Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Trinity Village Medical Center during CMS and state inspections, most recent first.
Care plans were not updated for two residents. One resident with a stroke history and severe cognitive impairment had side rails in use and assessments showing a desire for siderails/assist bars, but the care plan did not include them. Another resident with lung cancer reported a long smoking history, yet smoking was not included on the care plan even though staff said the resident had stated this on admission and the MDS coordinator forgot to add it.
Kitchen staff failed to keep food items properly covered or sealed and did not maintain the ice scoop holder in a sanitary condition. Staff also contaminated gloves by touching dirty surfaces and then handled ready-to-serve food and clean equipment without washing hands or changing gloves, including pasta, lettuce, beverage glasses, and blender parts. Facility policy required hand washing during food prep, when changing tasks, and after contamination.
Failure to complete smoking assessment for a resident who smoked. A resident admitted with lung cancer and cognitive intactness was not documented as a smoker on the care plan, and the EMR showed no smoking assessment had been completed. The resident stated they had smoked for 50 years and staff took them out for smoke breaks. The ADON confirmed the resident smoked and no assessment was done, while the DON and MDS Coordinator acknowledged the smoking status was missed in the care plan and assessment process.
EBP were not followed during PEG tube care for a resident with brain cancer, epilepsy, type II DM, NPO status, and severely impaired cognition. An LPN was observed exposing the PEG tube, checking placement, and administering water, medication, tube feeding, and flushes without a gown, while another LPN stood nearby without a gown or gloves. Interviews confirmed staff knew gown and glove use was required for PEG tube care, and the DON stated PPE should be in place for this type of device care.
A facility failed to protect residents' personal and medical information, violating HIPAA. LPNs left laptops open and unlocked on medication carts, displaying sensitive information. The Director of Nursing confirmed that nurses should secure computer screens to prevent unauthorized access, as per facility policy.
The facility failed to update care plans for two residents, one with a history of falls and another on antipsychotic medication. Despite a fall and increased fall risk for one resident, the care plan was not revised with new interventions. For the other resident, the care plan did not correctly document the antipsychotic medication or include monitoring for adverse reactions. The MDS Coordinator acknowledged these oversights.
The facility failed to properly assess and document the use of bed rails for two residents, leading to deficiencies in care. One resident, with a history of epilepsy, had side rails in use without a documented assessment or physician order, despite a care plan indicating they should remain down. Another resident, dependent on staff for mobility, was observed with bed rails up without a physician order or risk assessment. Staff interviews revealed inconsistencies in the initiation and monitoring of bed rail use.
The facility's medication error rate exceeded 5%, with errors involving two residents. One resident received an incorrect dose of a calcium channel blocker due to a pharmacy change, while another had an NSAID applied inconsistently with the prescribed order. Both residents were cognitively intact, and the errors were attributed to deviations from the facility's medication administration policy.
A facility failed to prevent significant medication errors for two residents. One resident received an incorrect dose of a calcium channel blocker for a month due to a pharmacy change, while another resident was given long-acting insulin past its 28-day usage period. The errors were confirmed by LPNs and acknowledged by the DON, indicating a lapse in adherence to medication administration policies.
The facility failed to secure medication carts, leaving them unlocked and unattended, which could allow unauthorized access to medications. Additionally, a resident's insulin was used beyond the recommended 28-day period, with staff unsure of the correct usage dates. The DON confirmed the need for secure storage and proper disposal protocols.
The facility failed to follow the planned menu for resident meals, resulting in residents receiving less food than required. Dietary staff served only one slice of pizza instead of two to residents on regular, mechanical soft, and chopped diets. Additionally, residents on pureed diets received only one scoop of pureed pizza instead of two. The staff did not adhere to menu guidelines, leading to incorrect portion sizes being served.
The facility failed to maintain proper food safety and sanitation standards, with uncovered and improperly stored food items, inadequate hand hygiene by dietary staff, and a poorly maintained kitchen environment. Observations included contaminated gloves used for food handling, stained ceiling tiles, and food items served at incorrect temperatures. The facility's policies on leftovers and handwashing were not followed.
A facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with multiple diagnoses, including Alzheimer's disease. Despite EBP signage and PPE availability, staff were observed providing care without PPE. The facility's policy requires PPE during high-contact activities, but some staff did not adhere to these precautions, leading to the deficiency.
A facility failed to implement a care-planned positioning device for a resident with a CVA to prevent further contracture. Despite the care plan's intervention to place a carrot in the resident's hand, observations revealed no device in place. An LPN mentioned Hospice's instruction to discontinue the carrot due to a past fracture, but no documentation was provided. The DON's review of the Hospice care plan showed no contracture addressal, and the facility's ROM policy lacked relevant information.
A facility failed to attempt gradual dose reductions for a resident on anti-anxiety medication without a physician's documented evaluation of risks versus benefits. The resident, cognitively intact, was on a PRN benzodiazepine without documentation of dose reduction attempts or justification. The DON acknowledged the deficiency, and the facility's policy on Drug Regimen Review was not adequately followed.
The facility failed to ensure pureed food items were blended to a smooth consistency for residents on pureed diets. A dietary staff member, DC #7, prepared pureed squash that remained runny and pureed pizza that contained pieces, indicating insufficient blending. The staff member acknowledged the issues during an interview.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, affecting 75 residents. Observations included dirty trash cans near food prep areas, ice buildup in the freezer, and improper storage of opened food items. The ice machine and scoop were unsanitary, and dietary staff did not follow hand hygiene protocols, handling food and equipment without washing hands. Hot food items were not kept at required temperatures, and the facility's hand washing policy was not adhered to.
The facility did not refund the remaining funds of two deceased residents to their families within the required 30 days. The Business Office confirmed a process failure, as the balances remained in the residents' accounts without charges. The facility's policy mandates timely conveyance of funds, which was not followed.
The facility failed to secure the G Hall shower room and beauty shop, leaving hazardous chemicals accessible to residents. Uncapped shampoo and personal cleanser were found in the shower room, while the beauty shop contained unlocked disinfectant spray and hairspray. Additionally, an open closet and unattended office housed harmful chemicals. Staff confirmed the lack of security measures and acknowledged the potential risk to residents.
Two residents with COPD and other respiratory conditions were not administered oxygen at the physician-ordered rate, receiving less than prescribed. This was confirmed by staff, including an LPN and the DON, who acknowledged the discrepancies and the responsibility of nurses to ensure correct oxygen settings.
A resident with severe cognitive impairment and atrial fibrillation was not properly monitored for adverse effects of anticoagulant medication, leading to unaddressed bruising. Staff, including LPNs and CNAs, were not adequately trained to access care plans or monitor high-risk medications, resulting in a failure to conduct necessary skin audits and document observations. The facility lacked documentation of training for aides on monitoring residents on high-risk medications.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for several residents, as required. A resident with severe cognitive impairment and significant medical diagnoses lacked documented MRRs for multiple months. Another resident, cognitively intact and on multiple medications, also had missing MRR documentation. A third resident, moderately cognitively impaired, had incomplete care planning and missing MRRs. The DON acknowledged the absence of these records, indicating a systemic issue in maintaining accurate medication review records.
The facility failed to securely store medications, with unlocked medication carts and medications left at the bedside for two residents. An oxygen concentrator propped open a door to a room with unsecured medications. Additionally, narcotic medications were not stored in permanently affixed compartments. The DON confirmed that no residents had self-administration rights and that families were instructed not to bring medications into the facility.
The facility failed to prepare and serve meals according to the planned menu for residents on pureed and mechanical soft diets. The dietary staff did not prepare or serve the required gravy and mashed potatoes, affecting 11 residents on pureed diets and 6 on mechanical soft diets. The staff admitted to rushing and overlooking these items, leading to insufficient servings and portions.
The facility failed to provide pureed food items with the required smooth consistency for residents on pureed diets. Observations revealed that pureed polish sausage, cornbread, and cabbage were not properly blended, resulting in lumpy, gritty, and runny textures. Staff interviews confirmed these deficiencies, affecting the dietary needs of 11 residents.
The facility did not follow the physician's orders for chopped meat diets for eight residents. During meal preparation, kielbasa was not pre-chopped, and three residents were served Polish sausage pieces that were too large, contrary to the prescribed diet. The Dietary Manager confirmed the non-compliance with the diet requirements, which were meant to ensure the food was soft, bite-sized, and easy to chew.
The facility did not ensure that the Binding Arbitration Agreement informed residents or their representatives that signing was not required for admission or continued care. The agreement lacked necessary wording, and a social worker confirmed families were verbally informed of their rights, but this was not documented.
The facility failed to implement a water management program to prevent Legionella growth, lacked enhanced barrier precautions for a resident with a PEG tube, and did not ensure proper hand hygiene and storage practices. Staff were not adequately trained on infection control measures, leading to potential cross-contamination and infection risks.
A resident with a hand contracture was not consistently provided with a prescribed palm guard, despite having a physician's order for its use during the day. Observations revealed the resident without the device on multiple occasions, and staff interviews indicated confusion over responsibility for its application. The facility's policy aimed to maintain or improve residents' abilities, yet the palm guard was not applied as required.
A resident with chronic kidney disease, dementia, and metabolic encephalopathy did not receive adequate dental care, as observed by surveyors. The resident required assistance with oral hygiene, but staff failed to provide necessary care, resulting in noticeable dental issues. The DON confirmed staff responsibilities for dental care, but the facility's policies were not followed, leading to this deficiency.
A resident with hemiplegia, hemiparesis, and dementia did not receive proper incontinent care, as observed by surveyors. Two CNAs failed to use the correct technique and adequate supplies, which was confirmed by the CNAs and the DON. This failure to adhere to the facility's perineal care policy posed a potential risk of infection.
Care Plans Missing Key Resident Needs
Penalty
Summary
The facility failed to ensure care plans were updated for two residents reviewed for care plan accuracy. Resident #11 was admitted with a diagnosis of stroke and had bed rail assessments dated 01/21/2025 and 05/15/2025 showing the resident expressed a desire to have siderails/assist bar for safety and/or comfort. The annual MDS with an ARD of 05/15/2025 showed a BIMS score of 5, indicating severe cognitive impairment, and did not indicate the resident used side rails. However, the care plan revised on 02/24/2025 did not include bed rails. During observation on 07/22/2025, Resident #11 was in bed with the bed in the lowest position and 1/4 sized rails up on both sides of the bed. Staff interviews indicated the resident used side rails as an enabler and for assistance with turning and feeling safer, and the DON and MDS Coordinator both stated side rails should have been on the care plan. Resident #12 was admitted with a diagnosis of cancer of the left lung and had an admission MDS with a BIMS score of 15, indicating cognitive intactness. The care plan revised on 07/22/2025 did not indicate the resident smoked. During interview, Resident #12 stated having smoked for 50 years. The ADON stated smoking was not on the care plan and the MDS Coordinator was responsible for completing it. The MDS Coordinator stated the resident reported smoking on admission and that she forgot to put smoking on the care plan. The facility smoking policy stated residents are informed of the smoking policy upon admission and that staff consult with the attending physician and DON to determine if safety restrictions are needed based on the Safe Smoking Evaluation.
Kitchen Food Storage and Hand Hygiene Lapses
Penalty
Summary
Food storage and sanitation practices were not maintained in the kitchen. During observation, loose coffee filters were seen on top of a bag on the tea maker, leaving them exposed to air and potential pests. In the walk-in freezer, an opened box of broccoli and an opened box of vegetable blend were not covered or sealed, and staff stated this could cause freezer burn. The ice scoop holder by the ice machine contained standing water with yellow flaky residue floating in it, and the ice scoop was resting in the holder; staff stated the holder was supposed to be cleaned daily and confirmed the ice was used for resident water pitchers and beverages served at meals. Dietary staff also failed to wash hands between dirty and clean tasks and before handling clean equipment during meal preparation. One staff member turned off the stove while wearing gloves, then used the same contaminated gloves to sprinkle shredded cheese on pasta for residents. Another staff member contaminated gloves by moving the blender motor, then handled a clean blade and attached it to the blender without removing gloves or washing hands. A dietary aide opened a bag of lettuce and used the same gloved hand to remove lettuce and place it into a salad pan. Another staff member turned off a sink faucet with gloved hands and then handled clean beverage glasses by their rims for lunch trays. The facility policy titled "Hand Washing" stated kitchen staff should wash hands when entering the kitchen, during food preparation, as often as necessary to remove soil or contamination, and when changing tasks or after activities that contaminate the hands.
Failure to Complete Smoking Assessment for Resident Who Smoked
Penalty
Summary
The facility failed to ensure a smoking assessment was completed for one resident who smoked tobacco products. The resident was admitted with diagnoses including lung cancer, had a Brief Interview for Mental Status score of 15 indicating cognitive intactness, and required supervision or touching assistance to walk 10 feet. The resident’s care plan, revised on 07/22/2025, addressed alteration in comfort related to lung cancer, depression, and generalized pain, but did not indicate that the resident smoked tobacco products. On 07/23/2025, the resident’s electronic medical record showed that a smoking assessment had not been completed. During interviews, the resident stated they had smoked for 50 years and were unsure whether they would smoke that day, and later stated staff took them out to smoke during smoke breaks. The ADON confirmed the resident smoked and that no smoking assessment had been completed, stating the nurses working the halls were responsible for completing smoking assessments. The DON stated she did not know the resident smoked when admitted and that staff failed to complete a smoking assessment once she learned of it. The MDS Coordinator stated the resident told her they smoked when admitted and verified she forgot to include smoking on the resident’s care plan. The facility’s smoking policy stated residents are informed of the smoking policy upon admission and that staff consult with the attending physician and DON to determine if safety restrictions are needed based on the Safe Smoking Evaluation.
EBP Not Followed During PEG Tube Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during high contact care for one resident with a PEG tube. Resident #41 had diagnoses including brain cancer, epilepsy, and type II diabetes mellitus, was NPO, received supplemental feedings four times a day, and had orders for water flushes before and after medications and feedings. The resident’s care plan indicated EBP related to the PEG tube, and the quarterly MDS showed severely impaired cognitive skills for daily decision making and that the resident had a feeding tube. On 07/23/2025, an LPN was observed pulling the resident’s gown up to expose the PEG tube and aspirating to check placement, then administering water, stomach medication in 6 ounces of water, tube feeding, and additional water without wearing a gown. A second LPN entered the room during the medication administration and stood beside the first LPN without wearing a gown or gloves. During interview, the first LPN stated she forgot to put the gown on and acknowledged that EBP required a gown and gloves for PEG tube care. The second LPN stated staff wear a gown and gloves when opening the PEG tube to prevent infections. The DON stated staff were expected to aspirate stomach contents to check placement and flush before and after medications, and that EBP should be in place, with PPE inside the room. The Administrator stated staff would have to wear gloves and use universal precautions, but was not sure staff would require a full dress out.
HIPAA Violation Due to Unsecured Laptops
Penalty
Summary
The facility failed to protect the personal and medical information of three residents, potentially violating the Health Insurance Portability and Accountability Act (HIPAA). The incidents involved Licensed Practical Nurses (LPNs) leaving laptops open and unlocked on medication carts in the hallway, displaying residents' personal and medical information such as names, dates of birth, code statuses, and physician's orders. These actions were observed by a surveyor during medication administration rounds. In one instance, an LPN left the laptop open while retrieving oxygen tubing, and in another, an LPN left the laptop open while getting over-the-counter medication. The Director of Nursing acknowledged that the nurses should lock or close the computer screens before walking away to prevent unauthorized access to residents' personal and medical information. The facility's policy on HIPAA Basics for Providers emphasizes the need to secure patient records containing Protected Health Information (PHI) to prevent access by unauthorized individuals. The failure to adhere to this policy resulted in the exposure of sensitive information for three residents, including one with moderately impaired cognition and another who was cognitively intact.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were revised to reflect the most recent care needs of two residents. Resident #24, who had a history of diabetes mellitus with foot ulcer, adjustment disorder with depressed mood, and myocardial infarction, experienced a fall on 12/13/2024. Despite a progress note by the nurse practitioner indicating increased fall frequency and a fall risk assessment confirming the resident's risk, the care plan was not updated with new interventions after the fall. The MDS Coordinator stated that care plans were updated as necessary and at least quarterly, but the care plan for Resident #24 did not reflect the necessary changes following the incident. Resident #45, diagnosed with depression, was prescribed an antipsychotic medication, which was not correctly documented in the care plan. The care plan failed to indicate that the medication was an antipsychotic and did not include monitoring for adverse reactions. The MDS Coordinator acknowledged the oversight, stating that the medication should have been documented under antipsychotic medications and that monitoring for adverse reactions should have been included. The facility's policy required care plan interventions to be derived from a thorough analysis of comprehensive assessment data, but this was not adhered to in these cases.
Deficiency in Bed Rail Use and Assessment
Penalty
Summary
The facility failed to ensure the proper use of bed rails for two residents, leading to deficiencies in their care. Resident #28, who had diagnoses of gastrostomy and a pressure ulcer, was observed with bed rails up despite no physician order for their use. The resident was totally dependent on staff for mobility and had not experienced falls, yet the care plan indicated the use of side rails for positioning. Staff interviews revealed a lack of clarity on when the bed rails were initiated and highlighted the absence of a risk versus benefit assessment or responsible party notification in the electronic health record. Similarly, Resident #1, diagnosed with symptomatic epilepsy, was found with side rails in use without a documented assessment or physician order. The care plan indicated a request for assist rails to remain down, yet staff interviews confirmed the use of side rails for turning and repositioning. The Assistant Director of Nursing acknowledged the need for care planning and documentation of side rail use, but no assessment was provided before the survey exit. These actions and inactions demonstrate a failure to adhere to facility policy and regulatory requirements for bed rail use.
Medication Error Rate Exceeds 5% Due to Incorrect Dosing and Application
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.14%. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident #44, who was cognitively intact with a BIMS score of 15, had a care plan addressing hypertension and hyperlipidemia. The resident was prescribed a calcium channel blocker at 90 mg daily, but was incorrectly administered only 30 mg by LPN #1 due to a pharmacy change. The Director of Nursing acknowledged the error, emphasizing the facility's responsibility to ensure accurate medication dosing. Another incident involved Resident #1, also cognitively intact with a BIMS score of 15, who had arthritis and was at risk for pain. The resident's care plan included the application of an NSAID to specific areas every four hours. However, LPN #6 applied the medication inconsistently with the prescribed order, applying it to the right leg, knee, and foot, and only to the left foot, based on the resident's preference rather than the prescribed method. The facility's policy required medications to be administered as prescribed, with verification of the right resident, medication, dose, time, and route, which was not adhered to in these cases.
Medication Errors in Dosage and Expiry in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first incident, a resident with a history of hypertension and hyperlipidemia was administered an incorrect dose of a calcium channel blocker medication for the entire month of January 2025. The resident was supposed to receive 90 mg of the medication daily, but was instead given only 30 mg due to a pharmacy change that resulted in the wrong dosage being supplied. This error was observed by a surveyor and confirmed by an LPN, who acknowledged that the resident was not receiving the prescribed amount of medication. The Director of Nursing admitted that the facility was responsible for ensuring the correct dosage was administered, despite the pharmacy change. In the second incident, another resident with type 2 diabetes mellitus was administered long-acting insulin past its recommended usage period. The insulin vial had conflicting dates, and the LPN responsible for administering the medication was unsure of the correct date the vial was accessed. The insulin was used beyond the 28-day period recommended by the FDA, as confirmed by the LPN after reviewing the calendar. The Director of Nursing stated that it was the nurses' responsibility to check the dates on insulin vials to ensure they were used within the appropriate timeframe. These incidents highlight the facility's failure to adhere to medication administration policies, resulting in significant medication errors for the residents involved.
Medication Storage and Insulin Disposal Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications and biologics, as observed during a survey. On multiple occasions, LPNs were seen leaving medication carts unlocked and unattended while administering medications to residents. This lapse in protocol was acknowledged by the LPNs, who admitted to not locking the carts, thereby potentially allowing unauthorized access to medications, including controlled substances. The Director of Nursing confirmed that medication carts should be locked when unattended to prevent unauthorized access. Additionally, the facility did not adhere to the proper disposal protocol for insulin. A vial of long-acting insulin for a resident with type 2 diabetes mellitus was found to have been in use beyond the recommended 28-day period. The LPN responsible for the insulin was uncertain about the correct date of first use and acknowledged that the insulin should have been disposed of and reordered after 28 days. The Director of Nursing confirmed that it is the nurses' responsibility to check the dates on insulin vials to ensure they are used within the appropriate timeframe.
Failure to Follow Menu Guidelines for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the lunch meal preparation, dietary staff did not follow the menu instructions for serving pizza to residents on different diets. Specifically, residents on regular, mechanical soft, and chopped diets were supposed to receive two slices of pizza each, but they were only given one slice. Additionally, residents on pureed diets were supposed to receive two #8 scoops of pureed pizza, but they were only given one scoop. The dietary staff, DC #10 and DC #9, did not adhere to the menu guidelines, resulting in residents receiving less food than required. The dietary staff's actions were based on instructions from the Dietary Manager, who directed them to serve only one slice of pizza per resident. Furthermore, DC #9 did not review the menu before serving the pureed pizza, leading to incorrect portion sizes being served. The staff also used incorrect scoop sizes for serving, with DC #9 using a #10 scoop instead of the required #8 scoop for pureed diets. These actions resulted in the residents not receiving the appropriate amount of food as per their dietary needs, as outlined in the facility's menu.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas of its kitchen and food storage facilities. Observations revealed that food items in the refrigerator, freezer, and storage room were not properly covered or sealed, including bags of pizza, apple pie, shredded cheese, and leftover spaghetti. Additionally, dented cans were found in the storage room, and an ice machine was discovered to have a black and brown slimy residue, indicating inadequate cleaning and maintenance. These conditions were not in accordance with professional standards for food storage and safety. Dietary staff were observed not adhering to proper hand hygiene and glove usage protocols. Staff members were seen handling food with contaminated gloves after touching dirty objects, such as trash can lids, without washing their hands. This included instances where staff used the same gloves to handle both dirty and clean items, such as cutting and serving food, which could lead to cross-contamination. The facility's policy on handwashing and glove usage was not followed, as staff did not wash their hands before handling food or clean equipment. The facility also failed to maintain the physical environment of the kitchen in a clean and sanitary condition. Observations included stained ceiling tiles, rust-stained vents, chipped walls, and loose baseboards. Additionally, hot food items were not maintained at the required temperature of 135 degrees Fahrenheit or above, with several food items being served at significantly lower temperatures. The facility's policy on the use of leftovers was also not adhered to, as leftover foods were used for pureed diets, contrary to the policy guidelines.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were consistently followed to prevent the spread of possible infection for a resident. The resident had multiple diagnoses, including gastrostomy, cerebral infarction, bipolar disorder, diabetes mellitus type 2, and Alzheimer's disease. Despite the presence of EBP signage on the resident's door and a stocked PPE cart, staff members were observed providing care without using the required PPE. Specifically, a Certified Nursing Assistant (CNA) was seen performing incontinent care without PPE, and a Hospice CNA bathed the resident without PPE, claiming it was her first time working with the resident and she was unaware of the EBP requirement. The facility's policy for EBP mandates the use of gloves and gowns during high-contact activities such as bathing, incontinent care, and when a resident has an indwelling device. The policy also requires signage and availability of PPE outside the resident's room. Interviews with other staff members confirmed they had been educated on EBP and understood its purpose and implementation. However, the lack of adherence to these precautions by some staff members led to the deficiency, as they failed to follow the established infection prevention and control measures.
Failure to Implement Positioning Device for Contracture Prevention
Penalty
Summary
The facility failed to ensure that a care-planned positioning device was in place to prevent further contracture for a resident who had a cerebrovascular accident (CVA) affecting their left non-dominant side. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15. The care plan, revised on January 4, 2023, included an intervention to place a carrot in the resident's left hand to prevent contracture. However, during multiple observations on January 13, 14, and 15, 2025, the surveyor noted that no positioning device was in place, and a hand roll was observed on the nightstand instead. The Licensed Practical Nurse (LPN) stated that Hospice had instructed them to discontinue the use of the carrot due to a past fracture of the resident's index finger, but no documentation was provided to support this order. The Director of Nursing (DON) later provided a care plan from Hospice, which did not address the contracture issue. Additionally, a review of the facility's Range of Motion Exercise policy, revised in October 2010, did not contain any pertinent information regarding the deficient practice.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted for a resident using anti-anxiety medication, specifically a benzodiazepine, without a physician's documented evaluation of the specific risks versus benefits of continuing the medication past 14 days. The resident, identified as cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, had an order for the medication to be administered every four hours as needed (PRN). However, there was no documentation in the resident's electronic medical record regarding attempts at dose reduction or any justification for not attempting a reduction. The Director of Nursing (DON) acknowledged the deficiency, indicating that the facility would have to accept the tag for the resident taking the anti-anxiety medication beyond the 14-day period without the necessary physician documentation to extend the medication. The facility's policy on Drug Regimen Review requires a monthly review and analysis of prescribed medication therapy, with findings and recommendations reported to relevant staff, but this process was not adequately followed in this case.
Inadequate Pureeing of Food for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets, as observed during a meal service. On January 13, 2025, at 11:22 AM, a dietary staff member, DC #7, attempted to puree boiled, seasoned squash but ended up with a runny consistency despite adding a cup of thickener. The pureed squash remained thin when served to residents. Later, at 11:51 AM, DC #7 attempted to puree pepperoni pizza by adding tomato sauce and tomato juice, but the mixture contained pieces of pizza and was not smooth. During an interview at 1:15 PM, DC #7 acknowledged that the pureed squash was thin and the pureed pizza contained pieces, indicating insufficient blending.
Sanitation and Hygiene Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and food storage areas, which had the potential to affect 75 residents who received meals from the kitchen. Observations revealed that trash cans with various stains were stored near food prep areas and food storage racks, and a kitchen sink had leaks with a bucket collecting dirty water. The walk-in freezer had ice buildup on the floor and shelves, and the chest freezer lacked a thermometer and was covered in ice. Opened food items in the refrigerator, freezer, and storage room were not covered, sealed, or dated, and expired foods were not promptly removed, increasing the risk of cross-contamination. The ice machine and ice scoop were not maintained in clean and sanitary conditions, with residues observed in areas where ice touches before dropping into the collector. The ice machine was used by CNAs for residents' water pitchers and in the kitchen for beverages served to residents. Dietary staff failed to practice good hand hygiene, as observed when a dietary staff member handled food and clean equipment without washing hands after touching dirty objects. Additionally, hot food items were not maintained at the required temperature on the steam table, with pureed chicken tender recorded at 116 degrees Fahrenheit. The facility's dietary staff did not adhere to proper hand hygiene protocols, as evidenced by multiple instances where staff members handled food and clean equipment without washing hands after touching dirty objects. This included using contaminated gloves to handle food and clean equipment, and failing to wash hands after engaging in activities that contaminated the hands. The facility's hand washing policy was not followed, which documented the need for hand washing during food preparation and after engaging in activities that contaminate the hands.
Failure to Refund Deceased Residents' Funds Timely
Penalty
Summary
The facility failed to ensure that refunds were issued to the responsible parties of two deceased residents within 30 days of their discharge. During an interview, the surveyor requested bank statements for the two residents, which showed that Resident #230 had a balance of $1,510.87 and Resident #231 had a balance of $407.00, with no charges deducted from these accounts. A review of the medical records revealed that both residents had passed away in the facility. The facility's Business Office confirmed a process failure in returning the funds to the deceased residents' families. The facility's policy requires that funds be conveyed within 30 days of a resident's death, but this was not adhered to in these cases.
Failure to Secure Hazardous Chemicals in Facility
Penalty
Summary
The facility failed to ensure that certain areas, specifically the G Hall shower room and the beauty shop, were secured to prevent residents from accessing potentially harmful chemicals. During observations, the surveyor noted that the shower room door was slightly open, with uncapped gallon jugs of shampoo and personal cleanser accessible. A CNA confirmed that residents could potentially enter the room and ingest these chemicals. Similarly, the beauty shop was found unlocked with various chemical products, such as disinfectant spray and uncapped hairspray, left on the counters and in unlocked cabinets. A Restorative Aide acknowledged that the beauty shop should be locked to prevent residents from accessing these products. Additionally, the surveyor observed an open closet and an unattended office containing Dakin's solution, oxy cleaner, wound cleanser, and antimicrobial soap. An LPN confirmed that the office door was never closed or locked, and acknowledged the presence of these chemicals, which could be harmful to residents. The Director of Nursing admitted that there was no existing policy or procedure for securing the shower rooms or beauty shop, highlighting a systemic issue in maintaining a safe environment for residents.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-ordered rate for two residents, leading to potential respiratory complications. Resident #60, diagnosed with chronic obstructive pulmonary disease (COPD), heart failure, and atrial fibrillation, was observed receiving 2 liters of oxygen instead of the prescribed 3 liters. This discrepancy was confirmed by both the resident and Licensed Practical Nurse (LPN) #3, who acknowledged the error and stated that the supervising Registered Nurse (RN) should check oxygen settings. The Director of Nursing (DON) also confirmed that nurses are responsible for ensuring oxygen is administered correctly and should check the settings daily. Similarly, Resident #25, with diagnoses of COPD with acute exacerbation and acute respiratory failure, was observed receiving 2.5 liters of oxygen instead of the prescribed 3 liters. This was confirmed by LPN #2, who acknowledged the discrepancy between the observed oxygen rate and the physician's order. The facility's policy on oxygen administration requires verification of physician orders and adherence to facility protocols, which was not followed in these instances.
Inadequate Monitoring of Resident on Anticoagulants
Penalty
Summary
The facility failed to ensure that staff were adequately trained to monitor residents on high-risk medications, specifically anticoagulants like Apixaban (Eliquis). This deficiency was identified through the case of a resident with severe cognitive impairment and a diagnosis of unspecified atrial fibrillation, who was taking both an antidepressant and an anticoagulant. The resident exhibited bruising on both arms, which was not documented or addressed by the staff, indicating a lack of proper monitoring and documentation. During the survey, it was revealed that skin audits, which are supposed to be conducted weekly to identify skin concerns such as bruising, were not completed for the resident. Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) were unaware of the bruising and had not been informed of the need to monitor for adverse effects of the anticoagulant medication. The facility's care plan for the resident included instructions to observe and report adverse reactions to anticoagulant therapy, but these were not effectively communicated or followed by the staff. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing (DON), revealed a lack of training and understanding of how to access and utilize care plans and electronic systems to monitor residents on high-risk medications. The DON admitted that there was no retraining to ensure competency in accessing care plans, and the facility could not provide documentation that aides were trained on monitoring residents taking high-risk medications. This lack of training and communication led to the oversight in monitoring the resident's condition and addressing the bruising observed by the surveyor.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for several residents, as required by their policies and procedures. Specifically, the facility could not provide documentation of completed MRRs for four residents, indicating a lapse in compliance with regulatory requirements. The Director of Nursing (DON) acknowledged the absence of these records during the surveyor's review. For Resident #41, the facility did not have MRR recommendations documented for several months, despite the resident having significant medical diagnoses, including respiratory failure, type II diabetes mellitus, and major depressive disorder. The resident's cognitive impairment was also noted, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The DON was unable to provide the missing MRR documentation for multiple months when requested by the surveyor. Similarly, for Residents #24 and #25, the facility failed to provide evidence of completed MRRs for various months. Resident #24, who was cognitively intact, was on multiple medications for anxiety, pain, and migraines, yet the facility lacked documentation of a gradual dose reduction. Resident #25, with moderate cognitive impairment, was on antidepressants, but the facility did not address insomnia in the care plan. The DON confirmed the absence of MRR documentation for these residents, highlighting a systemic issue in maintaining accurate and complete medication review records.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored securely, leading to several deficiencies. During an inspection, it was observed that an oxygen concentrator was used to prop open a door to the Employee Training/Staff Development room, where medications were left unsecured. The room contained unlocked medication carts with various medications, including wound and burn gel, Hibiclens, and prescription medications like Lageviro. The Assistant Director of Nursing confirmed that medications not stored behind a locked door could be taken by residents and should be secured. Additionally, the facility did not prevent medications from being left at the bedside for two residents. Resident #13 had a bottle of TUMs on the bedside table, which was brought in by family without a doctor's order for self-administration. Similarly, Resident #56 had a bottle of Tineacide on the chest of drawers, which was not authorized for self-administration. Both residents were cognitively intact, but the presence of these medications posed a risk as other residents could access them. The Director of Nursing confirmed that no residents had self-administration rights and that families were instructed not to bring medications into the facility. Furthermore, the facility failed to ensure that narcotic medications were stored in a permanently affixed compartment. Inspections of the medication rooms revealed that the locked boxes containing refrigerated controlled medications were not permanently affixed, which was confirmed by multiple nursing staff. The Director of Nursing acknowledged that the locked boxes were not affixed to anything, contrary to the facility's policy that required controlled medications to be stored in separately locked, permanently affixed compartments.
Failure to Adhere to Planned Menu for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, which affected residents on pureed and mechanical soft diets. During the noon meal preparation, the dietary staff did not prepare or serve the required gravy and mashed potatoes to residents on these diets. Specifically, the dietary staff pureed cornbread and cabbage but did not prepare enough servings to meet the needs of all residents requiring pureed diets. Additionally, the dietary staff prepared apple cobbler but discarded extra servings instead of ensuring all residents received the correct portion size. The dietary staff admitted to rushing and overlooking the preparation and serving of mashed potatoes and gravy, which were part of the planned menu. This oversight affected 11 residents on pureed diets and 6 residents on mechanical soft diets. The dietary staff acknowledged the need for larger portions for some residents but failed to prepare the necessary extra servings. This deficiency was observed and documented by the surveyor, highlighting the facility's failure to adhere to the planned menu and meet the nutritional needs of its residents.
Inadequate Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During an observation, it was noted that the dietary staff member placed servings of polish sausage, cornbread, and seasoned cabbage into a blender with additional ingredients, but the resulting mixtures did not achieve the required smooth consistency. The pureed polish sausage was lumpy with visible pieces of meat, the cornbread was gritty, and the cabbage was runny and not properly formed. Interviews with staff members, including Certified Nursing Assistants and the Dietary Manager, confirmed the inadequacy of the pureed food consistency. They described the pureed meat as chunky, the cornbread as too thick, and the vegetables as too thin. These observations and staff confirmations indicate that the facility did not meet the dietary needs of residents on pureed diets, potentially affecting 11 residents as documented by the Dietary Supervisor.
Failure to Follow Chopped Meat Diet Orders
Penalty
Summary
The facility failed to adhere to the physician's plan of care for eight residents who required chopped meat diets. During a kitchen observation, it was noted that kielbasa was not pre-chopped as required for these residents. Additionally, three residents were served regular Polish sausage with skin intact, with pieces ranging from 1 to 1.5 inches, which did not meet the prescribed chopped meat diet requirements. The Dietary Manager and a dietary staff member confirmed that the meat pieces were too large. A document provided by the Dietary Manager outlined the requirements for chopped diets, indicating that the food should be soft, bite-sized, and easy to chew, as advised by speech therapy.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreement clearly stated that residents or their representatives were not required to sign the agreement as a condition of admission or to continue receiving care. On July 15, 2024, the Director of Nursing provided a copy of the arbitration agreement used at admission, which lacked the necessary wording to inform residents or their representatives of their right to refuse signing without affecting their admission or care. A review of the arbitration agreements for several residents revealed that the signed contracts did not include this critical statement. Additionally, a social worker confirmed that families were verbally informed they could sign the agreement but were not obligated to do so for admission, yet this was not reflected in the written document.
Infection Control Deficiencies in Water Management and Resident Care
Penalty
Summary
The facility failed to implement a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens. During the survey, the Maintenance Director admitted that there was no water management plan in place, and the Director of Nursing confirmed this after consulting with the Administrator. The facility relied on city water and did not conduct any flushing of water pipes or other preventive measures. The provided documentation lacked any assessment or control measures for Legionella, indicating a significant oversight in infection prevention. The facility also failed to implement enhanced barrier precautions for a resident with a PEG tube and an open wound. Staff members, including CNAs and an LPN, were not adequately educated on enhanced barrier precautions, and there was no signage indicating such precautions for the resident. The Infection Preventionist acknowledged that residents with indwelling medical devices should be on enhanced barrier precautions, yet this was not practiced, highlighting a gap in staff training and infection control measures. Additionally, the facility did not ensure proper hand hygiene and storage practices to prevent cross-contamination and infection. Staff were observed not performing hand hygiene before assisting residents with meals, and dentures were improperly stored without a lid or cleaner. Furthermore, clean linens were not stored properly, with carts left uncovered, exposing them to potential contamination. These lapses in basic infection control practices further demonstrate the facility's failure to maintain a safe and hygienic environment for its residents.
Inconsistent Use of Hand Device for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a hand device, specifically a right palm guard, was consistently used for a resident with a hand contracture. The resident, who had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, was observed multiple times without the palm guard in place. Despite having a physician's order for the palm guard to be worn during the day, the resident was seen without it on several occasions, and the resident expressed an inability to open the contracted hand without assistance. Interviews with staff revealed a lack of clarity regarding responsibility for ensuring the palm guard was applied. An LPN stated that aides were responsible for applying the device, while nurses were to follow up. The Director of Nursing confirmed that nurses were responsible for ensuring aides applied the splints. The facility's policy on Activities of Daily Living (ADL) emphasized providing care to maintain or improve residents' abilities, yet the failure to apply the palm guard as ordered was evident, potentially leading to further contracture.
Failure to Provide Adequate Dental Care
Penalty
Summary
The facility failed to ensure proper dental care for a resident, identified as Resident #71, who had diagnoses of chronic kidney disease, dementia, and metabolic encephalopathy. The resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMs) score suggesting cognitive intactness and required set-up assistance for oral care. During observations, the resident was seen with protruding upper teeth, noticeable yellowing, and a thick white substance on the bottom teeth. Interviews with the resident and a Certified Nursing Assistant (CNA) confirmed the resident required assistance with oral hygiene, including brushing teeth and cleaning dentures. The Director of Nursing (DON) confirmed that all staff, including CNAs, are responsible for ensuring residents receive proper dental care, with nursing ultimately responsible for dependent residents. The facility's policy on denture care and activities of daily living (ADLs) emphasized the need for assistance with oral care for residents unable to perform these tasks independently. Despite these policies, the facility did not provide the necessary assistance to maintain the resident's oral hygiene, leading to the observed deficiency.
Improper Incontinent Care Technique
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident, leading to a potential risk of infection. The resident, who had hemiplegia, hemiparesis, and dementia, was always incontinent of bowel and bladder. During an observation, it was noted that two CNAs did not use the proper technique or sufficient supplies while providing incontinence care to the resident. This was confirmed by both CNAs during interviews, acknowledging that the care provided did not adhere to the required standards. The Director of Nursing also confirmed that the proper technique was not used during the provision of perineal care to the resident. The facility's policy on perineal care emphasizes the importance of cleanliness, comfort, infection prevention, and skin condition observation, which were not followed in this instance. The deficiency was identified through observation, interviews, and record reviews, highlighting a lapse in maintaining hygiene standards for incontinent care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pine Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Of Pine Bluff | 0.3 mi | ★★★★★ | 0 | 0 |
| Pine Bluff Transitional Care | 0.6 mi | ★★★★★ | 6 | 0 |
| The Blossoms At White Hall Rehab & Nursing Center | 9.1 mi | ★★★★★ | 0 | 0 |
| The Green House Cottages Of Southern Hills | 17.1 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Star City Rehab & Nursing Center | 18.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.