuropathy, depression, and hypertension, did not receive their medications on time. The medication administration audit revealed that the resident's medications, including antihypertensive and opioid pain medications, were administered late. The resident was observed requesting pain medication and reported not receiving their morning medications. The Social Services Discharge Nurse (SSDN) confirmed the late administration due to staffing issues and did not document provider notification for the late administration. Similarly, Resident #27 and Resident #28 also experienced delays in receiving their medications. Resident #27, with diagnoses of hypothyroidism, major depressive disorder, and anxiety, received their medications several hours late, and the second doses were not adjusted accordingly. Resident #28, who had moderate cognitive impairment and was receiving opioid pain medication, also received their medications late. The Director of Nursing acknowledged the delays and the lack of provider notification, which was not documented in the progress notes. Additionally, discrepancies in the controlled drug sign-out book were noted, with missing pills and incorrect counts on medication cards, indicating a failure in maintaining accurate controlled substance records.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, as observed during a survey. A Registered Nurse (RN) was seen administering medication at the end of a hallway, leaving the medication cart unlocked and unattended. Additionally, a medication card for a resident was left on top of the cart, and the computer screen was left open. The RN acknowledged the oversight, stating that the cart should be locked to prevent unauthorized access. The specific incident involved a resident's antifungal medication, which was left in an un-popped bubble on the medication cart. This situation was brought to the attention of the facility's Administrator, who was informed of the potential danger by the surveyor. The Nurse Consultant indicated that they would address the issue with the RN involved.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during meal service in one of the four dining rooms observed. Specifically, Nursing Assistant (NA) #9 and Certified Nursing Assistant (CNA) #10 did not perform hand hygiene before or between serving meal trays to residents in the 100-hall dining room. NA #9 served meals to seven residents without sanitizing hands between trays, while CNA #10 served meals to two male residents without performing hand hygiene and opened a milk carton with their finger, which was not sanitized. Interviews with the staff involved, including NA #9 and CNA #10, revealed an acknowledgment of the importance of hand hygiene to prevent the spread of infections. Both staff members admitted that hands should have been sanitized between serving meal trays and that inserting a finger into the milk carton opening was inappropriate. The facility's Administrator also confirmed that hand hygiene should be performed between serving trays to prevent infection spread.
Expired Food Items Found in Storage and Freezer
Penalty
Summary
The facility failed to ensure that expired food items were promptly removed from stock, which could potentially lead to foodborne illness for the 92 residents receiving meals from the kitchen. During an observation of the dry goods storage area, several expired items were found, including three plastic gallon jugs of red vinegar, ten individual serving containers of cocktail sauce, an open package of Italian seasoning, and fourteen bags of corn chips. These items were all past their use-by dates and were still present in the storage area, indicating a lapse in the facility's food safety practices. The Dietary Manager acknowledged that expired items should not be in the storage room and proceeded to remove them. Further observations in the walk-in refrigerator and freezer revealed additional expired food items, including six fried chicken patties with visible frost, ten pork fritters in a torn bag, seven more fried chicken patties, and a solid mass of uncooked boneless chicken thighs, all labeled with past use-by dates. The Dietary Manager confirmed that these outdated items should not be in the freezer and should not be served to residents. This oversight in monitoring and removing expired food items from storage areas highlights a significant deficiency in the facility's food safety management.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident during meal service. The deficiency was identified through record review, observations, and interviews. A resident with severe cognitive impairment, as indicated by a BIMS score of 2, required limited assistance for eating due to a self-care performance deficit related to dementia. During meal service, a CNA/Unit Manager was observed standing over the resident while assisting with feeding, which is contrary to the facility's policy of sitting at eye level with residents to ensure they do not feel inferior. Interviews with the CNA/Unit Manager, the Assistant Director of Nursing/Infection Control Preventionist, and the Director of Nursing confirmed that staff are expected to sit at eye level with residents during meal service to maintain their dignity. The facility's policy emphasizes the importance of treating residents with respect and dignity, which includes sitting down next to them during meals. The failure to adhere to this policy resulted in a deficiency related to the resident's right to a dignified existence.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as required by their documented Resident Rights. On two separate occasions, a surveyor observed unattended medication carts in a public hallway with computer screens displaying sensitive resident information. Resident #46's Medication Administration Record (MAR) was visible, showing medications and personal health information, while Resident #392's screen displayed their picture and medication details, including Hydrocodone. These incidents occurred on the 600 Hall, where passersby could easily view the information. Registered Nurse (RN) #6, responsible for the medication carts, admitted to routinely leaving the screens open, believing they would automatically turn off. The Director of Nursing (DON) later confirmed that leaving computer screens open with resident information in public areas constitutes a Health Insurance Portability and Accountability Act (HIPAA) violation. The residents involved had varying cognitive abilities, with Resident #46 having severe cognitive impairment and Resident #392 being cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores.
Failure to Maintain a Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for its residents, as evidenced by several observations and interviews. Resident #49, who was severely cognitively impaired, had a full tube of moisture barrier ointment left unattended in their room on multiple occasions. Staff interviews revealed that such ointments should be stored in a locked treatment or wound care cart to prevent resident access. Similarly, Resident #56, also severely cognitively impaired, had germicidal disposable wipes left out in their bathroom, which staff confirmed should be stored securely to prevent potential harm. Additionally, the facility did not conduct a smoking assessment for Resident #295, who was identified as a smoker with intact cognition. Despite being observed smoking with supervision and wearing protective gear, there was no documented smoking assessment in the resident's electronic health record. This oversight contradicts the facility's smoking policy, which mandates assessments upon admission and at regular intervals to ensure safe smoking practices. The facility also failed to secure hazardous items such as handheld razor blades, spray oil-based lubricant, and disinfectant wipes, which were left unattended on a maintenance cart in a resident hallway. Interviews with staff, including the DON, confirmed that such items should not be left unattended due to the risk they pose to residents. Furthermore, aerosol anti-perspirant was observed left out in the rooms of residents with cognitive impairments, contrary to safety protocols that require such items to be locked away. The facility lacked hazard policies to guide staff in preventing these safety lapses.
Failure to Document Controlled Narcotics
Penalty
Summary
The facility failed to ensure proper documentation of controlled narcotics, specifically Ativan oral concentrate, when acquired from the pharmacy. This deficiency was identified during an observation and record review by a surveyor. The surveyor found that there was no documentation for Ativan oral concentrate in the narcotic book, which is required to prevent misappropriation and ensure a record of receipt and disposition. Registered Nurse (RN) #1 acknowledged that the nurse who accepted and signed for the delivery should have documented the medication in the controlled narcotic book. The Director of Nursing (DON) later provided documentation showing that Ativan was received on a specific date, but the initial lack of documentation posed a risk of medication misappropriation. The deficiency had the potential to affect five residents who had a physician's order for Ativan. The facility's policy titled 'Medication Storage in the Facility' did not address the documentation of the receipt, documentation, and disposition of medications from the pharmacy. The DON stated that nursing staff are expected to count the medication with the delivery driver, sign the manifest, and immediately document the medication in the logbook to prevent any discrepancies. However, this procedure was not followed, leading to the deficiency noted by the surveyor.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, leading to potential safety risks for residents. In the case of Resident #49, who was admitted with muscle wasting and dementia, surveyors observed unattended packages of ultra powder collagen wound dressing and iodine swabs in the resident's room over several days. Interviews with staff, including a CNA, LPN, and the Director of Nursing (DON), confirmed that these items should have been stored in a locked wound care cart to prevent resident access. Additionally, the facility did not secure a narcotic box in the medication room, which contained controlled substances such as Ativan. The box was found unlocked, and RN #1 acknowledged that it should have been secured behind at least two locks. The Maintenance Supervisor and Administrator were aware of the issue, and a letter dated prior to the survey indicated the lock was not functioning. The DON confirmed that no residents were approved for self-administration of medications, emphasizing the importance of securing controlled substances. Further deficiencies were noted with Residents #72 and #342. For Resident #72, medications including nasal spray and a corticosteroid inhaler were left unattended in the room, despite the resident being cognitively intact. LPN #2 admitted to leaving these items and acknowledged the risk of other residents accessing them. Similarly, an open, undated bottle of sodium chloride was found in Resident #342's room, which LPN #2 confirmed was against standard practice. The presence of wandering residents increased the risk of unauthorized access to these medications.
Deficiency in Maintaining Safe Environment Due to Unreported Flooring Issues
Penalty
Summary
The facility failed to maintain a safe and functional environment, as evidenced by missing night light covers for two residents and inadequately maintained vinyl flooring in the 300 hall secure unit. Observations revealed multiple instances of missing vinyl tiles at doorway thresholds, creating gaps in the floor. These gaps were found in several rooms, with measurements indicating significant areas of missing flooring, which could potentially cause falls. Interviews with staff, including a CNA and an LPN, indicated that the process for reporting maintenance issues involved placing a work order in a designated drop box. However, neither staff member had reported the flooring issues, despite acknowledging the potential hazard. The Maintenance Supervisor confirmed that the areas had not been reported and identified the missing flooring as a trip hazard. The lack of reporting and subsequent inaction contributed to the deficiency in maintaining a safe environment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and necessary services to maintain good hygiene for a resident who was unable to perform personal care independently. The resident, diagnosed with depressive disorders, bipolar disorder, and rheumatoid arthritis, was occasionally incontinent of urine and required assistance for toilet use. Despite having a care plan that instructed staff to clean the perineal area with each incontinence episode, the resident reported being left in soiled linens after calling for assistance earlier in the morning. The resident expressed an inability to change the linens due to physical limitations and a recent bout of pneumonia. During the survey, a CNA confirmed the presence of a brown spot on the resident's sheets, indicating dried urine, and acknowledged that staff should round every two hours to prevent skin breakdown and infection. The resident also reported having a rash in the perineal area. The Director of Nursing confirmed that staff are expected to check on residents every two hours and provide necessary personal care. However, the policy provided by the Administrator did not apply to the situation, and the CNA involved had been trained in incontinent care prior to the incident.
Inadequate Hand Hygiene and Glove Use in Care Activities
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during various care activities, leading to potential cross-contamination and infection risks. During meal service, a CNA/Unit Manager assisted a resident with severe cognitive impairment without performing hand hygiene after disposing of a container of ice cream from the floor. This oversight occurred despite the facility's policy emphasizing hand hygiene as a primary means to prevent infection spread. In another instance, an RN did not perform hand hygiene during medication administration for two residents, one with severe cognitive impairment and another who was cognitively intact. The RN handled medications and entered and exited residents' rooms without washing hands, contrary to the facility's standard precautions policy, which requires handwashing between resident contacts to prevent microorganism transfer. Additionally, during incontinence care for two residents with severe cognitive impairment, CNAs failed to perform hand hygiene or change gloves between dirty and clean tasks. This included handling soiled briefs and clean items without proper glove changes, increasing the risk of cross-contamination. The facility's policies and training programs emphasize the importance of hand hygiene and glove changes to prevent healthcare-associated infections, yet these practices were not followed during the observed care activities.
Failure to Complete PASARR Evaluation for Resident
Penalty
Summary
The facility failed to coordinate with the state-designated office to ensure a proper evaluation for a resident under the Preadmission Screening and Resident Review (PASARR) process. Resident #44, who was admitted with diagnoses including schizophrenia and recurrent depressive disorders, did not have the necessary PASARR evaluation completed. The facility received a letter from the State Designated Professional Associates indicating the need to contact them upon the resident's admission to receive the completed PASARR evaluation, but this step was not taken. The Admission Coordinator, responsible for ensuring PASARRs are completed, was unable to confirm whether the State Designated Professional Associate was notified of the resident's admission or if the PASARR evaluation was received. This lack of communication and follow-up was evident during interviews with the Admission Coordinator, who stated they would need to check with the Administrator for guidance. The failure to notify the state office and obtain the PASARR evaluation resulted in a deficiency in the facility's admission process. Additionally, the LTC MDS Coordinator was unaware of the PASARR requirements and did not utilize the RAI Manual for guidance on completing the necessary sections of the MDS. The LTC MDS Coordinator admitted to relying on personal notes rather than the RAI Manual, which led to a lack of awareness regarding the PASARR process. This oversight contributed to the deficiency, as the facility did not ensure that the resident's care plan addressed the services specified in the Level II PASARR determination and evaluation report.
Failure to Include Oxygen Parameters in Resident Care
Penalty
Summary
The facility failed to ensure that oxygen orders for a resident included necessary parameters to prevent respiratory complications. Resident #12, who has diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus, was observed receiving oxygen at 1.5 liters via nasal cannula on multiple occasions. The resident's electronic health record included a physician's order for oxygen to be administered as needed for oxygen saturation levels below 90. However, the order lacked specific parameters for oxygen administration. The Director of Nursing acknowledged that oxygen orders should include parameters to prevent excessive oxygen administration, which can be harmful. Despite this, the facility's policy on oxygen safety did not address the need for such parameters.
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What surveyors actually found near you
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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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Nursing homes near Rogers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampton Place Healthcare, Llc | 0.1 mi | ★★★★★ | 0 | 0 |
| Promenade Health And Rehabilitation | 1.3 mi | ★★★★★ | 5 | 0 |
| The Blossoms At Rogers Rehab & Nursing Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Innisfree Health And Rehab, Llc | 1.8 mi | ★★★★★ | 0 | 0 |
| Rogers Health And Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
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