Below 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 Ararat Nursing Facility during CMS and state inspections, most recent first.
Failure to complete post-fall assessment and monitoring after an unwitnessed fall: A resident with dementia, Alzheimer’s disease, repeated falls, and impaired cognition was found on her knees beside her roommate’s bed by CNA staff. The LPN/RN assisted her back to bed, but staff did not complete a COC assessment, 72-hour monitoring, neuro checks, or document fall-prevention interventions, and the licensed nurse did not investigate how the resident got out of bed.
Failure to Develop and Implement Person-Centered Care Plans: The facility did not fully develop or follow care plans for several residents. A resident with HTN received metoprolol even when SBP was below the ordered hold parameter, another resident did not have a care plan for hydrogel use, a resident on EBP was bathed without the required gown, and a resident with a right heel DTI did not have a care plan developed after the wound was reclassified. The records also showed impaired cognition or lack of decision-making capacity for the affected residents.
A resident with DM and dementia had orders for blood sugar checks and physician notification for readings over 250 mg/dl, but elevated results were not documented as reported to the physician. Another resident with CHF, CKD stage 4, and pulmonary hypertension had a 1,000 ml/day fluid restriction, yet the MAR showed repeated daily intakes above the ordered limit. Staff interviews confirmed the orders were not followed as documented.
The facility failed to provide and document ordered wound care for three residents with pressure injuries. One resident with dementia and paralysis had blank TAR entries for multiple wound treatments and an incomplete skin check that omitted known pressure injuries. Another resident with dementia and weakness received zinc oxide instead of ordered hydrogel for a stage 2 buttocks wound, and weekly skin checks were incomplete or missing. A third resident with multiple pressure injuries also had blank TAR entries for several ordered treatments. Staff stated blank TAR entries meant treatment was not provided, and the RNM confirmed the incomplete assessments and missed treatments.
A resident with generalized muscle weakness and polyarthritis had orders for Tylenol for mild pain, then hydrocodone-acetaminophen and morphine for severe pain. The MAR showed nurses gave morphine and hydrocodone at pain levels below the ordered severe-pain range, including when the resident had no pain. RN and RMN interviews confirmed the medications were not administered according to the physician orders or the resident’s documented pain level.
Failure to Follow BP Hold Parameters for Medications: An LPN administered antihypertensive and hypotension-related medications to three residents without following ordered BP hold parameters. One resident received metoprolol when SBP was below the ordered threshold, another received amlodipine and metoprolol when BP was 97/54, and a third received midodrine when SBP was above the hold limit. RN review confirmed the orders should have been followed, and the facility policy required vital signs to be checked and recorded before giving medications tied to those values.
Multidose treatment medications on a treatment cart were found without open dates for four residents, including nystatin-triamcinolone cream, Silver Silvadene cream, Santyl ointment, and Dakins solution. An RN and the RMN stated open dates should be written on multidose meds when opened so they can be discarded on time, and facility policy required the date to be placed on the container.
Inaccurate wound documentation affected three residents. One resident with dementia had excoriation recorded on the wrong buttocks site, another resident with a right heel pressure ulcer had weekly skin checks and the TAR documenting the wrong heel and wrong wound stage after a WCP identified a DTI, and a third resident with DM had a weekly skin check that did not match the documented right shin blisters and change in condition. Staff stated the records were inaccurate and did not reflect the observed wounds.
Infection control was not followed for two residents. A resident’s oxygen tubing was observed touching the floor, an RN/TN applied dressing care to a stage 2 pressure injury without gloves while the resident was on EBP, and a CNA provided bed bath care to another resident on EBP without wearing a gown. The residents had conditions including respiratory failure, dementia, a urinary catheter, and a pressure injury, and the IP confirmed the missed PPE and tubing issue were inconsistent with infection control practices.
A resident with osteoporosis, dementia, and hypertension experienced hip pain and received PRN Tylenol, but the RN documented the assessment the next day without identifying it as a late entry. Social services recorded the resident’s hospital transfer on the wrong date, and an LVN failed to document a given dose of Tylenol on the MAR. These actions resulted in incomplete and inaccurate medical records that did not comply with facility policies for timely, accurate documentation of assessments, transfers, and medication administration.
A resident with multiple medical conditions, including atherosclerotic heart disease, GERD, and osteoporosis, had their electronic medical record left open and unattended on a medication cart computer at a nurse station, displaying their name, photo, and medication list while staff and others passed by. An LVN admitted not locking the computer before leaving to assist another resident, and the DON acknowledged that this allowed potential unauthorized access, contrary to facility policy requiring protected health information to remain confidential and inaccessible to unauthorized persons.
A resident with osteoporosis, dementia, and HTN experienced a change in condition with new right hip pain, for which Tylenol was given and the MD ordered a right hip x-ray. Despite this, nursing staff did not initiate or update a comprehensive, person-centered care plan to include measurable objectives and interventions for the new hip pain. During interviews, an RN and the DON confirmed that no care plan addressing the hip pain was created, even though facility policies required the care plan to be updated after a change in condition to reflect the resident’s current status and needed services.
A resident with osteoporosis, dementia, and hypertension reported right hip pain and received Tylenol, and the MD was notified with an order for a right hip x-ray. Facility policy required licensed nurses to assess and document the resident’s status every shift for 72 hours after a change of condition, including detailed nursing notes. However, there was no documentation of monitoring on one overnight shift, and an RN did not document a full assessment of the resident’s right lower extremity, including pain and appearance, meaning required COC monitoring and assessment were not carried out or recorded as required.
A resident with CHF, prior vertebral fracture, muscle weakness, and documented high fall risk experienced multiple falls after the facility failed to implement and maintain appropriate fall-prevention measures. Despite a high fall-risk score and a prior fall, the resident was not promptly placed in the facility’s Falling Star Program, and the care plan was not revised to reflect post-fall interventions. The care plan later indicated that two staff should assist with bed mobility, but a CNA provided morning care and bed mobility alone, did not verify the resident’s ability to hold herself on the bed edge, and turned the resident to her side at the edge of the bed while attempting to place a bed protector. With no floor mats in place, the resident slipped from the CNA’s hold, fell to the floor, and sustained a laceration and skin tears requiring sutures. After this fall, the facility did not complete a post-fall risk assessment, and observations showed that care-planned safety interventions such as bilateral floor mats were not consistently in place.
A resident with chronic diastolic CHF, musculoskeletal injuries, and muscle weakness, who had intact cognition but required extensive assistance with ADLs and bed mobility, had multiple Fall Risk Assessments in which the section assessing systolic BP variation from lying to standing was left uncompleted. During an interview and record review, an RN confirmed that these assessments were incomplete and did not correctly describe the resident’s condition, potentially resulting in a lower fall risk score and affecting care. This documentation did not meet the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate charting that fully describes the resident’s condition and the nursing response.
A resident with dementia, Alzheimer’s disease, severe cognitive impairment, high fall risk, and dependence on staff for ADLs was found in bed with both wrists firmly tied together with a scarf, unable to move or release her hands. An LVN had earlier asked a CNA assigned to the resident to check on the resident after increased chanting and yelling; the CNA reported the resident was fine, but shortly afterward the LVN entered the room and discovered the resident’s blanket on the floor and the resident’s hands bound. Facility policies required a licensed nurse assessment, IDT involvement, and consent before any restraint use, prohibited restraints for discipline or staff convenience, and mandated suspension of staff accused of abuse during investigation. The DON and Administrator identified the scarf as an unauthorized physical restraint and physical abuse, and the Administrator believed the CNA tied the resident’s hands for convenience, yet the CNA remained on duty and continued caring for the resident until the end of the shift.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found during a night shift with both wrists tightly bound together in bed with a scarf after exhibiting increased restlessness and chanting. An LVN discovered and photographed the binding and then removed it, while the assigned CNA denied tying the resident’s hands. Facility leadership later characterized the event as alleged physical abuse and a change of condition that should have triggered a formal change-of-condition (COC) process, including MD and family notification and 72-hour monitoring. However, no COC was initiated for the date of the incident, and there was no documentation that the MD or resident representative were notified at that time, contrary to facility policy requiring prompt notification and documentation of significant changes in condition.
A resident with dementia, Alzheimer's disease, high fall risk, and dependence on staff for most ADLs was found during a night shift by an LVN lying in bed with both wrists firmly bound together in front with a scarf tied multiple times, meeting the facility’s definition of a physical restraint and not supported by any assessment, MD order, or care plan. Earlier in the shift, the resident had been loudly vocalizing in another language, and the assigned CNA, who spoke the same language, told the LVN that the resident always behaved that way and later reported the resident was okay after checking the room. When the LVN entered the room again, she discovered the bound wrists, photographed them, untied the scarf, and assessed the resident with no visible injury, then later observed the CNA asleep at the nurses’ station; the CNA completed the shift and continued caring for the resident. Despite facility policy requiring immediate reporting of suspected abuse and notification to the Administrator and external agencies within two hours, the LVN did not notify the DON and RMN until several hours after discovering the bound wrists, resulting in a delay in reporting the suspected abuse.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence, who lacked decision-making capacity, was found in bed with both wrists firmly bound together in front using a scarf after becoming increasingly restless and vocal during a night shift. An LVN, unable to understand the resident’s language, relied on the assigned CNA—who spoke the same language—to assess the situation; the CNA reported the resident was fine. When the LVN later entered the room, she discovered the resident’s hands tightly tied, photographed the bindings, and then removed the scarf. The CNA, who had been assigned to the resident, remained on duty for the rest of the shift and continued caring for the resident and others, contrary to the facility’s abuse policy that requires suspension of staff accused of abuse pending investigation.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found in bed with her wrists tied together with a scarf after being reported as restless and yelling. An LVN discovered the restraint after re-entering the room when the resident continued yelling, untied the scarf, and noted no visible injury. Review of records showed there was no comprehensive, person-centered care plan addressing restraint use for this resident, despite her cognitive impairment and dependence on staff, and the facility’s policy required care plan updates following significant changes in condition.
A resident with dementia, Alzheimer’s disease, high fall risk, and significant ADL dependence was found by an LVN in bed with both wrists tied together with a scarf after being reported as restless and yelling. The CNA assigned to the resident had earlier stated the resident was fine, but no Change of Condition (COC) evaluation was initiated at the time of the alleged physical abuse. Facility leadership, including the DON and RMN, later confirmed that alleged abuse constitutes a change of condition requiring a COC, MD and family notification, and 72‑hour monitoring per facility policy. Documentation showed that the COC and 72‑hour monitoring were not started until days later and focused on restlessness and possible infection rather than the abuse incident, and there was no documentation that the MD or family were notified on the date of the event.
A resident with multiple risk factors for falls experienced an unwitnessed fall, and the facility failed to ensure that fall prevention interventions and documentation were complete and accurate. Key forms, including the SBAR and Incident Note, lacked essential details about the incident, and the IDT documentation was inconsistent, potentially impacting staff awareness and care planning.
A resident with multiple medical conditions and moderate cognitive impairment was allegedly subjected to verbal and physical abuse by a staff member, witnessed by another staff member. The incident was not reported to the DON or authorities within the required two-hour timeframe, resulting in a 24-day delay before the allegation was reported to the State Survey Agency, contrary to facility policy.
Three staff members, including an LVN, an RN, and a CNA, were found to have no documented criminal background checks in their employee files. Leadership interviews confirmed that background checks were not conducted for these employees, despite current policy requiring such screening prior to employment.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Residents were not provided with sufficient information to understand their health status, care, and treatments, resulting in a lack of informed decision-making.
Three residents received psychotropic medications without adequate monitoring or documentation of specific target behaviors, duration of therapy, or adverse effects. Orders for medications such as clonazepam, Ativan, and Remeron lacked clear behavioral indications and appropriate time limits, and pharmacy recommendations for clarifying diagnoses and limiting therapy duration were not followed up. Nursing staff did not consistently document required monitoring, leading to prolonged and potentially unnecessary use of these medications.
The facility did not develop or implement comprehensive care plans for four residents, including those with infections, high fall risk, and involvement in a resident-to-resident altercation. In each case, required care plans addressing new diagnoses, medication use, behavioral refusals, or incidents were either missing or not created in a timely manner, as confirmed by staff and record review.
The facility did not ensure that services provided met professional standards of quality, as observed through practices that did not align with established guidelines for care delivery.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. Observations and record reviews showed that interventions for pressure ulcer management and prevention were not consistently implemented.
Three residents did not receive respiratory care in accordance with professional standards, including a resident whose oxygen concentrator was not turned on while using a nasal cannula, a resident with nebulizer tubing and mask left on the floor, and another resident with nasal cannula tubing touching the floor and overdue for replacement. Staff interviews and facility policy confirmed these practices did not meet required standards for respiratory care.
A resident with cognitive impairment and multiple health conditions did not receive a scheduled dose of an ordered antibiotic, with no documentation or physician notification of the missed dose. Additionally, staff failed to reconcile controlled medications in six emergency medication kits across three medication rooms, as required by facility policy, resulting in missing accountability logs for the month.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Three residents experienced significant medication errors, including repeated insulin injections at the same site without rotation, a missed and late dose of azithromycin due to a transcription error, and the administration of nine doses of an expired fluticasone/salmeterol inhaler. Nursing staff and leadership confirmed these errors through record review and interviews, citing failures to follow physician orders, manufacturer guidelines, and facility policies.
Staff failed to remove expired hand sanitizer from a resident's bedside and did not discard an expired inhalation medication from a medication cart. The expired hand sanitizer was left accessible to a resident with dementia, and the expired inhaler was administered multiple times to a resident with COPD. Facility policies required removal and proper disposal of expired items, but these were not followed.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
Several residents with cognitive impairments did not have complete COVID-19 screening forms or fully filled vaccination consent forms, missing key information such as temperatures and representative details. For residents receiving RNA services, actual ambulation abilities and missed treatments were not accurately documented, with staff confirming discrepancies between records and care provided. These failures resulted in incomplete and inaccurate medical records, as acknowledged by nursing leadership.
Staff did not follow Enhanced Barrier Precautions or proper hand hygiene when providing care to two residents with indwelling urinary catheters. Gowns were not worn during high-contact care, and hand washing was not performed as required. Facility staff misunderstood when EBP should be implemented, leading to lapses in infection control for residents at risk.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or review antibiotic administration among residents, indicating a lack of oversight for antibiotic stewardship.
The facility did not assign a qualified infection preventionist to oversee the infection prevention and control program, resulting in a lack of designated responsibility for infection control practices.
Three residents with significant cognitive and physical impairments, including high fall risk, were found with call lights placed out of reach, despite care plans and facility policy requiring call lights to be accessible at all times. Staff interviews confirmed the call lights were not within reach, which could delay residents' ability to summon assistance.
Nine residents attending a council meeting were unaware of the location or availability of the facility's latest survey results and corrective actions. Staff interviews and observations confirmed that the survey result binder was either missing or incomplete, and facility policy requiring survey results to be readily accessible was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by policy.
Two residents did not receive care according to professional standards: one was not kept in an upright position after meals as required for dysphagia management, and another did not have required 72-hour shift charting completed after a significant weight loss, resulting in unmonitored oral intake. Facility staff did not follow established care plans, SLP recommendations, or documentation policies.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Two residents at high risk for falls did not receive necessary accident prevention measures. For one, a wheelchair was left on a floor mat intended to reduce injury from falls, despite staff awareness of the hazard and lack of care plan documentation addressing the resident's refusal to keep the mat clear. For another, no fall risk assessment was completed after a fall, contrary to facility policy. These actions increased the risk of accidents and injury.
A resident who required pain management did not receive care that met professional standards for safety and appropriateness.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
Nurses and nurse aides lacked the appropriate competencies to care for every resident in a manner that maximizes each resident's well-being, resulting in care that did not meet required standards.
Failure to Complete Post-Fall Assessment and Monitoring
Penalty
Summary
Facility staff failed to follow professional standards of practice after a fall involving a resident with dementia, repeated falls, and Alzheimer’s disease who lacked capacity to understand and make decisions. The resident’s record showed impaired cognitive skills and dependence for several activities of daily living, including toileting hygiene, showers, lower body dressing, and footwear. On 5/15/2025, CNA 1 found the resident on her knees beside her roommate’s bed, and LVN 1 and RN 1 assisted the resident back to bed. Staff interviews indicated the event was treated as an unwitnessed fall, but the licensed nurse did not investigate how the resident got out of bed and focused on separating the resident from the roommate. The facility did not complete a Change of Condition assessment, did not monitor the resident for 72 hours after the fall, did not perform neuro checks, and did not implement interventions to prevent further falls. The RM nurse stated the facility did not complete a COC because staff were focused on separating the resident from the roommate, and the ADON stated the fall management policy was not followed because the licensed nurse did not complete an incident report and post-fall assessment within 24 hours. The ADON also stated there was no documentation showing 72-hour monitoring, neuro checks, or fall-prevention interventions after the unwitnessed fall.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for four sampled residents. For Resident 3, the admission record showed a diagnosis of essential HTN, and the care plan dated 8/14/2025 included interventions to hold metoprolol for systolic blood pressure less than 120 mmHg and to administer medications as ordered per parameters. The order audit report later showed metoprolol tartrate 12.5 mg twice daily for HTN with the same hold parameter, and the MAR showed metoprolol was administered on multiple occasions when the recorded blood pressures were below 120 mmHg, including 119/76, 115/69, 117/79, and 115/75 mmHg. The H&P stated the resident did not have capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills for daily decisions. For Resident 4, the report states the facility failed to develop a care plan for hydrogel use. For Resident 6, the admission record and care plan review showed the resident had a urinary catheter and an EBP care plan dated 10/28/2025 that called for gown and gloves during high-contact resident care activities. During observation, CNA 1 provided a bed bath to Resident 6 while standing at the bedside and stated she did not wear a gown and should have worn one before providing the bed bath. CP 1 stated the EBP care plan was not followed when the CNA did not wear a gown, and the RMN stated care plans are guides nurses should follow to prevent spread of infection. For Resident 8, the admission record showed diagnoses including metabolic encephalopathy and a right heel stage three pressure injury. The H&P stated the resident did not have capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decisions and one stage three pressure injury. Progress notes dated 5/11/2026 documented that the WCP assessed and documented an unstageable upper mid back wound and a right heel DTI, but CP 1 stated the WCP notes were not relayed to care planners and no care plan was developed for the right heel DTI. RN 1 stated a care plan should have been developed for the right heel DTI, and the RMN stated no care plan was developed after the heel was reclassified from stage three to DTI.
Failure to Notify Physician of Elevated Blood Sugar and Follow Fluid Restriction Orders
Penalty
Summary
The facility failed to follow a physician order for a resident with DM and dementia who had orders for fasting blood sugar checks twice daily and to notify the physician if blood sugar was less than 70 mg/dl or greater than 250 mg/dl. The resident’s MAR showed blood sugar readings of 275 mg/dl on 4/17/2026, 285 mg/dl on 4/18/2026, and 254 mg/dl on 4/19/2026. The progress notes for those dates did not document physician notification for the elevated blood sugar readings. During interviews, ADSD 1 stated that if there was no documentation, it meant the physician was not notified, and that the elevated blood sugar should have been reported to prevent hyperglycemia. LVN 1 stated the same and said physician notification was important to allow modification of the plan of care and immediate action. RN 1 and the RMN also stated the physician should have been notified according to the order, and that the resident could experience hyperglycemia if the order was not followed. The facility also failed to follow a physician order for another resident with CHF, CKD stage 4, and pulmonary hypertension who had a 1,000 ml daily fluid restriction. The resident’s MAR showed multiple daily fluid intakes above the ordered limit, including 1,100 ml, 1,200 ml, 1,300 ml, and 1,500 ml on various days in April 2026. RN 1 stated the resident was on a 1,000 ml fluid restriction and that nurses should follow the physician order, while the RMN stated nurses should document accurately and follow the order.
Missed and Incorrect Pressure Injury Care and Incomplete Skin Assessments
Penalty
Summary
The facility failed to ensure pressure injury treatments were provided and documented for three residents with existing wounds. For Resident 3, who had vascular dementia, hemiplegia/hemiparesis after cerebral infarction, and was dependent on staff for all ADLs, the record showed an unstageable right heel pressure injury and physician-ordered wound care for the right heel, right buttocks, and left inner knee. The Treatment Administration Record for 5/14/2026 was left blank for those treatments, and TN 1 stated that a blank TAR meant treatment was not provided and that she was the assigned nurse for that resident on that date. Resident 3’s skin assessment was also incomplete. The Change of Condition record dated 5/8/2026 identified unstageable pressure injuries to the left inner knee and left buttocks, but the 5/10/2026 skin check only documented the right heel pressure injury. TN 1 stated the left inner knee and left buttocks wounds were not included and that all pressure injuries should have been documented to show the assessment was thorough. The RMN stated nurses should complete weekly skin checks and that incomplete assessment could allow pressure injuries to worsen. For Resident 4, who had unspecified respiratory failure, dementia, and generalized weakness, the wound treatment order was changed by the wound care provider from zinc oxide to hydrogel for a stage two left buttocks pressure injury, but the TAR continued to show zinc oxide was applied from 5/11/2026 through 5/14/2026. During observation, TN 1 applied zinc oxide to the wound. TN 1 stated she should have used hydrogel per the wound care order and that using medication not ordered could slow healing. Resident 4’s skin checks were also incomplete: the 5/7/2026 skin check documented bruising below the left elbow instead of the known left buttocks pressure injury, and there was no documented weekly skin check on 5/14/2026. TN 2 and the RMN stated the skin checks were incomplete and that weekly assessment and documentation were required. For Resident 6, who had chronic respiratory failure, a history of falls, fluctuating decision-making capacity, moderate cognitive impairment, and dependence on staff for ADLs, multiple pressure injuries and skin wounds were documented, including a stage two coccyx pressure injury, an unstageable right buttocks pressure injury, a left heel DTI, a left heel unstageable pressure injury, and a left buttocks skin tear. The TAR for 5/14/2026 was left blank for treatment of all of those wounds. TN 1 stated blank entries meant treatment was not provided because it was not documented, and the RMN stated a blank TAR indicated treatment was not provided and that wounds could worsen if treatment was not done.
Pain medication given outside ordered pain levels
Penalty
Summary
The facility failed to ensure pain management was provided according to physician orders for one resident with generalized muscle weakness and unspecified polyarthritis. The resident’s record showed orders for Tylenol and acetaminophen suppository for mild pain, later followed by hydrocodone-acetaminophen for severe pain and morphine sulfate solution for severe pain. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident’s cognitive skills for daily decisions were intact. The MAR showed nurses administered morphine on multiple occasions when the documented pain levels were 3/10, 5/10, and 6/10. The MAR also showed hydrocodone was administered when the resident had a pain level of 0/10, as well as several times when the documented pain level was 4/10, 5/10, and 6/10. During interview and record review, RN 1 stated severe pain is 7 to 10 out of 10, that hydrocodone should not have been given when the resident had 0/10 pain, and that pain levels of 4/10 to 6/10 were moderate pain for which the nurses should have called the physician for an order because the resident did not have medication for moderate pain. The RMN also stated severe pain is 7 to 10 out of 10 and that hydrocodone should not have been administered if the resident had 0/10 pain. The RMN stated nurses should have clarified the orders and must follow the physician’s order according to the resident’s pain level. The facility policy titled Pain Management stated the licensed nurse will administer pain medication as ordered and document all medication administered on the MAR.
Failure to Follow Blood Pressure Hold Parameters for Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by not following physician orders to hold blood pressure medications based on ordered systolic blood pressure parameters for three residents. For one resident with essential HTN and impaired decision-making capacity, metoprolol tartrate 12.5 mg twice daily was administered on multiple occasions when systolic blood pressure readings were below the ordered hold parameter of 120 mmHg. LVN 5 and LVN 4 documented giving the medication despite the lower readings, and both later stated the order should have been checked and followed before administration. For a second resident with CHF and DM who also lacked capacity and had severely impaired cognitive skills, the MAR showed amlodipine and metoprolol were administered when blood pressure was 97/54 mmHg, below the physician’s hold parameter of 110 mmHg for both medications. RN 1 reviewed the order and MAR and stated the medications should have been held. The resident’s record showed the medications were ordered via g-tube for HTN, with the hold instruction tied to the blood pressure threshold. For a third resident with unspecified hypotension, history of falling, fluctuating capacity, and moderately impaired cognitive skills, midodrine 10 mg three times daily was ordered to be held when systolic blood pressure was greater than 120 mmHg. The MAR showed midodrine was administered when blood pressures were 122/62 mmHg and 126/68 mmHg. RN 1 and the RMN stated the medication should have been held per the physician order. The facility policy required vital signs to be obtained and recorded before administering medications conditioned on those values.
Multidose treatment medications lacked open dates
Penalty
Summary
Safe provision of pharmaceutical services was not ensured for four sampled residents when treatment cart medications were observed without open dates. During a concurrent observation and interview on 5/19/2026 at 8:50 a.m. with Treatment Nurse 1, the facility's treatment cart for station A was reviewed and it was identified that Resident 4's nystatin-triamcinolone cream, Resident 6's Silver Silvadene cream 1%, Resident 10's Santyl external ointment 250 unit per gram, and Resident 11's Dakins solution did not have an open date written on the medication containers. TN 1 stated that each medication once opened should have a written open date. Earlier, during an interview on 5/15/2026 at 11:47 a.m. with Treatment Nurse 4, it was stated that the facility's treatment cart was not organized and medications had no written open dates. RN 1 later stated that nurses should write the open date on multidose medications when they open them so they can be discarded timely before the 30th day. The Risk Management Nurse also stated that it is important to write the open date on multidose medication to know when it should be discarded and that it is the facility's policy to write the open date on the medication container. The facility policy titled Specific Medication Administration Procedures stated that when opening a multi-dose container, the date should be placed on the container.
Inaccurate Wound Location and Stage Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three sampled residents by documenting incorrect wound locations and an incorrect wound stage in the nursing record. Resident 3 was admitted with vascular dementia, hemiplegia, and hemiparesis following cerebral infarction, and the H&P indicated the resident did not have the capacity to understand and make decisions. In the 5/8/2026 change in condition documentation, the wound location for excoriation was recorded as the left buttocks, but the treatment nurse later stated the excoriation was actually on the right buttocks and that the wrong location had been documented. Resident 8 was admitted with a stage three right heel pressure ulcer, generalized weakness, and impaired cognition. The care plan and progress notes identified the wound as being on the right heel, but the weekly Skin Checks on 4/23/2026, 4/30/2026, and 5/7/2026 documented a stage three pressure ulcer on the left heel instead. In addition, after the wound care provider assessed Resident 8 and identified a right heel DTI, the treatment administration record for 5/2026 continued to document daily treatment for a right heel stage three pressure ulcer rather than the DTI stage. Resident 9 was admitted with diabetes mellitus and generalized muscle weakness, and the H&P indicated the resident did not have the capacity to understand and make decisions. Progress notes documented right shin fluid-filled blisters and a change in condition with multiple ruptured blisters, but the weekly Skin Check on 4/16/2026 documented left medial foot scab and blister instead. Facility staff stated the skin assessments and wound documentation were not accurate, and the facility policy required wound documentation to include wound location and nursing documentation to be concise, clear, pertinent, and accurate.
Infection Control Failures During Oxygen Care, Wound Care, and EBP Bathing
Penalty
Summary
The facility failed to implement infection control measures for Resident 4 when the resident’s oxygen tubing was observed touching the floor in the room. Resident 4 was admitted with diagnoses including unspecified respiratory failure, unspecified dementia, and generalized weakness, and the record showed the resident had capacity to understand and make decisions. The resident’s order recap indicated oxygen at 3 liters per minute via nasal cannula continuously for shortness of breath. During observation, the oxygen tubing was seen touching the floor, and the LVN stated it should not touch the floor for infection control. The IP later stated the tubing should not touch the floor because it could be contaminated and spread infection. The facility also failed to follow infection control practices during wound care for Resident 4, who was on EBP. During observation of treatment care for a stage two pressure injury on the left buttocks, TN 1 cleansed the wound, removed gloves, performed hand hygiene, donned gloves, and dried the wound. TN 1 then removed gloves again, used a tongue depressor to apply zinc oxide to the pressure injury, and applied a new foam dressing without gloves. The IP stated TN 1 should have worn gloves when applying the dressing because Resident 4 was on EBP and gloves help prevent the spread of MDRO. The facility further failed to follow EBP precautions for Resident 6 during bed bath care. Resident 6 had diagnoses including chronic respiratory failure and UTI with urinary device, had a urinary catheter, and had a stage two coccyx pressure injury. EBP signage and an isolation cart were present outside the room. During observation, CNA 1 provided a bed bath without wearing a gown, then later stated she had forgotten to wear one and should have worn it to protect Resident 6 from infection. ADSD 2 and the IP both stated CNA 1 should have worn a gown before entering the room and providing bed bath care under EBP.
Incomplete and Inaccurate Documentation of Change in Condition, Hospital Transfer, and PRN Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident in accordance with accepted professional standards and its own policies. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia with severely impaired decision-making, and essential hypertension. Physician orders included Tylenol 325 mg, two tablets every four hours as needed for mild pain or general discomfort. On a documented change of condition evaluation, the resident complained of right hip pain, was given Tylenol, and the attending physician was notified, resulting in an order for a right hip x-ray. The resident’s change of condition and subsequent assessment were not documented in a timely or accurate manner by the RN. The RN stated she assessed the resident after the change of condition on one day, but the assessment was documented in the progress notes on the following day without being identified as a late entry. The Director of Nursing confirmed that the progress notes should have indicated that this was a late entry and that documentation was not completed by the end of the assigned shift, contrary to the facility’s documentation policy requiring prompt, dated, timed, and signed entries and clear identification of late entries. Additional inaccuracies were identified in the social services and medication administration documentation. Social services documented that the resident was transferred to a general acute care hospital on one date, while both the RN and the Director of Nursing stated the transfer actually occurred the following day. Furthermore, the RN reported witnessing an LVN administer two tablets of Tylenol 325 mg to the resident for right hip pain, but there was no corresponding entry on the medication administration record for that dose. This lack of documentation conflicted with the facility’s policies requiring that each medication administered be recorded on the MAR and that all entries be complete, accurate, and promptly recorded.
Failure to Protect Confidential Electronic Medical Record on Medication Cart
Penalty
Summary
The facility failed to protect the confidentiality of one resident’s personal and medical records when the resident’s electronic medical record was left visible and unattended on a medication cart computer. The resident had been admitted with diagnoses including atherosclerotic heart disease, gastroesophageal reflux disease, and age-related osteoporosis. During an observation at the nurse station, the medication cart computer was found open with the resident’s medical record displayed, including the resident’s name, picture, and medication list, while staff walked past the cart. In a concurrent observation and interview, an LVN acknowledged that she had not locked the medication cart computer before leaving to assist another resident and confirmed that the resident’s medical information was visible to people walking in the hallway. The DON stated that the resident’s medical records should not be left unattended and that staff not involved in the resident’s care, other residents, and visitors could potentially have unauthorized access to the records. Review of the facility’s policy titled “General Provisions” indicated that protected health information is confidential, will only be released in accordance with HIPAA policies, and that active records are to be located in an area not accessible to unauthorized persons.
Failure to Update Care Plan After Change in Condition With New Hip Pain
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions following a change of condition for one resident. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia, and essential hypertension. An MDS dated 11/24/2025 documented that the resident had severely impaired cognitive skills for daily decision-making. On 2/9/2026, a Change of Condition (COC) Evaluation documented that the resident complained of right hip pain, was given Tylenol, and that the attending physician was notified and ordered a right hip x-ray at 2:45 p.m. During interviews and concurrent record review, RN 1 confirmed that no care plan was created to address the resident’s right hip pain following the COC on 2/9/2026 and stated that a care plan should have been initiated so staff would be aware of interventions to address the change of condition. The DON similarly stated that a care plan is a list of care and services to be provided for residents and acknowledged that a care plan should have been created after the COC, but the resident’s care plan did not include the right hip pain. The DON stated that the facility failed to ensure the resident had a care plan after the COC that addressed the resident’s right hip pain. Review of facility policies showed that the Care Planning policy required a comprehensive, person-centered care plan based on assessed needs, and the Change of Condition Notification policy required a licensed nurse to update the care plan to reflect the resident’s current status.
Failure to Monitor and Document Resident After Change of Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its change of condition (COC) monitoring policy and professional standards of practice for a resident with age-related osteoporosis, unspecified dementia, and essential hypertension. The resident, who had severely impaired cognitive skills for daily decision-making per the MDS dated 11/24/2025, complained of right hip pain on 2/9/2026 at approximately 2:40–2:45 p.m. A COC Evaluation documented the complaint of right hip pain, administration of Tylenol, and notification of the attending physician, who ordered a right hip x-ray. Facility policy required that after a COC, a licensed nurse assess the resident, document observations and symptoms, and chart each shift for at least 72 hours, including the date, time, and pertinent details of the incident and subsequent assessment in the nursing notes. Record review and interviews showed that the resident’s COC status was not monitored or documented on the 11 p.m. to 7 a.m. shift on 2/9/2026, despite the requirement for every-shift monitoring for 72 hours. RN 1 acknowledged that the progress notes contained no documentation of monitoring for that shift and that she did not document her full assessment of the resident’s right lower extremity, including pain on palpation and the appearance of the right lower extremity. RN 1 and the DON both stated that care not documented is considered not done, and the DON confirmed there was no documented evidence of monitoring on the 11 p.m. to 7 a.m. shift and that RN 1 did not document the lower extremity assessment. The facility’s failure to assess and monitor the resident after the COC, as required by its policy, had the potential for the resident’s progress or decline to be missed and had the potential to negatively impact the resident’s health and safety.
Failure to Implement Fall-Prevention Measures and Safe Bed Mobility Assistance for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and fall-prevention measures for a resident with a known high risk for falls. The resident, originally admitted in 2019 and readmitted in 2024, had diagnoses including chronic diastolic CHF, a right shoulder rotator cuff tear/rupture, T11–T12 wedge compression fracture sequela, and muscle weakness. A fall risk assessment completed on 12/20/2024 showed a fall risk score of 28, indicating high risk, and documentation from that date showed the resident experienced a fall while ambulating to the restroom and being assisted to the floor by staff. Despite this, there was no documented evidence that the resident’s care plan was revised after the 12/20/2024 fall, and the resident was not added to the facility’s Falling Star Program until 11/1/2025, even though the program policy stated it was to be used as a post-fall intervention for residents at high risk for falls. The resident’s care plan for functional abilities, initiated on 5/19/2025, indicated the resident required assistance with bed mobility and that two or more staff would assist with bed mobility as needed. The MDS dated 10/27/2025 documented that the resident had intact cognition, was dependent on staff for toileting hygiene, showers, and lower body dressing, required maximal assistance for several bed mobility and ADL tasks, and required partial/moderate assistance for rolling from back to left and right side in bed. On 11/1/2025, during the 11 p.m. to 7 a.m. shift, CNA 1 entered the resident’s room around 6 a.m. to provide morning care, including changing bed linens and incontinence briefs, while the resident was sleeping. CNA 1 reported she did not recall asking the resident if she could hold herself on the side of the bed before starting care, and she proceeded to clean the resident in the supine position and then turn her onto her left side at the edge of the bed while attempting to place a bed protector. During this care on 11/1/2025, CNA 1 held the resident’s right arm with her right hand while trying to place the bed protector with her left hand. Approximately 10–15 minutes after initiating care, while the resident was lying on her left side at the edge of the bed, the resident slipped from CNA 1’s hold and fell to the floor. There was no floor mat next to the bed at the time of the fall, despite later care plan documentation (initiated after the fall) indicating the resident was to have bilateral floor mats. The incident report and nursing documentation described a laceration to the left eyebrow area, skin tears on the left forehead and left wrist/forearm, visible bleeding on the resident’s face and on the floor, and the need for wound cleansing and pain management. The resident was transferred to an acute care hospital, where she received seven sutures to the left eyebrow laceration. Following the 11/1/2025 fall, the facility did not complete a fall risk assessment specific to that episode, even though facility policy required fall risk assessments upon admission, quarterly, and after a fall. Licensed nursing staff later acknowledged there was no fall risk assessment completed after the 11/1/2025 fall and that this could result in incomplete or inaccurate fall-prevention interventions. Multiple nurses also confirmed that the care plan had not been updated after the 12/20/2024 fall to include fall-prevention interventions discussed in the IDT meeting, and that the resident was not placed in the Falling Star Program until 11/1/2025, despite having a high fall risk score and a prior fall. Additionally, during a later observation of the resident’s room, no floor mat was present next to the bed, even though the care plan for a witnessed fall (initiated after the incident) called for bilateral floor mats. Staff interviews consistently indicated that licensed nurses were responsible for ensuring care plan interventions were implemented and that CNA 1 should have requested additional assistance when providing bed mobility and morning care to this resident.
Incomplete Fall Risk Assessments and Inaccurate Nursing Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident by not fully completing required Fall Risk Assessments. The resident had been originally admitted in 2019 and readmitted in 2025 with multiple diagnoses, including chronic diastolic CHF, a right shoulder rotator cuff tear or rupture, wedge compression fracture of T11–T12 vertebra, and muscle weakness. A History and Physical dated 7/1/2025 documented that the resident had the capacity to understand and make decisions, and an MDS dated 1/21/2026 indicated intact cognitive functioning. The MDS further showed the resident was dependent on staff for toileting hygiene, showers, and lower body dressing, and required maximal assistance for bed mobility, transfers between lying and sitting, upper body dressing, and personal hygiene. During an interview and concurrent record review with an RN on 2/18/2026, Fall Risk Assessments dated 7/29/2025, 10/1/2025, and 10/22/2025 were reviewed and found to have section F, which assesses systolic blood pressure variation when changing positions between lying and standing, left unassessed. The RN acknowledged that the Fall Risk Assessments for July and October 2025 were incomplete and stated that the assessments did not correctly describe the resident’s condition, which could potentially lead to a lower score level and affect the resident’s care, leading to a higher risk for falls. The facility’s policy on Nursing Documentation, last reviewed on 1/26/2026, required nursing documentation to be concise, clear, pertinent, and accurate, and described expectations for alert charting to accurately describe the resident’s condition and the nursing response, which was not met in the incomplete fall risk documentation for this resident.
Failure to Protect Resident From Unauthorized Physical Restraint and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical restraints and abuse. A resident with dementia, Alzheimer’s disease, muscle weakness, gait and mobility abnormalities, and no capacity to make decisions was admitted in August 2025. The resident’s MDS dated 12/8/2025 showed severe cognitive impairment, with the resident rarely understanding and rarely being understood, and being dependent or requiring assistance for most ADLs. A fall risk assessment on the same date identified the resident as high risk for falls with a score of 21. These records established that the resident was cognitively impaired, physically vulnerable, and dependent on staff for care and safety. On the night in question, CNA 1 was assigned to the resident during the 11 p.m. to 7 a.m. shift and remained on duty until after 7 a.m. LVN 1 reported that around 2 a.m. the resident began chanting, which became louder and more frequent. LVN 1 asked CNA 1 to check on the resident; CNA 1 returned and stated the resident was okay and always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. At around 2:50 a.m., LVN 1 entered the resident’s room, found the blanket on the floor, and observed the resident lying in bed making wiggly body movements. LVN 1 then saw that the resident’s wrists were firmly tied together in front of her with a long scarf, with no wiggle room and no ability for the resident to move or release her hands. LVN 1 untied the scarf and assessed the resident, noting no visible injury. The facility’s own policies required that any physical restraint be preceded by a licensed nurse’s assessment, IDT involvement, determination of need, identification of the least restrictive device, and appropriate documentation and consent. The restraint policy also stated that residents are to be provided a restraint-free environment and that restraints are not to be used for discipline or staff convenience. The abuse prevention policy stated that each resident has the right to be free from abuse, neglect, and mistreatment, that the facility has zero tolerance for abuse, and that staff accused of abuse, neglect, or mistreatment are to be suspended until the investigation is complete. The DON and Administrator both stated that tying the resident’s hands with a scarf constituted a physical restraint and physical abuse, and the Administrator indicated he believed CNA 1 tied the resident’s hands for the CNA’s convenience because the resident was restless. Despite this, CNA 1, who was suspected of tying the resident’s hands and was found sleeping during that time, was not immediately removed from duty and continued to provide care to the resident until the end of the shift, contrary to the facility’s abuse prevention policy.
Removal Plan
- LVN 1 reported the alleged abuse incident to Human Resources and the Director of Nursing, stating Resident 1 was found with hands bound by a scarf; LVN 1 removed the scarf and notified the Ombudsman.
- The facility suspended CNA 1 pending Human Resources investigation.
- LVN 1 received a written warning for failing to report the incident to the RN Supervisor on duty.
- The facility terminated CNA 1.
- The Director of Staff Development reported CNA 1 to the CNA Licensing Board.
- RN Supervisors conducted rounds on all units to visually observe all residents for any signs of physical restraints, inappropriate devices functioning as restraints, or signs of abuse/neglect; no other residents were identified.
- RN Supervisors conducted another facility-wide sweep of all residents to screen for restraints; no other residents were identified.
- Human Resources and the Administrator suspended LVN 1 for failure to follow facility policy.
- The Assistant Director of Staff Development initiated in-service training for facility staff regarding restraints, with the Assistant DSD and DSD continuing in-services until completion.
- During orientation, the facility will in-service newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy and requirement to report suspected abuse immediately, and documentation requirements.
- The Director of Nursing created a root cause analysis.
- The Administrator and Director of Nursing instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected.
- Shift-to-shift report will include reporting of any suspected abuse and immediate suspension of staff involved.
- Department Managers, Managers of the Day, and the RN Supervisor on duty will conduct daily rounds on every shift (including weekends and holidays) to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.
Failure to Notify MD and Resident Representative After Alleged Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a significant change in condition and alleged abuse involving one resident. The resident was an individual with dementia and Alzheimer’s disease, admitted with diagnoses including muscle weakness and gait and mobility abnormalities. Assessments showed the resident had a high fall risk score of 21, lacked capacity to understand and make decisions, rarely understood and was rarely understood, and required varying levels of staff assistance for ADLs such as showering, dressing, toileting, oral hygiene, and personal hygiene. The resident’s care plan included education of staff about types of abuse, including physical restraint, prevention measures, reporting requirements, and respect for resident rights. On the night in question, during the 11 p.m. to 7 a.m. shift, the resident became restless and was heard chanting or yelling intermittently in a language not understood by the LVN on duty. The LVN asked the CNA assigned to the resident, who spoke the same language, what the resident was saying, and the CNA responded that the resident always did that. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room and then left, and the resident’s vocalizations continued and worsened. Later, at approximately 2:50 a.m., the LVN entered the resident’s room, observed the blanket on the floor, and when picking it up noted that the resident’s wrists were bound together in front with a scarf tied in a firm figure-eight pattern multiple times, with no apparent wiggle room for the resident to move her hands. The LVN reported that the resident appeared relieved and moved around as if to draw attention to the bound wrists. The LVN took a photograph of the bound wrists and then untied the scarf around 3 a.m. Subsequent interviews and record reviews showed that this incident was treated by facility leadership as alleged physical abuse and use of a physical restraint, and as a change of condition that should have triggered formal documentation and notifications. The DON and RMN both stated that an allegation of abuse is considered a change of condition and that a Change of Condition (COC) form should have been initiated on the date of the incident to communicate with all staff, the MD, the IDT, and the family, and to start 72‑hour monitoring. However, there was no COC documented for the date of the incident, and the RMN confirmed there was no COC entry for that date in the resident’s record. The MD reported being notified the next morning about the resident having a scarf-like object tied over her wrists and increased confusion, but the RMN stated there was no documentation that the MD was notified on the date of the incident. The DON stated that, because there was no COC documented for that date, the facility could not say that the MD or family were notified of the change in condition related to the alleged abuse, contrary to the facility’s policy requiring prompt notification and documentation of significant changes in condition.
Failure to Timely Report and Protect Resident After Discovery of Bound Wrists
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program by not reporting an allegation of abuse to the State Survey Agency, local law enforcement, adult protective services, and the Ombudsman within two hours as required by policy. During the night shift, an LVN discovered a resident with dementia and Alzheimer's disease lying in bed with her wrists firmly bound together in front of her with a long scarf tied in a figure-eight pattern multiple times, which the LVN described as having no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound wrists, untied the scarf at approximately 3:00 a.m., and later notified the DON and Resident Care Manager (RMN) around 7:15–7:20 a.m., resulting in a delay of about three hours in reporting the suspected abuse to the Administrator and triggering external reporting. The resident involved had been admitted with diagnoses including dementia, Alzheimer's disease, muscle weakness, and gait and mobility abnormalities. A prior H&P documented that the resident did not have capacity to understand and make decisions. The MDS indicated the resident rarely understood and was rarely understood, and required staff assistance with most ADLs, including showering, dressing, toileting, and personal hygiene. A fall risk assessment showed a high fall risk score of 21. The facility’s Restraints policy defined physical restraints as any device that the resident cannot easily remove that restricts freedom of movement or access to one’s body, and required assessment, physician orders, informed consent, and care planning before use; the resident’s wrists being bound with a scarf was not associated with any such assessment, order, or care plan. On the night of the incident, the LVN heard the resident chanting in another language and asked the assigned CNA, who spoke the same language, what the resident was saying; the CNA responded that the resident always behaved that way. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room, spoke with the resident, and then left, telling the LVN that the resident was okay. When the chanting worsened, the LVN entered the room around 2:50 a.m., found the blanket on the floor, and upon picking it up observed the resident’s wrists bound with the scarf. After untying the scarf and assessing the resident with no visible injury noted, the LVN later found the CNA asleep and snoring at the nursing station; the CNA subsequently completed the shift and continued caring for the resident. The RMN later confirmed seeing the photograph of the resident’s hands tied on top of each other and stated that the LVN should have immediately reported the incident to the Administrator and immediately removed the CNA from the assignment and premises, but instead the reporting to leadership was delayed and the CNA remained on duty with the resident.
Failure to Protect Resident From Abuse and Remove Alleged Perpetrator From Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to immediately remove an alleged perpetrator from resident care after an incident was discovered. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, gait and mobility abnormalities, and was assessed as a high fall risk. A recent MDS documented that the resident rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, toileting, and personal hygiene. The resident did not have capacity to understand and make decisions per the physician’s history and physical. During a night shift, the resident became restless and was heard chanting in a language not understood by the LVN on duty. The LVN asked the assigned CNA, who spoke the same language as the resident, what the resident was saying, and the CNA responded that the resident always did that. As the chanting increased in volume and frequency, the LVN directed the CNA to check on the resident; the CNA went into the room, spoke with the resident, and then left, reporting that the resident was okay. Later, when the chanting worsened, the LVN entered the room and observed the resident’s blanket on the floor. When the LVN picked up the blanket to cover the resident, she saw that the resident’s wrists were firmly bound together in front with a scarf, tied in a figure-eight pattern multiple times, with no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound hands and then untied the scarf at approximately 3 a.m. Afterward, the LVN found the assigned CNA asleep and snoring at the nursing station. The CNA’s timecard showed she remained on duty from late evening through the end of the night shift and, by her own account and that of facility staff, she continued to work with the resident and other residents for the remainder of the shift and was not removed from the resident’s care at that time. The RMN and Administrator later characterized the tying of the resident’s hands with a scarf as physical abuse and a form of restraint, and the facility’s abuse prevention policy stated that staff accused of abuse are to be suspended until the investigation is complete.
Failure to Care Plan for Restraint Use After Resident Found with Wrists Tied
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing the use of restraints for a resident with dementia, Alzheimer’s disease, muscle weakness, and gait and mobility abnormalities. The resident was admitted with significant cognitive impairment, as the physician history and physical documented that she did not have the capacity to understand and make decisions. A fall risk assessment showed a high fall risk score of 21, and the MDS indicated she rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, oral hygiene, toileting, footwear, and personal hygiene. Despite these conditions and her dependence on staff, there was no care plan in place addressing the use of restraints for this resident. On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA to check on the resident; the CNA later reported the resident was okay and that she always behaved that way. About 10 minutes later, the resident again yelled out, prompting the LVN to enter the room. The LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf while she was in bed. The LVN untied the scarf and assessed the resident, noting no visible injury. Subsequent review of the care plan with the resident care manager revealed that there had been no prior care plan for the use of restraints, and the manager acknowledged that the scarf had been used as a restraint and should have been care planned. The facility’s change of condition policy required updating the care plan to reflect the resident’s current status after significant changes, but the report indicates the lack of a comprehensive care plan addressing restraint use at the time of the incident.
Failure to Initiate Change of Condition Evaluation and 72‑Hour Monitoring After Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to create a Change of Condition (COC) evaluation and to initiate 72‑hour monitoring following an alleged physical abuse incident involving a resident. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, and gait and mobility abnormalities, and had been assessed as a high fall risk with significant dependence on staff for activities of daily living. The resident’s MDS indicated she rarely understood and was rarely understood, and her physician’s H&P documented that she did not have capacity to understand and make decisions. On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA assigned to the resident to check on her. The CNA reported back that the resident was okay and that she always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. When the LVN entered the room, the LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf. The LVN untied the scarf and assessed the resident, noting no visible injury at that time. The DON and RMN later reviewed a photograph of the resident’s wrists tied with a scarf and both described the wrists as bound in such a way that the resident could not pull her arms apart, and the DON characterized this as physical abuse and use of a physical restraint. Despite this alleged abuse incident, there was no COC evaluation initiated on the date the resident was found with her wrists tied. The RMN confirmed that alleged abuse is considered a change of condition and that a COC form should have been completed on that date to communicate with all staff, the MD, IDT, and family. The RMN and DON both stated there was no COC for the date of the allegation, and the RMN acknowledged that the RN supervisor should have started the COC at that time. The facility’s policy on Change of Condition Notification requires prompt notification of the physician, resident, and representative for significant changes in physical, cognitive, behavioral, or functional status, and requires licensed nurses to document the incident, physician notification, family notification, care plan updates, and to document each shift for at least 72 hours. In this case, the 72‑hour monitoring and COC documentation were not initiated until two days later, and the RMN stated there was no documentation that the MD was notified on the date of the incident, meaning the required timely COC evaluation and 72‑hour monitoring following the alleged abuse did not occur as required by policy. The RMN further explained that the COC form is used to identify the change in condition and to initiate 72‑hour monitoring, which includes checking the resident’s psychosocial well‑being, assessing for new skin issues such as bruising from restraints, and monitoring the resident’s overall status. However, the COC completed later focused on restlessness and possible infection, not specifically on the abuse incident that occurred earlier. The Health Status Note indicating monitoring status post abuse incident and the initiation of 72‑hour monitoring were dated two days after the alleged abuse, confirming a delay in both recognition and documentation of the change in condition related to the abuse. The facility’s own leadership acknowledged that, because there was no COC documented for the date of the allegation, they could not confirm that the MD or family were notified of the change in condition at the time it occurred.
Failure to Ensure Accurate Fall Prevention Documentation and Interventions
Penalty
Summary
The facility failed to ensure that interventions to prevent falls were properly implemented and documented for a resident identified as high risk for falls. The resident, who had diagnoses including osteoporosis, glaucoma, and generalized muscle weakness, was readmitted with a high fall risk score. The care plan included interventions such as keeping the bed in the lowest position, placing floor mats next to the bed, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall. Upon review, it was found that the SBAR Communication Form and Incident Note related to the fall were incomplete and inaccurate. Specifically, the SBAR form did not include the physician's recommendations, and neither the SBAR nor the Incident Note provided clear details on how the fall occurred. Additionally, the Interdisciplinary Care Conference documentation was inconsistent, with conflicting information about whether the fall was witnessed and lacking specific details about the incident. The Director of Nursing acknowledged during an interview that the documentation across the SBAR, Incident Note, and IDT did not match and failed to provide essential information regarding the circumstances of the fall. Facility policies required nursing documentation to be concise, clear, pertinent, and accurate, and for investigations to identify contributing factors to falls. The lack of accurate and complete documentation had the potential to impact the staff's ability to implement appropriate interventions for the resident.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident verbal and physical abuse within the required two-hour timeframe to the State Survey Agency (SSA). A Certified Nursing Assistant (CNA) reported to the Director of Nursing (DON) that a Life Enrichment Coordinator (LEC) allegedly threw a towel or sweater at a resident's face and yelled at the resident, which was considered verbal and physical abuse. The incident was witnessed by a Restorative Nursing Assistant (RNA), who reported the event to the DON on 8/29/2025, even though the alleged abuse occurred on 8/5/2025. The facility subsequently reported the allegation to the SSA 24 days after the initial incident. The resident involved had a history of hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, and dysphagia, and was assessed as having moderately impaired cognition. Interviews with facility staff, including the Assistant Administrator (Abuse Coordinator) and the DON, confirmed that the abuse allegation was not reported within the required two-hour window as outlined in the facility's Abuse Prevention and Prohibition Program policy. The delay in reporting was attributed to the RNA not promptly informing the DON, which led to the facility's late notification to the appropriate authorities.
Failure to Complete and Document Staff Background Checks
Penalty
Summary
The facility failed to complete and document criminal background checks for three sampled employees: a Licensed Vocational Nurse, a Registered Nurse, and a Certified Nurse Assistant. Review of their employee files showed no evidence of background checks, despite all three being currently employed. The employees were hired in 1997, 1998, and 2021, respectively, and their files lacked documentation of any criminal background screening at the time of hire or thereafter. Interviews with facility leadership revealed that background checks were reportedly not conducted prior to 2014, but no policy was provided to support this claim. The facility's current policy, dated August 1, 2023, requires criminal background screening for all prospective staff, contractors, and volunteers prior to employment. The absence of background checks for these employees was confirmed by both the Director of Staff Development and the Administrator during interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure adequate monitoring and documentation for three residents. For one resident with diagnoses including psychosis, depression, anxiety, insomnia, and dementia, the facility did not monitor specific, measurable target behaviors related to the use of clonazepam, a psychotropic medication prescribed for anxiety. The medication order lacked a specific duration, and the manifestations of the behaviors being treated were not clearly defined, leading to inconsistent monitoring and documentation by nursing staff. Interviews with nursing staff confirmed that the absence of specific target behaviors and duration in the medication order could result in inaccurate assessments and prolonged, unnecessary use of the medication. Another resident with Alzheimer’s disease, dementia, and anxiety disorder was prescribed Ativan (lorazepam) as needed for anxiety. The orders for this medication did not specify a duration or clearly define the target behaviors for which the medication was to be administered. Consultant pharmacist recommendations to clarify the diagnosis and add a 14-day duration to the therapy were not acted upon or documented as addressed with the physician. The lack of follow-up on these recommendations and the absence of specific, measurable behaviors in the orders resulted in the resident being at risk for prolonged and unnecessary use of psychotropic medication. A third resident with Alzheimer’s disease, dementia, and depression was prescribed Remeron (mirtazapine) for depression. The facility failed to monitor and document the resident’s pulse rate and adverse effects on the medication administration record when the medication was administered. Nursing staff and administration confirmed that monitoring for adverse effects and pulse rate was required but not completed, which could lead to inaccurate assessment of the medication’s necessity and effectiveness. Facility policies required specific indications, manifestations, and monitoring for psychotropic medications, but these were not consistently followed for the residents involved.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four out of five sampled residents, as required by their own policies and regulatory standards. For one resident with a diagnosis of pneumonia, there was no care plan created to address the infection, despite physician orders for antibiotic treatment and documentation of severely impaired cognitive skills. Both the Infection Preventionist and nursing leadership confirmed that a care plan should have been developed to guide nursing care and ensure continuity. Another resident, who was prescribed azithromycin for bronchitis, also did not have a care plan addressing the use of this antibiotic. The resident had a history of Parkinson’s disease, dementia, and fluctuating decision-making capacity. Nursing leadership acknowledged that the absence of a care plan for antibiotic use could result in a lack of guidance for staff and potentially impact the resident’s care. A third resident, identified as high risk for falls and with a history of Alzheimer’s disease and osteoporosis, refused to remove a wheelchair from atop a floor mat designed to prevent injury from falls. Although staff were aware of the risks and the resident’s refusal, there was no care plan documenting this behavior or interventions to address it. Additionally, for a fourth resident involved in a resident-to-resident altercation, the care plan addressing the incident was not developed until the day after the event, rather than immediately. Staff interviews confirmed that timely care planning was not performed, which could have delayed appropriate interventions and communication among the care team.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the provision of services, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews, which revealed that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents. For one resident with a history of congestive heart failure, COPD, and pulmonary hypertension, the oxygen concentrator was observed to be turned off on two separate occasions while the resident was wearing a nasal cannula and had orders for PRN oxygen for shortness of breath. Documentation showed that the resident had received PRN oxygen for shortness of breath, but during observations, the oxygen concentrator was not delivering supplemental oxygen as required. Staff interviews confirmed that the concentrator should have been turned on when the nasal cannula was in use, and the facility's policy required oxygen to be administered at the prescribed rate with verification of flow. Another resident, with diagnoses including UTI, E. coli infection, and Alzheimer's disease, was found to have nebulizer tubing and mask on the floor in their room. Staff acknowledged that the tubing and mask should not be on the floor due to the risk of contamination, and that the equipment should be stored in a plastic bag, labeled, and kept off the floor. The facility's policy and staff interviews confirmed that using contaminated respiratory equipment could lead to respiratory infections. A third resident, with heart failure, COPD, and Alzheimer's disease, was observed with nasal cannula oxygen tubing touching the floor. The tubing was also overdue for replacement according to the facility's policy, which required weekly changes. Staff interviews indicated that the tubing should have been stored properly and not allowed to touch the floor to prevent infection. The facility's policy specified that all oxygen delivery items are for single resident use, must be changed weekly or when soiled, and stored in a labeled plastic bag at the bedside.
Failure to Administer Ordered Antibiotic and Reconcile Controlled Medications in eKITs
Penalty
Summary
The facility failed to ensure that an antibiotic medication, sulfamethoxazole-trimethoprim, was administered as ordered by the physician for a resident with a history of atherosclerotic heart disease, generalized muscle weakness, and a urinary tract infection. The resident, who was cognitively impaired and required maximum assistance for daily activities, did not receive the scheduled 9 a.m. dose on 7/13/2025. Documentation in the Medication Administration Record (MAR) and progress notes did not confirm administration of the medication, and staff interviews confirmed that the dose was missed and not documented. The nurse responsible did not notify the physician about the missed dose or obtain further orders, resulting in an incomplete antibiotic course for the resident's abscess. Additionally, the facility failed to reconcile controlled medications (CMs) stored in emergency medication kits (eKITs) at every shift change in three medication rooms. Observations revealed that six eKITs containing CMs lacked accountability logs for July 2025, and staff interviews confirmed that these kits were not reconciled as required by facility policy. Nurses acknowledged the importance of reconciling CMs at each shift to ensure accountability and prevent diversion, but admitted that this was not done for the identified eKITs. Review of facility policies confirmed that all CMs, including those in emergency kits, must be physically inventoried and documented by two licensed nurses at each shift change. The Director of Nursing and Assistant Director of Nursing acknowledged that the facility did not follow its own procedures for CM reconciliation, and that the required documentation and accountability for these medications were not maintained during the period in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Significant Medication Errors Involving Insulin Administration, Antibiotic Dosing, and Expired Inhaler Use
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration and adherence to physician orders and manufacturer guidelines. One resident with type 2 diabetes and chronic kidney disease received insulin injections at the same anatomical sites repeatedly, rather than rotating injection sites as required by standard of care and facility policy. This practice was confirmed through review of administration records and interviews with nursing staff, who acknowledged that site rotation was not performed as required. Another resident with chronic obstructive pulmonary disease (COPD) and a recent diagnosis of bronchitis was prescribed a course of azithromycin. The physician's order specified a dosing schedule that was not correctly transcribed into the Medication Administration Record (MAR), resulting in the omission of a scheduled dose. The Assistant Director of Nursing admitted to the transcription error, which led to the antibiotic dose being administered late, contrary to the physician's instructions. A third resident, also with COPD, was administered nine doses of an expired fluticasone and salmeterol inhalation powder Diskus. The inhaler had been opened and stored beyond the manufacturer-recommended one-month period, but was not removed from the medication cart as required by facility policy. Multiple nurses administered the expired medication, and staff interviews confirmed awareness of the expiration guidelines and the error in not removing the medication from use.
Expired Medications and Hand Sanitizer Not Removed from Use
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not removing expired hand sanitizer from a resident's bedside and by not discarding an expired inhalation medication from a medication cart. In the first instance, a resident with a history of urinary tract infection, E. coli, and dementia was found to have two hand sanitizers on the bedside table, one of which had expired several years prior. Staff interviews confirmed that hand sanitizers should not be left at the bedside due to the risk of accidental ingestion and that expired sanitizers are ineffective and should be discarded according to facility protocol. The facility's policy also requires the environment to be free of hazards, including expired sanitizing agents. In the second instance, an expired fluticasone and salmeterol inhalation powder Diskus, used for treating COPD, was found in a medication cart. The medication had been opened and marked with the date, but was not removed after the one-month expiration period as required by both manufacturer guidelines and facility policy. Multiple licensed nurses, including the one interviewed, failed to remove the expired medication, resulting in nine doses being administered to a resident after the expiration date. Staff acknowledged that expired inhalers lose potency and are not effective in treating the resident's condition. Facility policies reviewed indicated that expired or discontinued medications must be immediately removed from stock and stored in a designated area for disposal. The policies also specify that medications should be stored and disposed of according to manufacturer recommendations. Despite these policies, the expired hand sanitizer and inhalation medication remained accessible and in use, contrary to both facility procedures and professional standards.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Incomplete and Inaccurate Medical Record Documentation for Infection Control and Restorative Nursing Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For several residents with cognitive impairments or lacking decision-making capacity, COVID-19 screening forms were incomplete, specifically missing required temperature documentation at the time of screening. Additionally, vaccination informed consent forms for COVID-19, influenza, and pneumococcal vaccines were not fully completed, lacking essential information such as the name and relationship of the resident’s representative, and in some cases, the resident’s name. These omissions were confirmed by both nursing staff and facility leadership, who acknowledged that incomplete consent forms constitute incomplete medical records. For residents receiving Restorative Nursing Aide (RNA) services, the facility did not accurately document the actual care provided. In one case, a resident’s RNA Weekly Progress notes did not reflect the resident’s true ability to ambulate, with discrepancies between the recorded ambulation distances and what was observed or reported by staff. The RNA daily treatment records also inaccurately indicated that ambulation was provided on certain days when, in fact, it was not performed due to the resident requiring assistance from two staff members, which was not available. Staff interviews confirmed that the documentation did not match the care delivered, and that the electronic documentation system was not used correctly to indicate when services were missed or not performed. Additional documentation failures included not recording missed RNA treatments for several residents and not documenting a resident’s inability to participate in sit-to-stand transfers. Facility policies required accurate and timely documentation of restorative nursing services and complete informed consent forms, but these standards were not met. The Director of Nursing and Assistant Director of Nursing confirmed that these documentation lapses resulted in incomplete and inaccurate medical records, which could lead to confusion regarding the care and services provided to residents.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to implement appropriate infection control practices for residents with indwelling urinary catheters, specifically by not following Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. For one resident with significant medical conditions including metabolic encephalopathy, carcinoma in situ of the vulva, breast cancer, and Alzheimer's disease, staff did not don gowns while providing indwelling catheter care, despite the resident being dependent on staff for all activities of daily living. Observations showed that staff entered the resident's room wearing only masks and gloves, and did not use gowns as required by EBP during catheter care. Interviews revealed that staff believed EBP was not necessary unless a resident had a known multidrug-resistant organism (MDRO), and the Infection Prevention Nurse confirmed that EBP had been discontinued based on a misunderstanding of guidance, which was later acknowledged as incorrect. Another resident with Alzheimer's disease, dementia, and neuromuscular bladder dysfunction, also dependent on staff for personal care and with an indwelling catheter, did not have EBP signage or PPE available in the room. During peri-care, a CNA did not wear a gown, used a double-gloving technique not in line with facility policy, and failed to perform hand hygiene at appropriate times during the care process. The CNA was unaware of EBP requirements and stated that isolation precautions were not in place for the resident. The Infection Preventionist and Director of Nursing later confirmed that EBP should have been implemented for residents with indwelling devices, regardless of MDRO status, and that hand hygiene and proper glove use were expected but not followed. Review of facility policies confirmed that EBP should be used for residents with indwelling devices during high-contact care activities, and that hand hygiene is required before and after resident care and glove changes. The failure to implement EBP and proper hand hygiene as outlined in facility policy and CDC guidance led to deficient infection control practices for residents with indwelling catheters.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff members were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist responsible for the infection prevention and control program. This omission indicates that the required oversight and management of infection control practices were not assigned to a qualified individual as mandated.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to keep the call light within reach for three residents who were reviewed for accommodation of needs and preferences. For one resident with a history of osteoporosis, traumatic fracture, chronic delirium, and high fall risk, the call light was observed placed on the foot of the bed, out of reach while the resident was in a wheelchair. Staff interviews confirmed that the call light was not accessible and acknowledged that the resident could not reach it, which was contrary to the care plan intervention requiring the call light to be within easy reach and answered promptly. Another resident, admitted with mild cognitive impairment, a left shoulder fracture, and osteoporosis, was also found with the call light placed on the foot of the bed while in a wheelchair. The resident's care plan included an intervention to keep the call light within easy reach due to high fall risk. Staff interviews confirmed the call light was not accessible and that the resident could not reach it, despite the facility's policy requiring call cords to be placed within the resident's reach. A third resident, diagnosed with Alzheimer's disease, dementia, and functional quadriplegia, was observed lying in bed with the call light placed at the uppermost edge of the bed, out of reach. The resident's care plan required the call light to be within easy reach to minimize the potential for falls or injury. Staff acknowledged that the call light was not within reach and that this oversight could delay meeting the resident's needs. Facility policies reviewed indicated that all residents should have immediate access to a functioning call light at all times, and that call cords must be placed within reach in resident rooms.
Failure to Provide Accessible Survey Results to Residents
Penalty
Summary
The facility failed to ensure that residents were aware of the availability and location of the most recent survey results, as well as the corrections made for identified deficiencies. During a Resident Council Meeting attended by nine residents, it was revealed through interviews and observations that none of the residents knew where to find the survey results or how to access information about the facility's corrective actions. Activity staff confirmed that all present residents were unsure of the survey results' location, and this was further corroborated by direct questioning and translation for non-English speakers. Subsequent observations showed that the survey result binder was either missing from its designated location or did not contain the latest survey results and plan of correction. The Administrator acknowledged that the binder was being updated in his office and that staff had not followed instructions regarding its maintenance. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the survey results and corrective actions should be accessible to residents, families, and staff without the need to request them from facility personnel. A review of facility policy also indicated that survey results should be posted in a readily accessible location.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Safe Swallowing Precautions and Incomplete Monitoring After Change in Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident with diagnoses including subdural hemorrhage, Alzheimer’s disease, dementia, muscle weakness, and dysphagia, the care plan and speech language pathology (SLP) evaluation required safe swallowing precautions, a puree diet, and maintaining an upright posture for more than 30 minutes after meals. Observations revealed that after a breakfast meal, the resident’s head-of-bed (HOB) was lowered to a flat position immediately after eating, contrary to SLP recommendations and facility policy. The staff member acknowledged that the HOB should have remained elevated after eating, even if the resident consumed only a small amount, but proceeded to lower the bed for comfort during range of motion exercises. The resident remained flat in bed for a period after eating, and the HOB was only slightly elevated after the exercises were completed. For another resident with dementia, psychosis, dysphagia, and generalized muscle weakness, the care plan required monitoring of food tolerance and oral intake by percentage at each meal, with interventions to prevent further weight loss. The resident experienced a significant weight loss, triggering a change of condition (COC) and a requirement for 72-hour shift charting to monitor the resident’s intake and response. However, there was no documented evidence that this monitoring was completed for the required period. Progress notes did not reflect the necessary 72-hour monitoring, and staff interviews confirmed that the required documentation and monitoring were not performed. Facility policies required staff to promote safe swallowing through proper positioning and to document resident status and care, especially during changes in condition. The failure to maintain the resident’s HOB in an elevated position after meals and the lack of required 72-hour monitoring and documentation for a resident with significant weight loss demonstrate noncompliance with professional standards and facility policy.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Prevent Accident Hazards and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with a history of repeated falls and diagnoses including Alzheimer's disease and osteoporosis, a floor mat intended to prevent injury was found with a wheelchair placed on top of it. Staff interviews confirmed that the resident placed the wheelchair on the mat himself, and that this practice was known to be hazardous. The care plan for this resident did not address the resident's refusal to keep the mat clear, and staff acknowledged that the mat should be free of objects or furniture to prevent injury and maintain its effectiveness. For another resident with chronic congestive heart failure, Alzheimer's disease, and dementia, who was identified as high risk for falls, there was no fall risk assessment completed after a fall incident. Progress notes indicated the resident was found on the floor mat after sliding off the bed, but no post-fall assessment was documented. Staff interviews revealed that fall risk assessments are required after such incidents to evaluate the resident's risk and determine necessary interventions, but this was not completed in this case. Facility policies reviewed indicated requirements for maintaining a hazard-free environment and for completing comprehensive, individualized care plans and fall risk assessments upon admission, quarterly, and after significant events such as falls. Manufacturer specifications for the floor mat also stated that heavy objects should not be left on the mat, as this could damage its protective function. The failure to follow these procedures and policies resulted in increased risk of accidents and injuries for the residents involved.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards for safety and appropriateness. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required.
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 3,659 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — 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 Mission Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Holy Cross Med Ctr D/p Snf | 0 mi | ★★★★★ | 17 | 2 |
| The Grove Post-acute Care Center | 1.6 mi | ★★★★★ | 41 | 0 |
| Granada Hills Convalescent | 1.6 mi | ★★★★★ | 19 | 0 |
| Rinaldi Convalescent Hospital | 1.7 mi | ★★★★★ | 42 | 0 |
| Astoria Healthcare Center | 2.3 mi | ★★★★★ | 24 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ararat Nursing Facility.
100% money-back within 48 hours.
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.