Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Manor Healthcare during CMS and state inspections, most recent first.
Wedge pillows were found tucked under fitted sheets for three residents, limiting movement and functioning as restraints. A resident with Parkinson’s disease, a resident with dementia and psychosis, and a resident with severe cognitive impairment and a prior head injury were observed with wedges placed under the sheets, and staff stated the wedges were being used to prevent falls or keep the residents in bed. The DON and other staff acknowledged that wedges under the sheet can be considered restraints, yet the records did not show the needed physician orders, consent, restraint assessments, or care plans for their use.
A resident with DM, dysphagia, malnutrition, and impaired cognition received repeated SQ Humulin R injections in the same abdominal site instead of having injection sites rotated as ordered. The same resident also received Prostat and ferrous sulfate via g-tube without the tube being flushed between medications during med pass, despite orders and facility policy requiring flushing with water between enteral meds.
A resident receiving Humulin R sliding scale insulin had repeated SQ injections in the same areas instead of rotated sites, despite an order and facility policy requiring site rotation. RN and DON both stated the repeated use of the abdomen and left upper arm was a medication error because it did not follow the prescriber’s order and could contribute to abnormal insulin absorption and skin changes such as lipodystrophy.
Failure to follow the menu and standardized recipe occurred when a cook prepared pureed foods for residents on pureed/IDDSI Level 4 diets without measuring the thickening powder. The cook poured thickener into pureed lasagna by sight and used a spoon tilt test instead of the recipe’s tablespoon directions, while the RD stated the recipe was needed to ensure the food was correct and safe for residents with chewing and swallowing problems.
Unsafe food storage and temperature control were observed in the kitchen. Surveyors found wet food storage bins stacked in the dish area, parmesan cheese with a lid not tightly sealed in a refrigerator, moldy tomatoes and spoiled lettuce in vegetable bins, and an unopened bouillon seasoning tub kept past the allowed storage period. During lunch service, peanut butter cup pudding was also found at 43 to 45 degrees F. The DS and DA acknowledged the storage and temperature problems and stated the items could contaminate food or make residents sick.
Hospice aide visits and documentation were not provided as scheduled for a resident receiving hospice care. The resident had advanced cognitive impairment, was totally dependent for ADLs, and was under hospice care for Alzheimer's disease. The hospice aide was scheduled to visit twice weekly, but two scheduled visits were not shown on the sign-in sheets, and the aide's visit notes were missing from the hospice binder and the resident's record. The DON stated hospice schedules should be followed and the aide notes should be readily available to facility staff.
Infection control failures occurred when CNAs provided direct care to a resident on EBP without wearing gowns, a soiled incontinence brief was left on top of another resident’s bed instead of being bagged and discarded, and dryer temperature checks were not documented for one morning shift. The resident on EBP had wound care orders, and staff and the DON confirmed gowns were required for direct care. For the other resident, RN and DON stated the soiled brief should have been placed in a plastic bag and discarded. Laundry staff and the DON stated dryer temperatures must be checked and recorded three times per shift to support sanitation and prevent mold or bacterial growth.
Call Light Not Within Reach of A Resident. A resident with schizoaffective disorder, drug induced dyskinesia, and mild cognitive impairment had a call light found on the floor beside the bed instead of within reach. The resident’s record and care plan included use of the call light for assistance and a working, reachable call light, and the DON, RN, and LVN all stated the call light should always be within the resident’s reach.
Damaged Bedside Floor Mat: A resident with a history of falls, severe cognitive impairment, and impaired vision had a bedside floor mat ordered for fall prevention, but surveyors observed the mat at the side of the bed had visible cracks and holes. RN and DON stated the damaged mat compromised its purpose as a soft landing surface and was not home-like.
Missing Care Plan for Antifungal Medications: A resident with pneumonia, acute respiratory failure with hypoxia, and pancytopenia was ordered micafungin IV and Cresemba PO for multifocal pneumonia, but the facility had no care plan addressing either antifungal medication. RN and DON stated the care plan should have included goals, interventions, and monitoring for adverse effects, and the facility policy required a comprehensive, person-centered care plan with measurable objectives and timeframes.
A resident with an unhealed stage 4 sacral pressure injury, osteomyelitis, and malnutrition had an order for a LALM for skin integrity and wound care. Staff observed the mattress set at level 2 and on an alternate setting, even though the resident weighed 111 lbs. and the manufacturer’s guidance indicated level 1 for patients up to 120 lbs. The RN and DON both stated the mattress should have been set according to the resident’s weight.
Failure to Provide Ordered ROM Exercises: A resident with hemiplegia/hemiparesis after CVA and ROM limitations in both lower extremities had an order and care plan for RNA AAROM to both legs for maintenance. During observation, the RNA performed some ROM to the hips, knees, and toes but did not complete the ordered left ankle flexion and circumduction exercises. The RNA stated she forgot the left ankle rotation, and the DON stated the exercises should have been provided to maintain ROM and prevent contractures.
A resident’s call light was found on the floor with banana peels in the pathway, and staff confirmed it should have been within reach and the area free of hazards. In another room, a floor mat intended for fall protection had a trash can placed on top of it, and RN and DON both stated the mat should be kept clear so it can function as intended. The residents involved had significant cognitive, mobility, and fall-risk issues, and their care plans called for safe environments with reachable call lights and clear floor mats.
A resident was found using a urinal labeled with another resident’s name after that resident had been discharged. CNA staff saw the urinal in plain sight, and the resident stated he had taken it as a spare and had been using it for a few days. The DON and DSD stated urinals are for one resident only, are labeled with the resident’s name, and staff did not identify and remove the mislabeled urinal during rounds, which the DON stated potentially resulted in a UTI.
An LN failed to complete the Narcotic Check Sheet for controlled medication reconciliation at shift change in the Station 1 med cart, with missing signatures documented on the shift count record. The DON stated the count is part of the controlled drug reconciliation process, and the facility policy requires the incoming and outgoing nurse to count controlled meds together and document any discrepancies.
Missing witness signatures were found on a medication destruction record for a resident’s discontinued Eliquis, even though the facility’s process required two licensed nurses to witness and sign the destruction. In a separate issue, Med Cart 1’s glucometer quality control log showed an out-of-range high control result that was accepted, while staff noted the meter date/time were not set correctly and the control testing was not repeated as required by the UIM and facility practice.
Failure to Monitor Antifungal Medication Adverse Effects: A resident with pneumonia, acute respiratory failure with hypoxia, and pancytopenia received micafungin IV and Cresemba PO, but nursing progress notes did not document monitoring for adverse effects or state that none were present. RN and DON both stated that adverse-effect monitoring should be documented in progress notes, and the DON noted that failure to do so could delay identification of medication-related complications.
A resident with multiple chronic conditions and intact cognitive function reported to staff that a staff member pushed him into the restroom, causing pain. Although the incident was disclosed to a CNA, it was not reported to supervisory staff as required by facility policy. Interviews confirmed that the failure to report the suspected abuse promptly could have resulted in ongoing harm, and the facility's abuse reporting procedures were not followed.
A resident with multiple health conditions had not been seen by their Attending Physician (AP) for six months, contrary to the facility's policy requiring visits every 60 days. Instead, a Nurse Practitioner (NP) conducted monthly visits. The resident expressed not having seen the AP for a long time, and the Director of Nursing (DON) confirmed the policy was not followed, highlighting the importance of timely AP visits for health assurance and trust.
A resident with diabetes was not served the prescribed therapeutic diet, as staff allowed extra food portions without notifying the charge nurse. This oversight could lead to elevated blood sugar levels. Interviews revealed a lack of communication and awareness among staff regarding the resident's dietary needs.
Two residents were not treated with dignity during feeding and hydration assistance, as staff stood over them instead of sitting at eye level. Additionally, staff referred to a resident's disposable brief as a diaper, contrary to facility policy, potentially impacting the resident's dignity.
A resident with dementia and muscle weakness was subjected to a pommel cushion restraint without a physician's order, informed consent, or a restraint assessment. Staff were aware of the cushion's use but lacked documentation and authorization, violating the facility's restraint policy.
The facility failed to develop comprehensive care plans for residents, leading to potential delays in care. A resident's care plan lacked the use of a pommel cushion despite a high fall risk, another resident's plan did not address a floor mat for fall prevention, and a third resident's plan failed to include oxygen therapy interventions. Additionally, a wheelchair obstructed a floor mat intended to prevent injury for another resident.
A facility failed to rotate insulin injection sites for several residents, increasing the risk of adverse effects like lipodystrophy. Despite policies and guidelines requiring site rotation, records showed repeated use of the same sites. The DON confirmed the deficiency, acknowledging the potential harm to residents.
The facility failed to maintain ARC/AHA CPR certification for key staff, as required by its policy. Three employees had certifications from the National CPR Foundation, which lacked hands-on training. Interviews revealed a lack of awareness about the need for in-person training. This deficiency could delay emergency care for residents.
The facility failed to maintain a safe environment for two residents by improperly using floor mats intended to prevent fall injuries. A resident's floor mat was incorrectly placed with a wheelchair and overbed table on top, while another resident's mat was obstructed by a wheelchair belonging to a different resident. These practices compromised the mats' effectiveness and increased the risk of injury.
The facility failed to rotate insulin injection sites for several residents, leading to significant medication errors. Despite clear guidelines and policies, insulin was repeatedly administered in the same areas, increasing the risk of adverse effects. This deficiency was confirmed through interviews and record reviews, highlighting a lapse in following professional standards.
The facility did not meet the nutritional needs of 17 residents on puree diets due to improper food texture. Observations revealed that polenta and carrots served were runny and unable to hold their shape, contrary to the facility's standardized recipes and IDDSI guidelines. The Dietary Supervisor and Registered Dietitian acknowledged these issues, emphasizing the importance of following recipes to ensure proper texture and nutrition.
A facility failed to prepare food that conserved flavor and appearance, as seen with a resident who received watery polenta and a frozen salad. The resident expressed dissatisfaction with the food's appearance and taste. The Dietary Supervisor and Registered Dietitian confirmed the issues, noting that poor presentation could affect residents' appetites. The facility's policies required food to be prepared using standardized recipes to maintain quality, but these were not followed.
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. Issues included unlabeled food items, improper storage of staff food, and a staff member drinking from an uncovered tumbler in the kitchen. Additionally, wet stacking of pans, dirty ice machine parts, and a cellphone stored in a clean area were noted, all contrary to facility policies and the Food Code 2022.
The facility failed to enforce its policy on storing food brought by family or visitors for residents, due to the lack of designated refrigerator space. The Dietary Supervisor and other staff acknowledged that food for more than one meal was disposed of, as storing it in the kitchen's refrigerator posed a risk of cross-contamination. This led to potential feelings of deprivation among residents, as confirmed by interviews with the LVN and DON.
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. A resident's indwelling catheter drainage bag was observed touching the floor, contrary to facility policy. Enhanced Barrier Precautions were not implemented for another resident, with staff failing to don gowns during high-contact activities. Additionally, a resident's nasal cannula tubing was found touching the floor, risking cross-contamination. These actions were against the facility's infection control policies, putting residents at risk of infection.
The facility failed to obtain informed consent for a COVID-19 vaccine for a resident lacking decision-making capacity, did not consult a physician before withholding the vaccine from another resident, and did not document vaccine education for a third resident. These actions were contrary to the facility's policies and procedures.
A resident with dementia and requiring maximal assistance was given hydration by an unqualified Activities Assistant, contrary to the care plan which specified that only CNAs should assist with feeding and hydration. This was confirmed by facility staff and policy documents, highlighting a failure to adhere to the resident's care plan.
A resident receiving enteral feeding did not have their tube feeding set replaced as required, leading to a deficiency in infection control practices. The facility failed to change the tube feeding formula and water flush bag after 24 hours, as confirmed by staff interviews and facility protocols. This oversight posed a risk of infection and disrupted nutrition delivery.
A resident with chronic respiratory failure and hypoxia did not receive continuous oxygen therapy as ordered, as their oxygen tank was found empty. The facility's staff, including an RN and the DON, acknowledged the oversight, which was contrary to the physician's order and the facility's policy for oxygen therapy.
A facility failed to assess the medical need and risks of bed rail use for a resident with dementia and epilepsy, leading to the use of inappropriate side rails without informed consent. Observations showed a gap between the mattress and side rails, posing an entrapment risk. Staff confirmed the discrepancy between the physician's order and the actual rails used, and the facility did not follow its policy for bed rail assessment and consent.
A resident was administered Celebrex daily without assessing their pain level, contrary to physician orders. The medication was prescribed for moderate pain, but was given even when the resident's pain level was documented as zero. The nurse failed to assess pain or attempt non-drug interventions before administering the medication, as confirmed by the DON.
A facility failed to store a Humalog insulin vial for a resident according to manufacturer's requirements. The vial was found at room temperature without a date indicating when storage began, contrary to guidelines. The Director of Nursing confirmed the vial should have been refrigerated or labeled with a date. This oversight could lead to medication errors due to the administration of expired insulin.
A facility failed to document the offering and review of advance directives for a resident with dementia and other conditions, as required by their policy. The resident's MDS indicated they could communicate effectively, but no advance directive was recorded. The DON and SSD acknowledged the lapse, with the SSD admitting to forgetting the documentation, which is crucial for understanding the resident's end-of-life care preferences.
A resident in an LTC facility received pneumococcal and influenza vaccines without informed consent. The resident, who lacked decision-making capacity, was administered vaccines without the necessary consent from their public guardian. The Infection Preventionist assumed consent was obtained, but the forms were unsigned. The Director of Nursing confirmed the facility's policy was not followed, risking unwanted treatment for the resident.
The facility failed to notify the physician when a resident with an indwelling catheter showed signs of a urinary infection. Despite policies requiring immediate reporting, staff observed changes in the resident's urine output but did not inform the physician, potentially delaying medical intervention.
A resident's urinary indwelling catheter was not secured with a securement device, contrary to the facility's policy. The resident, who had multiple urinary-related diagnoses, was observed without the necessary securement, and staff confirmed the catheter should have been anchored to prevent dislodgement and infection.
Wedge Pillows Used as Unordered Restraints
Penalty
Summary
The facility failed to ensure three sampled residents were free from physical restraints when wedge pillows were placed under fitted sheets on both sides of the body or at the middle of the bed. For Resident 29, who had diagnoses including Parkinson’s disease with dyskinesia, major depressive disorder, and encephalopathy, the record showed impaired decision-making capacity in the H&P and dependence on staff for multiple ADLs in the MDS. During observation, bilateral foam wedge pillows were seen tucked under the fitted sheet on both sides of the resident while the resident was in bed, and staff and the resident’s family member stated the wedges were being used to keep the resident from falling out of bed or moving freely. Staff interviews confirmed the wedges were under the sheet, that they limited movement, and that the resident did not have a physician’s order or care plan for their use. For Resident 9, whose diagnoses included dementia, psychosis, and a history of falling, the record showed fluctuating capacity in the H&P and severe cognitive impairment with total dependence on staff for ADLs in the MDS. The order summary did not show a physician’s order for wedge pillows tucked under the fitted sheet. During observation, wedge pillows were seen tucked under the fitted sheet on both sides of the resident’s legs, and a CNA stated the wedges were placed there so they would not slide down because the resident moved his legs. The DON stated the wedges were being used for positioning, but also acknowledged they could be considered a restraint if tucked under the fitted sheet because they limit voluntary movement and make it harder for the resident to get out of bed. The DON further stated there was no restraint order, consent, or evaluation for the wedges under the sheet. For Resident 77, who had diagnoses including traumatic subdural hemorrhage, history of falling, and a nondisplaced Type II dens fracture, the H&P described the resident as oriented to person only with confusion, disorientation, fatigue, and frequent agitation, and the MDS showed severely impaired cognition and dependence on mobility and ADLs. The order summary did not include an order for wedge pillows. During observation, a bilateral wedge pillow was placed in the middle of the bed and tucked under the sheets while both upper side rails were up. Staff stated the wedges were used to prevent the resident from getting out of bed and falling, and one LVN stated the wedges were being used as a physical restraint. That LVN also stated there was no physician’s order, informed consent, restraint assessment, or care plan for the use of the wedges as a restraint. The DON stated that wedges tucked under the sheet become a restraint because they limit the resident’s ability to get out of bed easily.
Failure to Rotate Insulin Sites and Flush G-Tube Between Medications
Penalty
Summary
Licensed nursing staff failed to provide insulin administration in accordance with professional standards for one resident with type 2 diabetes mellitus, dysphagia, moderate protein-calorie malnutrition, and severely impaired cognition. The resident had orders for Humulin R sliding scale insulin with instructions to rotate injection sites. The resident’s location of administration report showed repeated subcutaneous injections in the same abdominal left lower quadrant site on multiple occasions, with additional injections given in the left rear upper arm and then again in the abdominal left lower quadrant. RN 1 stated there were multiple occasions when licensed staff did not rotate the insulin administration sites, and the DON stated the site should have been rotated. The resident’s care plan included diabetes medication as ordered by the physician and monitoring/documenting side effects and effectiveness. The facility’s insulin administration policy stated that injection sites should be rotated, preferably within the same general area, and the Humulin-R prescribing information stated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. The record review and staff interviews established that the resident’s insulin was repeatedly administered at the same site rather than being rotated as ordered and as described in the facility policy. Licensed nursing staff also failed to flush the resident’s g-tube between medications during medication administration. The resident had diagnoses including dysphagia and anemia and had orders for Prostat and ferrous sulfate via g-tube, along with an enteral order allowing fluids via the tube before and after medication administration. During observation, LVN 1 administered Prostat and ferrous sulfate through the g-tube without flushing the tubing with water in between the medications. LVN 1 stated the medications should have been flushed in between, and RN 1 and the DON both stated the g-tube should have been flushed between medication administrations.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident receiving insulin was free from significant medication errors when licensed staff did not rotate subcutaneous insulin administration sites as ordered and as required by the facility’s insulin administration policy. Resident 4 was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and type 2 DM, and the record also indicated impaired cognition and that the resident did not have the capacity to understand and make decisions. The resident had an order for Humulin R sliding scale insulin subcutaneously twice daily, with the instruction to rotate the injection site. Review of the insulin location administration record showed repeated injections in the same area, including multiple administrations in the abdomen-left lower quadrant and repeated use of the left rear upper arm. During interview, RN 1 stated there were multiple occasions when licensed staff did not rotate the insulin administration sites and stated this was a medication error because it did not follow the physician’s order and could lead to skin irritation and lipodystrophy. The DON also stated the site should have been rotated and identified the failure to rotate as a medication error. The facility’s policy on insulin administration stated that injection sites should be rotated, preferably within the same general area, and the facility’s medication error policy defined a medication error as administration not in accordance with the physician’s orders, manufacturer specifications, or accepted professional standards. The manufacturer information for Humulin R also stated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Failure to Follow Pureed Diet Recipe and Menu
Penalty
Summary
The facility failed to follow the menu and did not meet the nutritional needs of 15 of 85 residents on pureed texture diets when Cook 1 prepared pureed vegetables for lunch service without following the recipe for the amount of thickening powder. During observation in the food preparation area, Cook 1 was seen pouring a white powder into a container of pureed Italian lasagna without using a measuring tool. Cook 1 stated the powder was thickening powder and that the facility did not use a measuring spoon to thicken the pureed diet, instead checking consistency by doing a spoon tilt test. Cook 1 also stated the facility usually used potato powder to thicken pureed diet, but it had run out because the delivery earlier in the day did not arrive as expected, so food thickener was used instead as indicated in the recipe. Record review showed the facility’s Winter Menus for the day included pureed Italian lasagna, pureed seasoned broccoli, pureed garlic bread, peanut butter cup pudding, and milk for residents on pureed and IDDSI Level 4 diets. Review of the recipe for Pureed IDDSI Level #4 Meats showed that stabilizer such as instant potato, non-fat dry milk, or commercial instant food thickener could be used, with the amount specified in tablespoons depending on the number of servings. The recipe stated the finished pureed item should be smooth, free of lumps, hold its shape, not be too firm or sticky, and pass IDDSI Level 4 testing requirements. The RD stated the recipe should be followed to ensure the food is correct and safe for residents on pureed diets, and that Cook 1 should have used the measuring spoon as indicated rather than pouring thickener from the can. The facility policy stated menus are planned to meet nutritional needs and standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
Unsafe Food Storage and Temperature Control
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During an initial kitchen tour with the Dietary Supervisor, surveyors observed seven clear food storage bins stacked wet in the area next to the dishwashing area, a container of grated white cheese labeled parmesan cheese inside Refrigerator 2 with a lid that was tightly sealed, two tomatoes with black spots and two tomatoes with white fluffy material in a clear vegetable bin, one head of lettuce with brown discoloration on the leaves and bottom part in another vegetable bin, and an unopened tub of beef bouillon seasoning in the dry storage room with a received date of 9/17/2025 and an expiration date of 2/5/2026. The Dietary Supervisor stated the wet pans should not have been stacked before air drying, the cheese container lid should have been tightly sealed, the tomatoes with mold should have been discarded, the lettuce with discoloration should have been discarded, and the bouillon seasoning should have been checked for expiration at delivery. During the same observations and interviews, the Dietary Supervisor stated that the tomatoes with black spots and white fluffy material were moldy and that all tomatoes in the bin should have been discarded because they were contaminated. The Dietary Supervisor also stated the lettuce showed signs of spoilage and should have been discarded, and that serving an expired food item could place residents at risk for foodborne illnesses. The facility’s policies and procedures reviewed by surveyors stated that dishes are to be air dried before stacking and storing, food and supplies are to be stored properly and safely, food items are to be used according to dry storage guidelines, and no food is to be kept longer than the expiration date on the product. Surveyors also observed a temperature issue during lunch service when the peanut butter cup pudding was checked and found between 43 degrees F and 45 degrees F. A Dietary Aide stated the dessert cart had just been removed from the walk-in refrigerator and did not know why the temperature was between 43 degrees F and 45 degrees F. The Dietary Aide stated cold food should be at least 41 degrees F and below and that the pudding contained milk. The report also cited Food Code provisions related to cold holding temperatures and protecting food from contamination during storage.
Hospice aide visits and documentation were not provided as scheduled
Penalty
Summary
The facility failed to ensure hospice services were provided consistently for one resident receiving hospice care. The resident was admitted under hospice care for routine level of care with a primary diagnosis of Alzheimer's disease and had a history of dementia, psychosis, and falls. The resident's H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognition, inability to understand and make needs known, and total dependence on staff for all ADLs. A review of the hospice binder and clinical record showed the hospice aide was scheduled to visit the resident two times per week according to the hospice Team Care Plan and calendar of visits. The sign-in sheets did not show visits on two scheduled dates, and the hospice aide visit notes were not present in the binder or the resident's record for the reviewed visit dates. RN 4 stated the aide should have visited as scheduled and that the visit notes should have been completed and placed in the binder as soon as the visits were finished. The DON stated hospice providers have a schedule of visits that should be followed and that if hospice staff are unable to visit as scheduled, it should be documented in the notes or calendar on the day the visit is to be replaced. The DON also stated the hospice aide notes should be part of the resident's medical record and readily available in the hospice binder or EHR so facility staff are aware of the services provided. The facility policy stated hospice and facility staff are to coordinate care and communicate to ensure the resident's needs are addressed and met 24 hours per day.
Infection Control Program Failures
Penalty
Summary
The facility failed to maintain its infection prevention and control program in multiple areas. Resident 44 was admitted and later readmitted with diagnoses including cholelithiasis, hypertensive heart disease, and normal pressure hydrocephalus. The resident’s H&P indicated capacity to understand and make decisions, while the MDS indicated the resident could make himself understood and understand others, with moderately impaired cognition. The resident had an order for enhanced barrier precautions due to wound care, and the care plan directed staff to use gloves, gown, and mask before providing ADL care and respiratory treatment care. During a concurrent observation and interview, two CNAs were seen in Resident 44’s room wearing gloves while boosting the resident in bed and assisting him with lunch, but they did not wear gowns. One CNA stated the resident was on enhanced barrier precautions due to wounds and acknowledged that both CNAs should have worn gowns while repositioning the resident and assisting with lunch. The CNA stated she had been trained on enhanced barrier precautions and what PPE to wear, but had forgotten to wear the gown. RN 1 and the DON both stated the CNAs should have worn gowns while providing direct care to the resident, and the DON stated staff should wear a gown, mask, and gloves when providing direct care to residents on enhanced barrier precautions. The facility also failed to manage soiled linen appropriately for Resident 68. Resident 68’s record showed diagnoses including alcohol use, traumatic subdural hemorrhage, and abnormalities of gait and mobility. The resident was documented as unable to understand and make decisions in the H&P, while the MDS indicated intact cognition, incontinence of bowel and bladder, and need for substantial to maximal assistance with ambulation and other ADLs. During observation in the resident’s room, a soiled incontinence brief was found rolled up on top of the bed at the foot area. RN 1 stated the brief should have been placed in a plastic bag and discarded after ADL care rather than left on the bed, and the DON stated the brief should have been placed in a plastic bag and discarded in the designated bin because it contaminated the bed sheets. The facility further failed to complete dryer temperature documentation for three dryers on one morning shift. Laundry staff reviewed the dryer temperature log and found the entry blank for that shift. A laundry staff member stated she was responsible for checking and documenting dryer temperatures three times per shift, and another laundry staff member stated she forgot to document the temperatures because the morning shift was busy. The Maintenance Supervisor stated laundry staff are required to record dryer temperatures three times per shift, and the DON stated the checks are done to maintain accurate temperatures and prevent mold and bacterial growth. The facility’s infection control and laundry policies stated that infection control measures are intended to maintain a safe, sanitary, and comfortable environment and that dryer temperatures must be checked and documented three times per shift.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to keep the call light within reach of one sampled resident, Resident 26. Resident 26’s record showed diagnoses including schizoaffective disorder, drug induced dyskinesia, and mild cognitive impairment. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident could make self-understood and understand others and had intact cognition. The resident’s OSR documented orientation to the room using the call light for assistance, and the care plan included an intervention for a safe environment with a working and reachable call light. During a concurrent observation and interview, the resident’s call light was found resting on the floor at the left side of the bed. LVN 1 stated the call light should always be within the resident’s reach because the resident is a fall risk and could fall while reaching for it. RN 1 reviewed the photograph and stated the call light was on the floor and the resident could fall while reaching for it; RN 1 also stated the facility policy is to always keep the call light within the resident’s reach so the resident can call for help when needed. The DON stated the call light should always be within the resident’s reach so the resident can make needs known, and that CNAs and charge nurses were responsible for checking call light placement during safety rounds.
Damaged Bedside Floor Mat
Penalty
Summary
The facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment by allowing a bedside floor mat at the left side of the bed to remain in use with visible cracks and holes. Resident 77 was admitted with diagnoses including traumatic subdural hemorrhage, history of falling, and nondisplaced type II dens fracture, and was described as oriented to person only with ongoing confusion, disorientation, fatigue, frequent agitation, impaired vision, severely impaired cognition, and dependence for mobility and ADLs. The resident's records showed the floor mat was ordered as a less restrictive fall-prevention measure and was included in the care plan for fall risk related to psychoactive drug use, dementia, vision/hearing problems, and a history of falls with injury. During observation, RN 1 saw the damaged mat and stated it should not have cracks or holes because it compromised its use and was not home-like. The DON also stated the mat should not have any cracks or holes because it compromised the purpose of providing a soft, safe landing surface and did not promote a home-like environment.
Missing Care Plan for Antifungal Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one sampled resident who was receiving antifungal medications. The resident was originally admitted on 12/4/2025 and later readmitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, and pancytopenia. The resident’s H&P dated 1/10/2026 indicated the resident had the capacity to understand and make decisions, and the MDS dated 1/14/2026 indicated the resident could make self-understood and understand others, but required substantial assistance with toileting hygiene, showering/bathing, and several mobility tasks. The resident had orders for micafungin sodium-sodium chloride IV solution 150 mg daily for multifocal pneumonia for 28 days, dated 1/10/2026, and isavuconazonium sulfate (Cresemba) 186 mg, two capsules by mouth daily for multifocal pneumonia until 3/08/2026, dated 1/14/2026. During interview and record review, RN 1 stated there was no care plan addressing the use of micafungin and Cresemba and that a care plan should have been developed and implemented when the medications were started. RN 1 stated the care plan is used to monitor the resident, includes interventions and goals of care, and is used to monitor for adverse effects. The DON stated the care plan is a communication tool to address the resident’s care and that monitoring for adverse effects is one of the interventions for antifungal medications. The facility policy stated a comprehensive, person-centered care plan with measurable objectives and timeframes is to be developed and implemented for each resident.
Low Air Loss Mattress Set Incorrectly for Resident With Stage 4 Pressure Injury
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for one resident with an unhealed stage 4 sacral pressure injury. The resident had diagnoses including osteomyelitis of the vertebra, sacral and sacrococcygeal pressure ulcer, and protein-calorie malnutrition. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognition, dependence for mobility and ADLs, and risk for pressure injuries with a pressure-reducing device for bed in place as a treatment. The resident had an order for a low air loss mattress for skin integrity maintenance and wound care management, with staff to check placement and function every shift. The care plan also included use of a low air loss mattress for the stage 4 sacrococcyx pressure ulcer. During observation, the resident’s low air loss mattress was set at two and on an alternate setting. The resident’s weight was documented as 111 lbs. During interview and record review, the RN stated that when there is no specific physician setting, the mattress should be set according to the resident’s weight and that the manufacturer’s specification indicated the mattress should have been set at one for a resident weighing 111 lbs. The DON also stated the resident’s weight should have been set to one per the operations manual. The facility’s owner’s manual stated that for patients up to 120 lbs., the comfort level should begin at level one.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to ensure that one sampled resident received appropriate restorative nursing services to maintain range of motion in the left lower extremity. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, moyamoya disease, and dysphagia. The resident’s assessment indicated functional limitation impairments in ROM on both lower extremities and substantial to maximal assistance needs for mobility, including rolling, sitting, transfers, and other bed and chair movements. The resident had an order for RNA active assistive ROM exercises to both lower extremities five times per week or as tolerated for maintenance, and the care plan included RNA services to maintain maximum joint mobility. During observation, the resident was lying in bed with the left foot sole against the footboard while the RNA performed ROM to the left hip and knee, turned the sole of the foot laterally, and performed ROM to the left toes. The RNA did not perform flexion and circumduction ROM exercises on the left ankle and foot. The RNA also performed ROM to the right hip and knee, then stopped when the resident complained of right leg pain. During interview, the RNA stated she forgot to perform the left ankle rotation and thought she may have performed left ankle flexion, but acknowledged she should have provided the exercises and that ROM is intended to maintain movement and prevent contractures. The DON stated the exercises should have been provided to maintain range of motion and that not providing them could result in contractures, muscle strains, and joint sprains. The facility policy on ROM exercises stated the purpose was to improve or maintain joint mobility, prevent contractures, increase strength and activity tolerance, reduce pain, and prevent complications of immobility.
Unsafe Resident Environment and Obstructed Fall Protection
Penalty
Summary
The facility failed to keep a resident’s call light within reach and failed to keep the resident’s room free of banana peels on the floor. Resident 26 was admitted and later readmitted to the facility with diagnoses including schizoaffective disorder, drug induced dyskinesia, and mild cognitive impairment. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated intact cognition and a need for supervision assistance with mobility and ADLs. The resident’s care plan included interventions for a safe environment, including a working and reachable call light and floors free from spills and clutter. During a concurrent observation and interview, the resident’s call light was seen resting on the floor at the left side of the bed, and banana peels were observed on the floor pathway. An LVN stated the call light should always be within the resident’s reach and that banana peels should not be on the floor because the resident could step on them and slip. RN 1 later reviewed the photograph and confirmed the call light was on the floor and banana peels were on the resident’s pathway. RN 1 stated the facility policy is to keep the call light within reach and to keep the environment free of clutter or hazards. The DON also stated the call light should always be within reach and that banana peels should not be on the resident’s pathway. The facility also failed to keep a floor mat clear of objects for another resident. Resident 77 was admitted with diagnoses including traumatic subdural hemorrhage, history of falling, and a nondisplaced type II dens fracture. The resident’s H&P described the resident as oriented to person only with ongoing confusion, disorientation, fatigue, and frequent agitation. The MDS indicated severely impaired cognition, impaired vision, and dependence for mobility and ADLs. The resident’s care plan included a safe environment with a working and reachable call light, bed in low position, and floor mats if ordered. During a concurrent observation and interview, the resident’s floor mat at the right side of the bed was observed with a trash can on top of it. RN 1 stated there should be no objects or equipment on top of the floor mat because it defeats the purpose of the mat as a soft, safe landing surface. The DON stated the floor mat should not have any objects on top of it because it compromises the mat’s purpose and could cause injury if the resident falls or rolls from the bed. The facility’s floor mat guidance stated bedside floor mats must be clear of obstruction or clutter to maintain their purpose and function.
Urinal Labeled for Discharged Resident Left in Another Resident’s Room
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent UTIs for one resident when a urinal labeled for a discharged resident was left in the resident’s room and available for use. Resident 5 was admitted with diagnoses including acute and chronic venous hypertension with bilateral lower-extremity ulcers, MRSA, and an open wound on the left thigh. The resident’s assessment indicated he could understand others and make himself understood, but he was dependent on staff for toileting and mobility, and his history and physical noted he had recently been hospitalized for sepsis and had the capacity to understand and make decisions. Resident 42 had been admitted with bacteriuria and was totally dependent on staff for toileting. During observation, Resident 5 was seen awake in bed with a urinal hanging from the left side of the bed that was labeled with Resident 42’s name. CNA 3 entered the room and saw the urinal in plain sight. Resident 5 stated he needed a spare urinal and had taken Resident 42’s urinal a couple of days earlier when that resident was discharged. CNA 3 then left the room, leaving the urinal labeled for Resident 42 within reach of Resident 5. During follow-up interview, CNA 3 stated Resident 5 had been using Resident 42’s urinal and that Resident 42 had been discharged three days earlier, meaning Resident 5 must have been using the urinal for a few days. CNA 3 stated Resident 5 should not be using another resident’s urinal because there was a risk for infection. The DSD and DON stated urinals are used for only one resident, are labeled with the resident’s name, and should be identified during rounds; they stated CNA 3 did not make initial rounds to check Resident 5’s urinal. The DON stated the facility procedure was not followed when Resident 5 had a urinal labeled for Resident 42, potentially resulting in a UTI in Resident 5.
Incomplete Controlled Medication Reconciliation Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet residents’ needs by not ensuring licensed nurses completed the Narcotic Check Sheet at every change of shift for controlled medications in the Station 1 Medication Cart. During a medication storage observation, LVN 2 reviewed the 2/2026 Narcotic Check Sheets and identified that on 2/10/2026 at 3 p.m. the outgoing and incoming LN signatures were not documented, and on 2/10/2026 at 11 p.m. the outgoing LN signature was not documented. LVN 2 stated that if the narcotic count was not documented, it was considered not done. LVN 1 stated he forgot to sign the Narcotic Check Sheet on 2/10/2026 at 3 p.m. with the incoming LN because it was a crazy shift. The DON reviewed the facility policy and stated the Narcotic Check Sheet is part of the controlled drug reconciliation process that occurs at every shift change by the incoming and outgoing LN. The DON stated the nurses did not follow the policy when the Narcotic Check Sheet was not completed, which could result in unidentified discrepancies and missing narcotics. The facility policy stated nursing staff count controlled medication inventory at the end of each shift, the incoming and outgoing nurse make the count together, and discrepancies are documented and reported.
Missing Witness Signatures on Medication Destruction and Out-of-Range Glucometer Control Testing
Penalty
Summary
The facility failed to ensure proper documentation when Eliquis for a resident with Alzheimer’s disease, pain in both legs, and hypotension was discontinued and destroyed. The resident’s record indicated the resident lacked capacity to understand and make decisions. During observation in the medication room, RN 4 stated the discontinued Eliquis had already been destroyed and that two licensed nurses are supposed to witness medication destruction and sign the medication destruction log. However, the medication destruction log for the resident’s Eliquis did not contain the required signatures of the two licensed nurses who destroyed the medication. During interview, the DON stated the facility’s process requires two licensed nurses to count the remaining medication, document the medication information on the log, and sign the record. The DON stated the signatures should have been recorded when the medication was destroyed and that the missing signatures created a gap in documentation and no proof that the medication was destroyed. The facility policy titled Discarding and Destroying Medications stated that the medication disposition record must contain, at a minimum, the signature of witnesses. The facility also failed to properly perform and repeat glucometer control solution testing on Med Cart 1. Review of the glucometer quality control log and memory showed a high control result of 343, which was outside the acceptable high range. Staff observed that the glucometer date and time were not set correctly and that some control testing results did not display the control icon. RN 5 stated that when a control solution result is out of range, the test should not be accepted and must be repeated, and the DON stated the out-of-range result should not have been accepted and the test must be repeated. The user instruction manual stated that if the control solution result is out of range, the system should not be used until the result is within range.
Failure to Monitor Antifungal Medication Adverse Effects
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for one sampled resident by not monitoring for adverse effects while the resident received micafungin and isavuconazonium sulfate (Cresemba). Resident 37 was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, and pancytopenia. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident could make self-understood and understand others and required substantial assistance with several ADLs. Physician orders showed micafungin sodium-sodium chloride IV 150 mg daily for multifocal pneumonia for 28 days and isavuconazonium sulfate 186 mg capsules, two by mouth daily for multifocal pneumonia until 3/8/2026. Drug information reviewed for Cresemba listed warnings and precautions including severe hepatic adverse drug reactions, anaphylactic reactions, and severe skin reactions. Micafungin drug information listed side effects including anxiety, black tarry stools, bleeding gums, swelling, coma, confusion, cough, decreased urine output, agitation, back pain, chest pain, dizziness, headache, and nervousness. During record review, nursing progress notes from 2/8/2026 through 2/11/2026 did not specify that there were no adverse effects from micafungin and Cresemba. RN 1 stated that when residents are started on antibiotics, the facility monitors for adverse effects and documents this in the nursing progress notes, including either no adverse effects or assessments such as vital signs, fever, and GI problems. The DON stated Cresemba should be monitored for adverse effects and that nurses document this in progress notes, with a change of condition completed if adverse effects occur; the DON also stated that if the resident is free from adverse effects, nurses would document that there are no adverse effects on the medication.
Failure to Timely Report Suspected Physical Abuse
Penalty
Summary
The facility failed to report an incident of suspected physical abuse involving a resident with multiple diagnoses, including COPD, schizoaffective disorder bipolar type, and diabetes mellitus. The resident, who had intact cognitive functioning and required staff assistance for daily activities, reported to a registered nurse that a staff member had pushed him into the restroom, causing pain, while he was resisting by holding onto the door frame. The incident was also disclosed to a certified nurse assistant, who acknowledged understanding that such actions could constitute physical abuse but did not report the incident to her supervisor as required. Interviews with staff confirmed that the incident was not reported immediately, and the facility's policy mandates that all employees are required to report suspected abuse, neglect, or exploitation immediately to the administrator and appropriate authorities. The administrator and registered nurse both recognized that the failure to report the incident on the same day as the complaint could result in ongoing harm to the resident. The facility's policy on abuse reporting and investigation was not followed in this case, as the initial report of abuse was not promptly communicated to supervisory staff or external authorities.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Attending Physician (AP) visited a resident in a timely manner, as required by their policy. The resident, who was admitted with conditions including hypertension, chronic kidney disease, diabetes mellitus, and epilepsy, had not been seen by the AP for six months. Instead, a Nurse Practitioner (NP) conducted monthly visits. The resident expressed during an interview that he had not seen his AP for a long time, indicating a lapse in the required face-to-face visits. The facility's policy mandates that the AP must visit residents at least once every 30 days for the first 90 days following admission, and then at least every 60 days thereafter. However, the AP last visited the resident on 5/17/2024, with subsequent visits conducted by an NP. The Director of Nursing (DON) acknowledged that the policy was not followed, emphasizing the importance of timely AP visits to ensure the resident's health and to build trust. This deficiency had the potential to result in an undetected decline in the resident's medical, health, or psychosocial condition.
Failure to Adhere to Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed by the physician for a resident with schizoaffective disorder, diabetes mellitus, and essential hypertension. The resident was admitted with a physician's order for a controlled carbohydrate diet, regular texture, thin regular liquid consistency, non-fat milk, and large portions with all meals. However, the facility did not adhere to this order, as the resident was allowed to request and receive a second plate of food without the knowledge or approval of the charge nurse, which could lead to elevated blood sugar levels. Interviews with facility staff revealed a lack of communication and adherence to the prescribed diet. A Certified Nursing Assistant (CNA) did not inform the charge nurse when the resident requested additional food, and the CNA was unaware of the resident's diabetic condition. The Dietary Supervisor and a Registered Nurse confirmed that providing extra portions could result in uncontrolled blood sugar levels. The Director of Nursing stated that the facility's policy required CNAs to inform charge nurses of such requests, who would then communicate with the kitchen staff. The facility's policy and procedure for diet orders emphasized the importance of following the physician's orders, which was not done in this case.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of two residents during feeding and hydration assistance. Certified Nursing Assistant 6 assisted a resident with feeding while standing over them, rather than sitting at eye level, which is against the facility's policy for maintaining resident dignity. Similarly, Activities Assistant 1 provided hydration to another resident while standing over them, without being informed of the proper procedure to sit at eye level. Both actions were observed during interviews and were acknowledged by the staff as not aligning with the facility's standards for resident dignity. In another incident, the facility staff failed to use appropriate language when referring to incontinence products for a resident with an indwelling catheter. Treatment Nurse 1 and CNA 2 repeatedly referred to the resident's disposable brief as a diaper, which is considered a dignity issue according to the facility's policy. The staff acknowledged their mistake and the potential negative impact on the resident's self-esteem and dignity. The facility's policies emphasize the importance of treating residents with dignity and respect, including using appropriate language and maintaining eye-level interaction during care. The deficiencies observed in these cases highlight a failure to adhere to these policies, potentially affecting the residents' psychosocial wellbeing.
Improper Use of Restraints Without Authorization
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and assessment. Specifically, a pommel cushion was used on Resident 60, who was admitted with diagnoses including dementia and generalized muscle weakness, without obtaining a physician's order, informed consent from the resident or their representative, and without completing a restraint assessment. The pommel cushion was intended to prevent the resident from sliding out of the wheelchair due to a history of falls, but it restricted the resident's movement. Observations and interviews revealed that staff, including an Activity Assistant, a Restorative Nursing Assistant, and a Certified Nursing Assistant, were aware of the use of the pommel cushion on Resident 60 but could not specify when it was first used. The Registered Nurse confirmed that there was no physician's order, informed consent, or restraint assessment documented for the use of the pommel cushion. The Director of Nursing also acknowledged that the facility's policy and procedure for the use of restraints were not followed, as evidenced by the lack of necessary documentation and assessments. The facility's policy on the use of restraints, last reviewed in July 2024, clearly states that restraints should only be used for the safety and well-being of residents after alternatives have been tried unsuccessfully, and only with a physician's order and informed consent. The policy also emphasizes that restraints should not be used for staff convenience or to prevent falls. The failure to adhere to these guidelines resulted in the inappropriate use of a restraint device on Resident 60 without proper authorization and assessment.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential delays in necessary care and services. For Resident 60, the care plan did not include the use of a pommel cushion, which was being used to prevent the resident from sliding out of the wheelchair due to a high risk of falls. Despite the resident's history of falls and the use of the cushion being verified by staff, the care plan lacked this critical intervention. Similarly, Resident 17's care plan did not address the use of a floor mat, which was intended to prevent injury from falls. Although the resident was at high risk for falls and the floor mat was observed in use, the care plan had not been updated to reflect this intervention since it was marked as resolved in 2017. This oversight left staff without guidance on the current interventions in place to minimize fall risks. For Resident 57, the care plan included the use of floor mats to decrease injury from falls, but the presence of another resident's wheelchair on the mat compromised its effectiveness. The care plan did not address this issue, potentially placing the resident at risk of injury. Additionally, Resident 3's care plan failed to include interventions for oxygen administration, despite the resident's need for oxygen therapy due to COPD. This omission could lead to a delay in care during episodes of respiratory distress.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for four out of five sampled residents. This deficiency was identified during a survey that included interviews and record reviews. The residents involved were receiving insulin for diabetes management, and the failure to rotate injection sites increased the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. Resident 14, who was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and obesity, had insulin administration sites that were not rotated as per the facility's policy and manufacturer's guidelines. The Medication Administration Record (MAR) for several months showed repeated use of the same injection sites, which was confirmed by both a registered nurse and the Director of Nursing (DON) during interviews. The DON acknowledged that the facility's policy and the manufacturer's guidelines required site rotation to prevent tissue damage. Similarly, Residents 37, 56, and 60 also experienced non-rotation of insulin injection sites. The MARs for these residents indicated that licensed nurses administered insulin without rotating the sites, contrary to the facility's policy and standard practices. The DON confirmed these findings and recognized the potential harm caused by this practice, including the development of skin abnormalities at the injection sites. The facility's policies and procedures, as well as the manufacturer's guidelines, clearly stated the importance of rotating injection sites to minimize adverse consequences.
Failure to Maintain Proper CPR Certification
Penalty
Summary
The facility failed to implement its policy and procedure on cardiopulmonary resuscitation (CPR) by not maintaining American Red Cross (ARC) or American Heart Association (AHA) CPR certification for three of five sampled employees. During a review of employee files, it was found that the Activity Assistant and two Certified Nursing Assistants had CPR certifications from the National CPR Foundation, which did not include hands-on training. Interviews with the Activity Assistant and the Director of Staff Development revealed a lack of awareness that CPR training should be hands-on or in-person from ARC/AHA certified providers. The Director of Nursing confirmed that all staff, whether licensed or non-licensed, are required to have CPR certification that includes hands-on training from ARC/AHA certified instructors. The facility's policy and procedure titled 'Emergency Procedure - Cardiopulmonary Resuscitation' indicated that CPR certification should be obtained and maintained through ARC/AHA for key clinical staff members. The failure to adhere to this policy had the potential to delay emergency care for residents who wish to have full treatment in life-threatening situations.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to potential risks of injury. For Resident 17, the facility did not properly manage the use of a floor mat intended to prevent injuries from falls. The floor mat was incorrectly placed with the label 'This Side Down' facing up, and both a wheelchair and an overbed table were placed on top of it. This improper placement and use of the floor mat were verified by both a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), who acknowledged that such practices could lead to a slip and fall accident, thereby defeating the purpose of the mat. Resident 17's medical history includes dementia, gait and mobility issues, and a high risk for falls, as indicated by multiple fall risk evaluations. Despite these risks, the care plan for Resident 17 did not include an active intervention for the use of floor mats, and there was no physician's order for the mat. Observations and interviews with staff confirmed that the wheelchair and overbed table were routinely placed on the mat, which could thin the mat over time and reduce its effectiveness in preventing injuries. Similarly, for Resident 57, the facility failed to maintain a clear and safe environment around the resident's bed. Observations revealed that a wheelchair belonging to another resident was consistently placed on top of Resident 57's floor mat, which was intended to minimize injury in the event of a fall. Staff interviews indicated that attempts to remove the wheelchair were unsuccessful due to resistance from the other resident. The Director of Nursing confirmed that the presence of the wheelchair on the mat compromised its function and placed Resident 57 at risk of injury.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For four of the five sampled residents, the facility did not rotate subcutaneous insulin administration sites as required by professional standards and manufacturer guidelines. This failure was identified during interviews and record reviews, where it was noted that insulin was repeatedly administered in the same areas, increasing the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. Resident 14, who was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and obesity, received insulin aspart and insulin glargine injections without proper site rotation. The Medication Administration Record (MAR) for several months showed repeated use of the same injection sites, which was confirmed by the Registered Nurse and Director of Nursing during interviews. The facility's policy and procedure, as well as the manufacturer's guidelines, were not followed, leading to this significant medication error. Similarly, Residents 37, 56, and 60 also experienced improper insulin administration practices. Their MARs indicated that licensed nurses failed to rotate injection sites, contrary to the facility's policy and professional standards. The Director of Nursing acknowledged these errors, noting that such practices could cause harm to the residents by leading to skin abnormalities. The facility's policies clearly outlined the need for site rotation to prevent adverse consequences, yet these were not adhered to, resulting in the identified deficiencies.
Failure to Meet Nutritional Needs for Puree Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu and did not meet the nutritional needs of 17 out of 96 residents on puree texture diets. On November 5, 2024, during lunch, the polenta served was watery and unable to maintain its shape on the plate. Similarly, on November 6, 2024, the puree carrots were observed to be runny and could not hold their shape. These inconsistencies in food texture were identified through observation, interviews, and record reviews, indicating a failure to follow the facility's standardized recipes and dietary guidelines. The Dietary Supervisor acknowledged that the polenta was runny and emphasized that puree foods should maintain a pudding-like consistency to facilitate ease of eating for residents with chewing and swallowing difficulties. The Registered Dietitian also noted that the puree carrots were watery and suggested that the cook might have added excess water, which could dilute the nutrients. Both the Dietary Supervisor and the Registered Dietitian highlighted the importance of following standardized recipes to ensure the correct texture and nutritional content of puree foods. The facility's standardized recipes and diet manual specify that puree foods should be smooth, free of lumps, and able to hold their shape without weeping. The failure to meet these requirements was documented in the facility's policies and procedures, which mandate the use of approved recipes to conserve nutritive value, flavor, and appearance. The IDDSI guidelines further reinforce these standards, indicating that Level 4 pureed foods should maintain their shape on the plate and not separate into liquid and solid components.
Deficiency in Food Preparation and Presentation
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, as observed in the case of Resident 10. The polenta served to Resident 10 was watery and runny, and it was touching other foods on the plate, while the fresh green salad with dressing was served frozen and wilted. These issues were identified during a concurrent observation and interview with Resident 10, who expressed dissatisfaction with the food's appearance and taste, stating that he did not like the food and could not even recognize it. The facility's daily menu indicated that residents on a regular diet were to receive lemon chicken piccata, polenta, spinach au gratin, fresh green salad, gelatin, and milk, but the presentation and quality of the food did not meet these standards. The Dietary Supervisor confirmed during a test tray evaluation that the polenta was watery and the salad was frozen, acknowledging that the tray was not well presented. The Registered Dietitian also emphasized the importance of following standardized recipes to ensure food is appetizing and retains its flavor, noting that poor presentation could lead to residents losing their appetite. The facility's policies and procedures on food preparation, dated July 19, 2024, stated that food should be prepared to conserve nutritive value, flavor, and appearance, using approved and standardized recipes. However, these guidelines were not adhered to, resulting in the observed deficiencies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Several deficiencies were noted, including the lack of labeling on food items such as garbanzo salad and sherbet, which were not marked with product names. This oversight was acknowledged by the Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS), who admitted that the labeling process was not followed, potentially leading to the wrong food being served to residents, which could cause allergic reactions. Additionally, staff food items, such as eggs and hash browns, were improperly stored in the preparation area, posing a risk of cross-contamination. The DS confirmed that these items should not have been in the preparation area. Furthermore, a staff member was observed drinking from an uncovered coffee tumbler inside the walk-in refrigerator, which violated the facility's policy against eating and drinking in the kitchen area. This behavior was identified as a potential source of cross-contamination, which could lead to foodborne illnesses among residents. Other issues included wet stacking of domes and pans, which can promote bacterial growth, and the presence of brown and black slimy dirt in the internal parts of an ice machine, indicating inadequate cleaning. The mixer also had dried food residues, suggesting it was not cleaned after use. A staff member's cellphone was found stored on top of a pot in the clean area, which could lead to contamination. These practices were contrary to the facility's policies and the Food Code 2022, highlighting significant lapses in maintaining food safety standards.
Failure to Enforce Food Storage Policy for Resident's Outside Food
Penalty
Summary
The facility failed to enforce its policy and procedures regarding the storage of food brought in by family or visitors for residents. The Dietary Supervisor (DS) acknowledged that while families were allowed to bring food for residents, they were not permitted to bring food for more than one meal due to the lack of designated refrigerator space. The DS expressed concerns about the potential for cross-contamination if such food were stored in the kitchen's refrigerator, which was not a sanitary practice. This lack of proper storage facilities led to the disposal of food brought by families, which could result in residents feeling angry and deprived. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of a designated refrigerator for storing residents' food from outside sources. The LVN suggested the need for a designated refrigerator to prevent food spoilage, while the DON noted that the previous refrigerator in Station 2 was labeled for staff use only. The facility's policy on food from outside sources required monitoring and proper storage of such food, but the lack of designated storage facilities led to the disposal of food, potentially causing residents to feel deprived.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved Resident 16, who had an indwelling catheter drainage bag that was observed touching the floor on multiple occasions. Despite the presence of a privacy bag, the drainage bag was not adequately elevated, which was acknowledged by Certified Nursing Assistants (CNAs) who stated that the bag should not be on the floor to prevent infection. The facility's policy clearly indicated that catheter drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections, yet this protocol was not followed. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Resident 16, who was at risk of infection due to the presence of an indwelling catheter. Housekeeper 1 and CNA 5 failed to don gowns while performing tasks in the resident's room, despite the presence of an EBP sign indicating the need for gown and glove use during high-contact activities. The Infection Preventionist and Director of Nursing confirmed that the failure to use gowns could lead to the spread of multidrug-resistant organisms (MDROs) and cross-contamination, which was against the facility's policy. Another deficiency was noted with Resident 3, whose nasal cannula tubing was observed touching the floor while connected to the resident. This was confirmed by CNA 6, who acknowledged that the tubing should not be on the floor to prevent cross-contamination and potential infection. The Director of Nursing reiterated that the floor is a potential source of infection, and the facility's policy emphasized the need for ongoing surveillance to prevent healthcare-associated infections. These observations highlight the facility's failure to adhere to its own infection control policies, putting residents at risk of infection.
Deficiencies in COVID-19 Vaccine Administration and Documentation
Penalty
Summary
The facility failed to obtain informed consent prior to administering the COVID-19 vaccine to Resident 16. The resident, who was admitted with chronic obstructive pulmonary disease, metabolic encephalopathy, and benign prostatic hyperplasia, did not have the capacity to make decisions. Despite this, the Infection Preventionist (IP) administered the vaccine without obtaining consent from the resident's public guardian, assuming it had been received during the admission process. This oversight was acknowledged by the IP during a review of the resident's records. For Resident 57, the facility did not offer or clarify the appropriateness of the COVID-19 vaccine administration with the resident's physician. The resident, who had fluctuating capacity to understand and make decisions, was recently hospitalized and had not received the 2024/2025 COVID-19 vaccine. The IP decided against administering the vaccine without consulting the resident's physician, which was outside the IP's scope of practice. This decision was made without the necessary medical consultation, potentially impacting the resident's health. Resident 91 received the COVID-19 vaccine without documented education on the risks and benefits being provided to the resident's representative. The resident, who was admitted with severe sepsis, urinary tract infection, osteomyelitis, and skin infection, did not have the capacity to make decisions. Although verbal consent was obtained, there was no evidence of documented education regarding the vaccine, as required by the facility's policy. This lack of documentation was confirmed during a review of the resident's clinical notes.
Unqualified Staff Providing Hydration
Penalty
Summary
The facility failed to ensure that services were provided by qualified personnel according to the resident's plan of care, specifically for a resident identified as Resident 52. The deficiency was observed when an Activities Assistant (AA) provided hydration to Resident 52, who had a care plan indicating that only certified nursing assistants (CNAs) were responsible for assisting with feeding and hydration. Resident 52, who had diagnoses including dementia and required maximal assistance for activities of daily living, was observed drinking from a cup held by the AA, who was not qualified to provide such assistance. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that only CNAs and licensed nurses were authorized to assist residents with feeding and hydration. The facility's policy and procedure documents also indicated that CNAs were responsible for assisting residents with meals and drinks. The Activities Assistant's job description did not include feeding residents as part of their duties. This oversight had the potential to result in Resident 52 aspirating during the intake of fluids, as the AA was not trained to recognize signs of aspiration.
Failure to Replace Tube Feeding Set in a Timely Manner
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feeding, leading to a deficiency in infection control practices. Resident 90, who was admitted with a gastrostomy and required tube feeding due to impaired swallowing and poor oral intake, did not have their tube feeding set replaced as required. Observations revealed that the tube feeding formula and water flush bag were not changed after 24 hours, contrary to the facility's protocol. This oversight was confirmed by RN 1, who acknowledged that the formula and water should be changed every 24 hours to prevent potential gastrointestinal issues. Further interviews with RN 5 and the Director of Nursing highlighted that the entire tube feeding set, including the water bag, should be replaced when the formula is replaced to prevent infection and blockages. The facility's own instructions for use of the enteral feeding pump indicated that the tube feeding set should be replaced after 24 hours to prevent bacterial growth. The failure to replace the tubing set as required posed a risk of infection and disrupted delivery of nutrition and hydration to Resident 90.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered for a resident, identified as Resident 13, who was diagnosed with sick sinus syndrome and chronic respiratory failure with hypoxia. The resident was readmitted to the facility with a physician's order for continuous oxygen administration at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92%. However, during an observation, it was found that the resident's oxygen tank was empty, indicating a lapse in the continuous administration of oxygen as prescribed. Interviews with the facility staff, including a Registered Nurse (RN 1) and the Director of Nursing (DON), revealed that the responsibility for ensuring the oxygen tank was not depleted lay with the charge nurses. RN 1 acknowledged that residents dependent on continuous oxygen therapy could experience a drop in oxygen saturation and respiratory complications if the therapy is interrupted. The DON confirmed that the resident should not have run out of oxygen if the order was followed correctly, highlighting a failure to adhere to the facility's policy and procedure for oxygen therapy, which mandates administration as ordered by the physician.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess the medical need and evaluate the risks associated with the use of bed rails for a resident, identified as Resident 17. The resident, who was admitted with diagnoses including dementia, epilepsy, and mobility issues, was at high risk for falls. Despite this, the facility did not obtain a physician's order or informed consent for the use of bed rails, which were intended to aid in mobility and serve as a seizure precaution. The resident's care plan included the use of padded side rails, but the facility did not ensure that the appropriate type of side rails was used, nor did they assess the risk of entrapment. Observations and interviews revealed that the resident was using 1/2 length side rails instead of the 1/4 length rails as ordered by the physician. There was a gap between the mattress and the side rails, which posed a risk of entrapment. Staff members, including a CNA and RN, confirmed the presence of this gap and the potential for injury. The Director of Nursing also acknowledged the discrepancy between the physician's order and the actual side rails in use, as well as the lack of a proper assessment for entrapment risk. The facility's policy required informed consent and an assessment of risks before using bed rails, but these procedures were not followed. The bed safety evaluation forms did not include an assessment for entrapment risk or document any attempts to use less restrictive measures. The facility's failure to adhere to its own policies and procedures regarding bed rail use resulted in a deficiency that placed the resident at risk of injury.
Failure to Assess Pain Before Administering Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not assess the resident's pain level before administering Celebrex, a medication used to decrease pain, on multiple occasions. The resident was given Celebrex daily despite having a documented pain level of zero, which was against the physician's order that specified the medication should only be administered for moderate pain levels between 4 and 6. The report details that the resident was prescribed Celebrex 200 mg to be administered once daily for moderate pain, with non-drug interventions to be attempted first. However, the medication was administered daily without assessing the resident's pain level or attempting non-drug interventions. This was observed during a medication administration where the nurse did not inquire about the resident's pain level before giving the medication. The nurse acknowledged the failure to assess pain and follow the physician's orders, which led to the unnecessary administration of Celebrex. Interviews with the Director of Nursing confirmed that the medication should not have been administered without assessing the resident's pain and trying non-drug interventions first. The facility's policies on medication administration and pain management were not followed, as medications must be administered as prescribed, and pain should be assessed regularly. This oversight placed the resident at risk for adverse effects from unnecessary medication use.
Improper Storage and Labeling of Insulin Vial
Penalty
Summary
The facility failed to store an insulin vial, specifically Humalog, for Resident 49 according to the manufacturer's requirements. During an observation and interview, it was found that the unopened Humalog vial was stored at room temperature without a date indicating when this storage began, contrary to the manufacturer's instructions and facility policy. The vial was supposed to be refrigerated or labeled with a date if stored at room temperature, as it should be discarded after 28 days in such conditions. Licensed Vocational Nurse 3 acknowledged the improper storage and labeling, stating it was unknown when the vial was placed at room temperature, making it unclear when it would expire. The Director of Nursing confirmed that the insulin vial should have been refrigerated or labeled with a date when it was stored at room temperature. The facility's policies and procedures, as well as guides provided by the facility, indicated that insulin vials like Humalog should be stored in a refrigerator or labeled with an opening date if stored at room temperature. The failure to adhere to these guidelines resulted in the potential for medication errors due to the administration of expired insulin, which could lead to ineffective treatment of blood sugar levels for Resident 49.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to maintain proper documentation regarding the offering and review of advance directives for a resident, as per their policy and procedure. Specifically, for one resident with diagnoses including dementia, major depressive disorder, and paranoid schizophrenia, the facility did not document the offering of advance directive information upon admission or during the annual care conference. The resident's Minimum Data Set (MDS) indicated the ability to make themselves understood and understand others, yet it was noted that the resident did not have an advance directive. During interviews, the Director of Nursing (DON) and the Social Services Director (SSD) acknowledged the lapse in documentation. The SSD admitted to forgetting to document the discussion of advance directives for the resident, which is a requirement according to the facility's policy. The policy mandates that advance directives be reviewed annually and documented in the resident's medical record. This oversight could potentially lead to not knowing the resident's wishes regarding end-of-life care and life-sustaining treatments.
Failure to Obtain Informed Consent for Vaccinations
Penalty
Summary
The facility failed to obtain informed consent before administering the pneumococcal and influenza vaccines to a resident, identified as Resident 16, during an Infection Control task. Resident 16 was admitted with several diagnoses, including chronic obstructive pulmonary disease, metabolic encephalopathy, and benign prostatic hyperplasia. The resident's records indicated a lack of capacity to make decisions, yet the Minimum Data Set showed the resident could understand and be understood by others. Despite this, the facility did not secure informed consent from the resident or their public guardian before administering the vaccines. The Infection Preventionist (IP) noted in the clinical records that consent was obtained for both vaccines, but upon review, the consent forms were unsigned and unmarked, indicating no consent was actually obtained. The IP admitted to assuming that consent had been received from the resident's public guardian without verifying it. This oversight led to the administration of vaccines without the necessary informed consent, potentially infringing on the resident's rights and exposing them to unwanted medical treatment. The Director of Nursing (DON) confirmed that the facility's policy and procedures for vaccine administration were not followed. The facility's policies require that informed consent be obtained and documented before administering vaccines, and that residents or their representatives have the right to refuse treatment. The DON acknowledged that the failure to obtain consent could result in harm to the resident from adverse effects or unwanted vaccination, highlighting a significant lapse in following established protocols.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that the physician was notified when a resident had a change in condition. The resident, who was admitted with diagnoses including a urinary tract infection, benign prostatic hyperplasia, and obstructive and reflux uropathy, had an indwelling catheter and was dependent on staff for toileting hygiene. Despite the care plan indicating the need to monitor and report signs of urinary infection, the resident's urine output was noted to be yellow with whitish sediments, and later white, thick, and cloudy, without notifying the attending physician of these changes. During observations, it was found that the resident's indwelling catheter was not secured with a securement device, which could lead to dislodgment and infection. Certified Nursing Assistant and Licensed Vocational Nurse both observed the resident's condition but did not report the change in urine output to the physician. The Director of Nursing confirmed that the facility's policy required the catheter to be secured and any changes in condition to be reported immediately. The facility's policies on urinary catheter care and change in a resident's condition or status were reviewed, indicating that the attending physician should be promptly notified of any adverse changes. However, the staff failed to follow these policies, resulting in the physician not being informed of the resident's change in condition, which had the potential for delayed medical interventions.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to secure a resident's urinary indwelling catheter with a securement device, which is necessary to stabilize the catheter and prevent dislodgement. The resident, who was admitted with diagnoses including urinary tract infection, benign prostatic hyperplasia, and obstructive and reflux uropathy, was observed without a securement device on the catheter. This observation was confirmed by both a Certified Nursing Assistant and a Registered Nurse, who acknowledged that the catheter should have been anchored to prevent potential complications such as dislodgement and infection. During the observation, the resident was found lying in bed with feces in the disposable brief and on the bed cover, indicating a lack of proper hygiene care. The facility's policy on urinary catheter care, reviewed with the Director of Nursing, clearly stated that the catheter should be secured with a leg strap to reduce friction and movement at the insertion site. The failure to follow this policy was confirmed by the Director of Nursing, who acknowledged that the catheter should have been anchored to prevent pulling, accidental dislodgement, and infection.
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.
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What surveyors actually found near you
We read the 4,014 citations issued within 25 miles in the last 12 months — including the 28 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 Lake View Terrace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maclay Healthcare Center | 2 mi | ★★★★★ | 58 | 1 |
| Pacifica Hospital Of The Valley Dp Snf | 3 mi | ★★★★★ | 22 | 0 |
| The Grove Post-acute Care Center | 3 mi | ★★★★★ | 41 | 0 |
| Mountain View Conv Hosp | 3.1 mi | ★★★★★ | 41 | 0 |
| The Hills Healthcare Center | 3.3 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.