Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Osage Healthcare & Wellness Centre during CMS and state inspections, most recent first.
The facility failed to follow ordered respiratory care for three residents. One resident with heart failure, stroke history, and dementia was observed without the ordered continuous O2 via NC despite an order for 2 lpm. Another resident with respiratory failure had O2 tubing that was not labeled or dated, and a third resident with COPD, respiratory failure, and sleep apnea had no documentation that the BiPAP filter was replaced as required by policy. The DON confirmed the orders and policy expectations during the survey.
Unlabeled resident food and undated produce were found during observation. An opened bottle of Italian dressing and an opened jar of Hamburger Dill Chips brought in from outside were in a resident’s room without labels or dates, even though the DSS stated they should be labeled and stored in the resident refrigerator in the activity room. In the kitchen, a clear container of lettuce in the vegetable refrigerator was also found without a date label, and the DSS stated food items were required to have an open and used-by date.
A resident with dementia and schizophrenia was started on Olanzapine for disorganized speech and thought processes without a written informed consent signed by the IDT. Records showed the resident lacked capacity for healthcare decisions, and the DON confirmed no IDT meeting was completed before the first dose of the psychotropic medication was given.
Call Device Not Within Reach: A resident with dementia, dysphagia, lack of coordination, and generalized muscle weakness was observed sitting in a wheelchair at the doorway of the room while the call alert device was on the bed about 3 feet away and no staff were present. CNA and DON interviews confirmed the resident would not be able to call for help if the device was not within reach, and the facility policy stated the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Repeated BIPAP Refusals: A resident with OSA, COPD, and HF had an order for BIPAP at bedtime and PRN, but the MAR showed repeated refusals of the treatment. The MDS nurse stated the physician was not notified of the refusals, and the DON stated physician notification is important when a resident refuses treatment because it is a change of condition.
Failure to Inform Resident of Grievance Process for Missing Eyeglasses: A resident with glaucoma, cataracts, hemiplegia, and hemiparesis reported missing prescription eyeglasses after a room change and said she told the social worker and DON, but was not told how to file a grievance. The DON stated residents have a right to file grievances and that staff can explain the process, but she did not inform the resident how to do so.
A resident’s PASARR Level 1 screening did not accurately document diagnosed mental illnesses, despite records showing schizoaffective disorder, major depressive disorder, psychotic disorder with delusions, and anxiety disorder. The resident also had no capacity to make decisions, severe cognitive impairment, and dependence on staff for multiple ADLs. The MRA and DON stated the diagnoses should have been documented to support accurate PASARR review and Level 2 evaluation.
Failure to care plan BIPAP refusal: A resident with OSA, COPD, and HF had a BIPAP order for bedtime and PRN use, but the MAR showed repeated refusals and the DON confirmed there was no comprehensive care plan addressing the refusal. The resident’s record also showed mixed cognitive findings, and the facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
Missing Eyeglasses Not Replaced for A resident A resident with glaucoma, cataracts, hemiplegia, and hemiparesis had a care plan directing staff to ensure she wore glasses when awake at all times, but her prescription eyeglasses were misplaced during a room change and were not replaced. The resident reported blurry vision and frustration, and the SSD and DON confirmed the issue was reported but not documented or escalated per facility process.
A resident with a Stage 4 pressure ulcer, paraplegia, PVD, and MRSA carrier status did not have ordered daily wound care documented on 4 days in the TAR. The TN stated the resident had an order to cleanse and pack the wound daily, that she had been the treatment nurse during the month, and that there was no documentation of the wound care on those days; she also stated she may have provided the care but forgot to document it.
Oxygen concentrators for two residents were left switched on when not in use. One resident had severe cognitive impairment and the other had moderate cognitive impairment; both required oxygen therapy. During observation, one resident was not wearing oxygen and the other was not in the room, yet both concentrators remained on. An LVN and the DON stated concentrators should be turned off when not in use to prevent equipment malfunction, overheating, and fires, and the facility oxygen therapy policy did not address this procedure.
Missing staff competency and orientation validation records were identified for an RN, an LPN, and a CNA. The RN's annual evaluation was absent, the LPN's onboarding checklist lacked validation for multiple required care topics, and the CNA's orientation and sit-to-stand lift competency were incomplete. The DSD stated the sit-to-stand competency was not completed, and the DON stated incomplete documentation could result in staff failing to provide the right care.
Failure to rinse a resident’s mouth after Breo Ellipta administration. A resident with COPD, asthma, dysphagia, and moderate cognitive impairment received the inhaler without being instructed to rinse afterward, despite the pharmacy label directing a thorough mouth rinse after each use. The LVN acknowledged the omission, and the DON stated the rinse was important to prevent fungal infection and related mouth discomfort.
Medication Error Rate Exceeded 5 Percent: Two medication errors were identified during med pass, resulting in a 5.88% error rate for one resident. An LVN did not administer ordered Vitamin D because only a different dose was available on the cart and could not explain why the ordered nasal spray was also not given. The resident had a left femur fracture, COPD, asthma, allergic rhinitis, dysphagia, and moderate cognitive impairment, and the DON stated prescribed meds are needed to treat ongoing symptoms or disease.
A resident with dementia and legal blindness signed a Binding Arbitration Agreement without full understanding. The AC stated the resident should not have been asked to sign the legal document, while the resident said her vision was too blurry to see and she could not recall signing it. The SSD and DON both stated the resident lacked intact cognition and that the agreement was not valid because she could not understand the legal rights involved.
Failure to use PPE during gtube care for a resident on EBP. An LVN assessed a resident’s gtube without gloves, even though the resident had a stroke history, dysphagia, gastrostomy status, severe cognitive impairment, and dependence on staff for many ADLs. The LVN acknowledged gloves should have been worn, and the DON stated PPE is important during care of residents on EBP to prevent spread of infection.
Failure to document and provide COVID-19 and influenza vaccines for a resident with COPD, asthma, cognitive communication deficit, malnutrition, and shortness of breath when lying flat. The resident’s EMR showed no COVID-19 or influenza immunizations, and the IPN stated vaccines should be listed in the EMR so staff can monitor for adverse reactions. The DON and ADM stated residents should have immunizations, and facility policy required documentation of vaccine status.
Excess Occupancy in 5-Bed Resident Rooms: Two resident rooms were found to accommodate five residents each, exceeding the limit of no more than four residents per room. During tour, one room had space for beds, side tables, and resident care equipment, and the ADM confirmed both rooms were set up for five residents. The facility’s waiver request noted both rooms were about 420 sq. ft. and were intended for mixed ambulatory and non-ambulatory residents.
A resident with cognitive impairment, Parkinson’s disease, and dependence in several ADLs had an MDS assessment completed inaccurately when the MDS nurse failed to follow RAI Section B guidelines for assessing hearing and hearing aid use. Although the social services assessment documented bilateral hearing aids, the MDS was coded as having adequate hearing and no hearing aid, based only on the nurse not seeing the resident using a hearing aid during the look-back period and without fully reviewing the record or consulting other sources, contrary to facility policy and CMS RAI manual instructions.
A resident with severe cognitive impairment, multiple medical diagnoses, and total dependence on staff for several ADLs had a missing right hearing aid documented on a theft/loss report. Despite this identified problem, staff, including the RN, MDS nurse, and DON, acknowledged that no comprehensive, person-centered care plan was developed by the IDT to address the missing hearing aid, contrary to facility policy requiring measurable objectives and timeframes for all identified needs.
A resident with severe cognitive impairment, Parkinson’s disease, and documented bilateral hearing aids had one hearing aid reported missing and had stopped using the other. An ENT provider identified hearing loss and recommended an audiogram, and a physician ordered an audiology consult with follow-up treatment. However, the audiogram was not completed until 39 days after the ENT recommendation, despite facility policies requiring Social Services to arrange indicated audiology services and to support residents in maintaining their highest practicable well-being. The resident reported being upset at times when unable to hear staff.
A resident with cognitive impairment and multiple medical conditions was admitted with personal belongings, but the Personal Effects Inventory Form was not signed by the resident or representative, nor by staff, and no copy was provided to the representative. RN, SSD, and DON interviews confirmed that the form should be completed at admission, is part of the medical record, and should be signed and shared, yet the facility had not been following this practice. Review of facility policies showed that a signed inventory must be placed in the medical record and a copy given to the resident or representative, and that medical records must be complete and accurate, which did not occur in this case.
A resident with paraplegia and total dependence for transfers was moved from a wheelchair to bed by a single CNA using an improper technique, despite care plans and therapy assessments requiring a two-person assist. The resident experienced discomfort during the transfer, and the CNA could not explain how he determined the level of assistance needed or how he was informed of residents' care requirements.
A CNA did not receive a required annual skills competency assessment, as confirmed by a review of employee records and an interview with the DSD. The DSD stated the assessment was missed due to an oversight, despite facility policy requiring annual competency validation to ensure staff performance and resident safety.
A resident's sandwich was found undated and unlabeled, posing a risk of foodborne illness. The resident, with intact cognitive skills and requiring assistance for ADLs, noted the sandwich appeared old. Interviews with the Dietary Service Supervisor and Registered Dietitian highlighted a lack of adherence to food safety protocols, as the facility's policy requires all food items to be labeled and dated.
A resident's call light was not within reach, contrary to their care plan and facility policy, placing them at risk for accidents. Staff interviews confirmed the importance of call light accessibility for resident safety and communication.
A resident with major depressive disorder repeatedly refused trazodone, but the facility failed to notify the physician as required by policy. Despite the resident's cognitive impairment, the facility did not document the refusals or inform the physician, risking the resident's health.
A facility failed to accurately complete an MDS assessment for a resident receiving dialysis, resulting in incorrect data being sent to CMS. The MDS Nurse admitted an error in marking the dialysis treatment section, despite the resident undergoing dialysis three times weekly. The resident had diagnoses of ESRD and CHF, and the facility's policy stressed the need for accurate assessments to meet guidelines.
A resident on a prescribed pureed diet was not monitored for outside food brought by family, leading to potential choking risks. The facility lacked a care plan to track the frequency and type of food, as confirmed by the DON and RD.
A resident with COPD, DM, and GERD was at risk of aspiration, requiring a pureed diet and oxygen therapy. Despite a care conference identifying the need for aspiration precautions, the care plan was not updated. The DSD and DON confirmed the oversight, which violated the facility's care planning policy.
A facility failed to reposition a resident with a stage 4 pressure ulcer every two hours, as required. The resident, with severe cognitive impairment and multiple health issues, was observed lying in the same position over two days. Staff interviews revealed a lack of documentation and clarity regarding repositioning schedules, despite facility policy requiring such interventions.
A resident with long, thick toenails did not receive timely podiatry care despite requests and visible discomfort. The CNA was aware but did not report it, and the Social Service Director, responsible for referrals, was not informed. Facility policies required referral to a podiatrist for such conditions, but this was not adhered to.
A resident at high risk for falls had their bed positioned too high, contrary to their care plan, which required the bed to be in the lowest position to prevent injuries. A CNA and the Director of Staff Development confirmed the oversight, which violated the facility's fall management and safety policies.
A resident with severe cognitive impairment and total dependence on staff for toileting was not provided with a scheduled toileting plan, despite being a candidate for such a program. The facility's policy requires individualized toileting programs for incontinent residents, but no evidence of implementation was found in the resident's records.
A resident with End Stage Renal Disease did not receive recommended nutritional care due to a failure in communication between the facility's staff and the physician. The Registered Dietitian recommended a high-calorie supplement, Novasource, which was not communicated to the physician because the facility lacked the supplement. This oversight risked the resident's nutritional status and health, contrary to the facility's policy requiring collaboration among care providers.
A LTC facility failed to label and date medications for two residents, leading to potential harm. One resident's ophthalmic solutions lacked open dates, while another's expired inhalation solution was not removed. The LVN and DON acknowledged the importance of proper labeling to ensure medication efficacy.
A facility failed to date and label a nasal cannula for a resident with COPD, contrary to its policy requiring weekly changes and labeling. Observations and interviews with the DSD and DON confirmed the oversight, which placed the resident at risk for respiratory infection.
The facility failed to comply with regulations by accommodating five residents in two rooms, exceeding the maximum allowed capacity of four residents per room. Observations and a Client Accommodations Analysis confirmed the presence of five beds in each room, despite some beds being empty at the time. The Administrator requested a renewal for a variance to address this issue.
Failure to provide and maintain ordered respiratory equipment
Penalty
Summary
Resident 2 had diagnoses including heart failure, history of cerebral infarction, and dementia, and the MDS indicated shortness of breath lying flat and a need for oxygen therapy. The care plan included administering oxygen at 2 lpm via nasal cannula to keep oxygen saturation above 95% every shift for shortness of breath, and the physician order specified continuous supplemental oxygen at 2 lpm via nasal cannula. During observations on 2/11/2026, Resident 2 was seen sitting in a wheelchair beside an oxygen concentrator without wearing a nasal cannula or oxygen mask. LVN 1 stated Resident 2 should have been on supplemental oxygen as ordered, and the DON later confirmed the order for continuous oxygen and stated the resident had started oxygen therapy for episodes of shortness of breath and had a recent hospitalization for the same reason. Resident 22 was admitted with diagnoses including respiratory failure with hypoxia, dementia, and history of cerebral infarction. During observation in the resident’s room, the oxygen tubing did not have a label or date showing when it was last changed. LVN 1 stated oxygen tubing should be replaced every seven days and labeled with the date it was last changed. The DON stated licensed nurses were expected to change oxygen tubing weekly and label it with the date, time, and staff name, and the facility’s Oxygen Therapy policy stated tubing and mask should be changed at least every seven days and labeled with the date changed. Resident 30 had diagnoses including COPD, respiratory failure with hypoxia and hypercapnia, heart failure, and obstructive sleep apnea. The physician ordered BiPAP at bedtime when sleeping and as needed. A BiPAP machine was observed in the resident’s room, and the resident stated she used it at night and had been using it for several months. LVN 1 was not aware where the filter system was located, and the DON stated there was no documentation that the BiPAP filter had been replaced and that no one had been responsible for the task. The DON also stated the facility did not have a filter replacement, while the facility’s BiPAP and CPAP policy stated filters should be changed every 2 weeks.
Unlabeled resident food and dated produce in storage
Penalty
Summary
The facility failed to ensure food brought in from outside was labeled, dated, and stored in the designated resident refrigerator for one resident. The resident was admitted and later readmitted to the facility, with diagnoses including OSA, COPD, and heart failure. The H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognitive skills for daily decision making and that the resident required setup assistance with eating and oral hygiene. During an interview, the resident stated family had brought in one bottle of Italian dressing and one jar of Hamburger Dill Chips about one month earlier. During observation in the resident’s room, the Dietary Service Supervisor found an opened bottle of Italian dressing and an opened jar of Hamburger Dill Chips with no date or label. The DSS stated the opened Hamburger Dill Chips were perishable and should be kept in the resident refrigerator in the activity room, and that resident food brought from outside should be labeled with the resident’s name, the date received, and the date opened. The DON stated all resident food brought from outside should be labeled and kept in the resident refrigerator in the activity room, especially perishable items. The facility also failed to ensure a clear Tupperware container holding 6 heads of lettuce in the vegetable refrigerator was labeled and dated. During the initial kitchen tour, the DSS observed the container without a date label and stated the lettuce was approximately 1 week old. The DSS stated food items in the refrigerator were required to have an open and used-by date and that not labeling the lettuce container could result in residents consuming possibly expired food. The facility policy titled Food Storage and Handling indicated all food items were to be correctly labeled and dated.
Failure to Obtain IDT Informed Consent Before Starting Psychotropic Medication
Penalty
Summary
The facility failed to obtain a written informed consent from the interdisciplinary team before starting Olanzapine for a resident with dementia and schizophrenia. Resident 39 was admitted and readmitted to the facility with diagnoses including dementia, legal blindness, and schizophrenia. The resident’s H&P stated that she did not have the capacity to understand and make decisions, and a neuropsychiatric progress note stated that she suffered from dementia and cognitive communication deficit and that recommendations were subject to IDT approval. The MDS showed moderately impaired cognitive skills for daily decision making, and the order summary indicated the resident was incapable of making healthcare decisions due to dementia. A telephone order was placed for Olanzapine 5 mg at bedtime for schizophrenia manifested by disorganized speech and thought processes, and the medication was administered from 2/6/2026 through 2/11/2026. During interview and record review, the DON reviewed the Psychotherapeutic Drug Informed Consent Form and stated that the consent for Olanzapine was not signed by the IDT. The DON also stated that Resident 39 lacked capacity to give informed consent because of dementia and that no IDT meeting had been completed before initiation of the psychotherapeutic drug. The facility policy stated that if a resident lacks capacity and does not have a surrogate decision-maker, the facility will convene a surrogate IDT and the licensed nurse will verify that informed consent was obtained before the first dose of psychoactive medication.
Call Device Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that Resident 35 had a call device within reach. Resident 35’s admission record, dated 7/10/2025, identified dementia, dysphagia, lack of coordination, and generalized muscle weakness. The History & Physical, dated 7/14/2025, stated that Resident 35 did not have the capacity to understand and make decisions. The Order Summary Report, dated 7/10/2025, showed a poor discharge potential and ordered skilled occupational therapy services three times a week for four weeks for generalized weakness using therapeutic exercise and therapeutic activities. During an observation on 2/10/2026 at 12:11 p.m. in room [ROOM NUMBER]A, Resident 35 was sitting in a wheelchair at the doorway of the room, while the call alert device was on the bed approximately 3 feet behind the resident and no staff were in the room. During interview, CNA 2 stated Resident 35 would not be able to call for help and that it was not safe for residents to not have a call alert device available. The DON stated that the call alert device should be in reach of the resident and that if it was not, the resident would not be able to call for assistance. The facility policy on the call system stated that the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Repeated BIPAP Refusals
Penalty
Summary
The facility failed to notify the physician when a resident refused ordered BIPAP treatment. Resident 30 was admitted with diagnoses including OSA, COPD, and heart failure, and the H&P stated the resident had the capacity to understand and make decisions. The MDS later indicated the resident's cognitive skills for daily decision making were moderately impaired and that the resident required setup assistance with eating and oral hygiene. An order was in place for BIPAP at bedtime and as needed with IPAP 18/5 cm H2O, FiO2 28%, and a full face mask size 18. Review of the MAR showed the resident refused BIPAP on multiple occasions, including 1/3/2026, 1/4/2026, 1/10/2026, 1/23/2026, 1/24/2026, 2/5/2026, and 2/8/2026. During interview, the MDS nurse stated the physician was not notified of these refusals and said refusal of a physician-ordered treatment should be reported because it is considered a change of condition. The DON also stated it is important to notify the physician when a resident refuses treatment so the physician is aware and can make treatment adjustments and provide intervention.
Failure to Inform Resident of Grievance Process for Missing Eyeglasses
Penalty
Summary
The facility failed to inform a resident of how to file a grievance regarding missing eyeglasses. Resident 32 was admitted and later readmitted to the facility and had diagnoses including glaucoma, cataracts, hemiplegia, and hemiparesis. The resident's H&P indicated she had the capacity to understand and make decisions, and the MDS indicated she was cognitively intact and dependent on staff for ADLs. During interview, Resident 32 stated she had worn prescription eyeglasses since age 8, had eyeglasses on admission, and believed they were misplaced during a room change. She reported telling the social worker and DON about the missing eyeglasses but was not informed how to file a grievance, and she stated the lack of eyeglasses caused blurry vision and frustration. The DON stated the protocol was to inform residents that they have a right to file a grievance with staff, that grievances are then given to the SSD for follow-up, and that all staff can explain the process. The DON also stated Resident 32 had reported the missing eyeglasses a week prior and the night before, but the DON did not inform her how to file a grievance.
PASARR Screening Did Not Reflect Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that one resident’s PASARR Level 1 screening accurately reflected diagnosed mental illnesses. Resident 2’s face sheet showed admission and readmission to the facility with diagnoses including schizoaffective disorder, major depressive disorder, psychotic disorder with delusions, and anxiety disorder. The resident’s H&P dated 9/18/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 12/10/2025 indicated severe cognitive impairment, dependence on staff for oral care, toileting and personal hygiene, showering, upper and lower body dressing, and putting on or taking off footwear, with active diagnoses of anxiety disorder, depression, and psychotic disorder. A review of the PASARR Level 1 screening dated 3/15/2024 showed that Resident 2 did not have a serious diagnosed mental disorder. During interview and record review, the MRA stated the resident’s mental health diagnoses should have been accurately documented and that omission of those diagnoses could prevent the resident from receiving appropriate services or treatment. The DON stated the importance of documenting mental health diagnoses was to ensure a Level 2 evaluation was completed to support plan of care development, and that an inaccurate Level 1 screening created the potential for the resident not to receive appropriate treatment in the facility.
Failure to Care Plan BIPAP Refusal
Penalty
Summary
Failed to develop a person-centered care plan for Resident 30 by not creating a comprehensive care plan to address refusal to use BIPAP. Resident 30 was initially admitted to the facility and later readmitted, with diagnoses including OSA, COPD, and heart failure. The H&P dated 11/21/2025 indicated Resident 30 had the capacity to understand and make decisions, while the MDS dated 11/25/2025 indicated moderately impaired cognitive skills for daily decision making and that the resident required setup assistance with eating and oral hygiene. The physician ordered BIPAP on 11/21/2025 with IPAP 18/5 cm H2O, FiO2 28%, full face mask size 18, at bedtime when sleeping and as needed. Review of the MAR showed Resident 30 refused BIPAP on 1/3/2026, 1/4/2026, 1/10/2026, 1/23/2026, 1/24/2026, 2/5/2026, and 2/8/2026. During interview and record review, the MDS Nurse stated the resident was non-compliant and refused BIPAP treatment, and the DON stated there was no comprehensive care plan to address the refusal. The facility policy on person-centered care planning stated the facility must develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's identified medical, nursing, and psychosocial needs.
Missing Eyeglasses Not Replaced for Resident With Vision Impairment
Penalty
Summary
The facility failed to ensure that missing eyeglasses were replaced for a resident with glaucoma, cataracts, hemiplegia, and hemiparesis. The resident’s care plan, dated 11/2024, directed staff to ensure she wore glasses when awake at all times. Her H&P dated 9/5/2025 indicated she had the capacity to understand and make decisions, and her MDS dated 12/17/2025 indicated she was cognitively intact and dependent on staff for ADLs. During interview, the resident stated she had worn prescription eyeglasses since age 8, had eyeglasses on admission, and that they were misplaced during a room change. She reported telling the social worker and DON about the missing glasses but had not received replacement eyeglasses, and she stated her blurry vision caused frustration. The SSD stated the protocol for misplaced eyeglasses was to contact the outside ophthalmology clinic immediately to determine whether the resident qualified for replacement, and if not, the facility would offer to pay. The SSD could not recall whether the resident reported the missing glasses. The DON stated the resident told her about the missing eyeglasses a few days prior and again the night before, but she did not notify Social Services or document the issue. The facility’s Theft and Loss policy required Social Services staff or designee to document lost or stolen resident property on the Theft and Loss Log, and the Social Services Coordinator job description included arranging ancillary services necessary to maintain residents’ concrete needs.
Missed Documentation of Ordered Pressure Ulcer Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident with a Stage 4 pressure ulcer of the left hip. The resident’s diagnoses included paraplegia, peripheral vascular disease, and MRSA carrier status. The history and physical stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident was cognitively intact and required maximal assistance with ADLs. The February 2026 TAR showed the ordered daily wound care treatment for the left hip pressure ulcer was not documented as administered on 4 days: February 5, February 8, February 9, and February 10, 2026. During interview, the Treatment Nurse stated the resident had an order to cleanse and pack the wound daily, that she had been the treatment nurse for the resident during February, and that there was no documentation of wound care treatment for those 4 days. She also stated the physician order for wound care treatment to the right hip should have been reordered for the resident and that she may have provided the wound care but forgot to document it.
Oxygen concentrators left on when not in use
Penalty
Summary
The facility failed to ensure that oxygen concentrators for two residents were turned off when not in use. Resident 2 was admitted with diagnoses including heart failure, history of cerebral infarction, and dementia, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed severe cognitive impairment, dependence on staff for multiple activities of daily living, and the need for oxygen therapy. Resident 22 was admitted with diagnoses including respiratory failure with hypoxia, dementia, and history of cerebral infarction. The H&P indicated Resident 22 had the capacity to understand and make decisions, and the MDS showed moderate cognitive impairment, dependence on staff for several activities of daily living, and the need for oxygen therapy. During observation, Resident 2 was not wearing oxygen and the concentrator remained switched on in the room. Resident 22 was not in the room and the concentrator remained switched on. In a concurrent observation and interview, LVN 1 stated that oxygen concentrators should be turned off when not in use to prevent equipment malfunction and electrical fires. The DON also stated that turning off oxygen concentrators when not in use prevents the machine from overheating and helps prevent fires. The facility policy titled P-NP94 Oxygen Therapy, revised 10/10/2025, did not include procedures for maintaining oxygen equipment when not in use.
Missing Staff Competency and Orientation Validation
Penalty
Summary
The facility failed to ensure employee performance, competency validation, initial orientation validation, and orientation activities checklists were completed for 3 of 6 employees reviewed: RN 1, LVN 2, and CNA 2. In the employee file for RN 1, the 2024 annual evaluation was missing. In the employee file for LVN 2, the Licensed Nurse Onboarding Activities Checklist dated 12/24/24 was missing validation for multiple care requirements, including Resident's Rights, admission procedures, discharge/transfers, psychotropics, treatment procedures, enteral care, change of condition, falls management, weights, resident care plans, interdisciplinary referrals, lab, advance directive documentation, Medicare documentation, medical records, death of a resident, rounds, committees, and external resources. In the employee file for CNA 3, the Initial CNA Orientation Validation Checklist was undated and was not checked as completed for Basic Tuberculosis, and the Sit-to-Stand Lift Competency did not have check marks showing competency for that task. During interview, the DSD stated the sit-to-stand competency for CNA 3 was not completed and that staff need to know how to complete the task. The DSD stated that if staff do not know, the resident could fall, the machine could slide if the brake was not placed, the resident could be hurt if the device was not adjusted properly or cleaned, and germs could be spread to residents. The DON stated that if the expected documents are not completed, staff could fail to provide the right care and residents would not receive proper care according to the facility's education process.
Failure to Rinse Mouth After Inhaler Administration
Penalty
Summary
The facility failed to ensure that Resident 49’s mouth was rinsed after administration of prescribed Breo Ellipta inhaler. Resident 49 was admitted on 10/9/2025 and later readmitted with diagnoses including COPD, mild intermittent asthma with acute exacerbation, and dysphagia. The resident’s H&P dated 1/29/2026 indicated the resident did not have the capacity to make needs known or make decisions, and the MDS dated 2/4/2026 indicated moderate cognitive impairment. The MDS also showed the resident needed partial assistance with eating and oral hygiene and maximum assistance with upper body dressing and personal hygiene. The pharmacy label for Breo Ellipta 100 mcg/25 mcg, started on 1/28/2026, directed to inhale 1 puff once daily and rinse the mouth thoroughly after each use. During an observation on 2/12/2026, LVN 3 administered the inhaler in the resident’s room but did not instruct the resident to rinse her mouth afterward. In interview, LVN 3 stated she should have instructed the resident to rinse her mouth after taking the inhaler and explained the purpose was to prevent fungus or bacteria in the mouth and possible sores that could become infected. The DON also stated the rinse was important to prevent fungal infection in the mouth and that failure to rinse could lead to pain while eating and potentially other infections. The facility’s Oral Inhaler policy dated 1/1/2012 did not include procedures regarding administration of corticosteroid medication.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. During observation, interview, and record review, two medication errors were identified out of 34 total opportunities, resulting in an overall error rate of 5.88% for one resident observed during medication administration. The resident involved had been admitted and later readmitted to the facility with diagnoses including a left femur fracture, COPD, mild intermittent asthma with acute exacerbation, allergic rhinitis, and dysphagia. The resident’s H&P dated 1/29/2026 stated the resident did not have the capacity to make needs known or make decisions, and the MDS dated 2/4/2026 indicated moderate cognitive impairment and dependence or assistance with multiple activities of daily living. The resident’s physician orders dated 1/28/2026 included cholecalciferol 400 units, 1 tablet by mouth daily for supplement, and fluticasone propionate nasal spray 50 mcg/actuation, 1 spray in each nostril daily for allergy. During interview, the LVN stated she did not administer the Vitamin D because the medication cart only had a 1000-unit dose available and she needed to check with central supply for the 400-unit dose. She also could not provide a reason for not administering the nasal spray. The DON stated prescribed medications are important to treat ongoing symptoms or disease and that if medications are not administered as prescribed, symptoms could worsen and medical issues could remain unresolved or uncontrolled. The facility policy stated all medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.
Resident Signed Arbitration Agreement Without Understanding Due to Dementia and Legal Blindness
Penalty
Summary
The facility failed to ensure that a resident with dementia and legal blindness understood the legal documents she signed during admission, including a Binding Arbitration Agreement. Resident 39 was initially admitted and later readmitted to the facility, and her diagnoses included dementia, legal blindness, and CHF. Her H&P stated she did not have the capacity to understand and make decisions, and a neuropsychiatric progress note documented dementia with cognitive communication deficit and that recommendations were subject to IDT approval. Her MDS indicated moderately impaired cognitive skills for daily decision making and highly impaired vision. During a concurrent interview and record review, the Admission Coordinator stated Resident 39’s Arbitration Agreement was signed electronically by the resident and acknowledged that the agreement is a legal document, that both parties are bound by it, and that he should not have asked the resident to sign it because she was legally blind and had dementia. Resident 39 stated her vision was so blurry she could hardly see and she could not recall signing the agreement. The Social Service Director stated the resident did not have intact cognition and that legal documents such as an Arbitration Agreement should not be signed if the resident did not have the capacity to understand. The DON also stated the agreement was not valid because the resident was visually impaired and had dementia, and that having her sign it was unacceptable because it takes away her right to go to court.
Failure to Use Gloves During Gtube Care for a Resident on EBP
Penalty
Summary
The facility failed to ensure staff wore PPE when handling one resident’s gastrostomy tube while the resident was on Enhanced Barrier Precautions. Resident 21 was admitted with diagnoses including hemiplegia, hemiparesis after a stroke, dysphagia, and gastrostomy status. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe problems with thinking and memory, dependence on staff for multiple activities of daily living, and maximum assistance needed for upper body dressing. During an observation in the resident’s room, an LVN assessed the resident’s gtube without wearing gloves. In an interview shortly afterward, the LVN stated she should have worn gloves before touching the gtube and explained that gloves during high-contact activities help prevent the spread of bacteria throughout the facility. The DON stated PPE is important when caring for residents on EBP to prevent the spread of infection to other residents. The facility’s PPE policy stated staff wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin, and the EBP policy stated standard precautions include gown, gloves, mask, and face shield when exposure is anticipated.
Failure to Document and Provide COVID-19 and Influenza Vaccines
Penalty
Summary
The facility failed to ensure that Resident 49 was provided COVID-19 and influenza vaccines. Resident 49 was admitted with chronic obstructive pulmonary disease, mild intermittent asthma, and a cognitive communication deficit. The resident’s history and physical stated that the resident did not have the capacity to understand and make decisions, and the order summary directed that the head of bed be elevated 30 to 45 degrees because the resident experienced shortness of breath when lying flat. The minimum data set also identified malnutrition, an active lung disease, and shortness of breath when lying flat. A review of the resident’s electronic immunization record showed no COVID-19 or influenza vaccines documented. The Infection Preventionist stated resident vaccines are supposed to be listed in the electronic medical record and that staff would not be able to observe residents for adverse reactions if vaccines are not documented. The DON and Administrator stated residents should have immunizations and that it is important for them to have a choice in receiving them. Facility policies stated residents are encouraged to receive COVID-19 vaccination and boosters and that the medical record should document whether the resident received the influenza vaccine, had a medical contraindication, or refused it.
Excess Occupancy in 5-Bed Resident Rooms
Penalty
Summary
The facility failed to ensure that two sampled resident rooms, room [ROOM NUMBER] and room 18, accommodated no more than four residents per room. During a facility tour, room [ROOM NUMBER] was observed to have space for beds, side tables, and resident care equipment, with no concerns noted for privacy or safety, and it contained five empty beds. In an interview, the Administrator confirmed that room [ROOM NUMBER] beds A, B, C, D, and E and room 18 beds A, B, C, D, and E each accommodated five residents. A review of the facility’s letter titled Request for Waiver/Variations to Section 483.70, dated 2/10/2026 and completed by the Administrator, showed the facility was submitting a renewal variation for accommodation of more than four residents in one room. The waiver stated that rooms with 5 residents were room [ROOM NUMBER] and 18, each with approximately 420 square feet, and that each room had approximately 50% non-ambulatory and 50% ambulatory residents when fully occupied, with both rooms having a door with direct access to the corridor and outside exposure at floor level.
Inaccurate MDS Hearing and Hearing Aid Coding for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for one resident by not properly assessing and coding the resident’s hearing status and use of hearing aids. The resident had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, and was documented as lacking capacity to understand and make decisions. An MDS assessment dated 10/29/2025 showed the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for oral hygiene, toileting hygiene, and lower body dressing. A Social Services Assessment dated 10/27/2025 documented that the resident had both right and left hearing aids. During an interview and concurrent record review, the MDS nurse acknowledged that Section B of the MDS, which covers hearing, speech, and vision, was completed inaccurately. The nurse stated that the hearing item (B0200) was coded as 0 (Adequate) instead of 1 (Minimal difficulty), and the hearing aid item (B0300) was coded as 0 (No) instead of 1 (Yes), despite the Social Services Assessment indicating the resident had hearing aids. The MDS nurse reported she did not see the resident using hearing aids at the time of the assessment and did not follow the RAI Section B guidelines, which require ensuring the resident is using their normal hearing appliance, reviewing the medical record, and consulting family and staff. The DON confirmed that MDS assessments must be completed accurately to meet resident needs and develop an appropriate plan of care, and facility policy and the CMS RAI User’s Manual both require accurate, guideline-based resident assessments.
Failure to Care Plan for Missing Hearing Aid
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a resident’s missing right hearing aid. The resident had been admitted and later readmitted with diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia. A History and Physical documented that the resident lacked capacity to understand and make decisions, and an MDS assessment showed severely impaired cognitive skills for daily decision-making, with total dependence on staff for oral hygiene, toileting hygiene, and lower body dressing. A Theft/Loss Report documented that the resident’s right hearing aid was missing. During a concurrent interview and record review, RN 1 confirmed that there was no comprehensive care plan addressing the missing right hearing aid and described the care plan as a communication tool among the IDT that should include a problem, goal, and interventions. The MDS nurse stated that care plan development is a consolidated team effort and that the IDT should develop a care plan to address any identified resident problems or concerns. The DON stated that the care plan serves as guidance on how to care properly for residents and emphasized the importance of developing a comprehensive care plan to provide appropriate care. The facility’s policy on Person-Centered Care Planning required development and implementation of a comprehensive person-centered care plan for each resident, with measurable objectives and timeframes to meet identified needs, but this was not done for the missing hearing aid.
Delay in Audiology Consultation After Loss of Hearing Aids
Penalty
Summary
The facility failed to ensure timely access to audiology services for a resident who had documented hearing impairment and missing hearing aids. The resident, who had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, was cognitively severely impaired and totally dependent on staff for several activities of daily living. The resident’s social services assessment documented bilateral hearing aids, and a theft/loss report later showed the right hearing aid was missing. An ENT consultation subsequently documented that the resident had hearing loss and had stopped wearing hearing aids after losing the left one, and recommended an audiogram for further assessment. A physician telephone order was placed for an audiology consultation with follow-up treatment. Despite these findings and orders, the audiogram was not completed until 39 days after it was recommended by the ENT provider. The Social Service Director acknowledged responsibility for scheduling the audiogram and stated that the referral should have been made within seven days of the recommendation. The DON stated that the resident should have been referred to audiology as soon as the missing hearing aid was identified. The resident reported losing her hearing aids and stated she sometimes became upset when she could not hear well, especially when staff spoke to her. Facility policies on resident rights and care of hearing-impaired residents required that residents receive services to maintain their highest practicable well-being and that Social Services refer residents to an audiologist when indicated, but these were not followed in a timely manner for this resident.
Failure to Complete and Share Signed Personal Effects Inventory
Penalty
Summary
The facility failed to ensure that a personal effects inventory was properly completed, signed, and shared for one resident. The resident, who had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, was documented in the History and Physical as lacking capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills and total dependence on staff for several ADLs. On review of the resident’s Personal Effects Inventory Form dated 10/23/2025, the form was found not to be signed by the resident or a resident representative, nor by facility staff at the time of admission. The resident’s representative was not provided a copy of the initial admission inventory form. RN 1 stated that the Personal Effects Inventory Form should be completed upon admission, readmission, and as needed, and acknowledged that it had never been the facility’s practice to inform and provide a copy of the inventory to the resident’s representative for items brought from the hospital. RN 1 also stated that the inventory form is part of the medical record and should be completed accurately for transparency and continuity of care. The Social Service Director stated it is important to properly document and sign the Personal Effects Inventory Form for items brought for safekeeping. The DON stated that facility staff and the resident representative should sign the form and that a copy should be provided to the representative, and that not completing and signing the form creates a risk for missing or lost personal items and incomplete medical records. The facility’s policies titled “Personal Property” and “Completion and Correction” required that the personal property inventory form be signed, placed in the medical record, and a copy provided to the resident or representative, and that medical records be complete and accurate, which was not followed in this case.
Improper Single-Person Transfer of Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with paraplegia, muscle weakness, and contractures, who was dependent for transfers and unable to stand, was transferred from a wheelchair to bed by a single CNA using an inappropriate technique. The resident's care plan specified the need for assistance with locomotion, and the physical therapy discharge summary indicated that transfers required two or more helpers for safety. Despite these documented requirements, the CNA transferred the resident alone, lifting the resident under the arms and placing him in bed without assistance. The resident reported discomfort and stated that the CNA 'picks me up and throws me in the bed,' and that this had previously resulted in foot pain. Interviews with facility staff confirmed that the resident should have been transferred with a two-person assist for safety, and that it would be difficult and unsafe for one person to perform the transfer. The CNA involved was unable to explain how he determined it was appropriate to transfer the resident alone and could not articulate how he is informed of residents' assistance needs. Facility policies reviewed emphasized the importance of safe and efficient transfers based on residents' physical abilities and the need to provide care that maintains dignity and quality of life.
Annual Skills Competency Not Completed for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had an annual skills competency assessment completed as required. During an interview and review of employee records with the Director of Staff Development (DSD), it was found that the CNA's new hire competency was completed, but the annual competency, which was due, had not been performed. The DSD acknowledged that the annual competency was missed due to an oversight. According to the facility's policy and procedure, annual competency validation is necessary to evaluate staff performance, meet regulatory standards, and address any problematic issues to protect residents' health, safety, and well-being.
Failure to Label and Date Resident's Food
Penalty
Summary
The facility failed to ensure that a sandwich for a resident was properly labeled and dated, which is a violation of food safety standards. During an observation and interview, an undated and unlabeled sandwich was found on the bedside table of a resident who was admitted with diagnoses including anxiety, COPD, and muscle weakness. The resident, who had intact cognitive skills and required assistance for activities of daily living, expressed uncertainty about the sandwich's freshness, indicating it looked old and should be discarded. Interviews with the Dietary Service Supervisor and the Registered Dietitian revealed a lack of clarity and adherence to food labeling and dating protocols. The Dietary Service Supervisor admitted to not knowing when food should be disposed of and expressed hope that staff would discard old food to prevent food poisoning. The Registered Dietitian confirmed that all sandwiches should be labeled and dated to prevent residents from consuming old food, which could lead to illness. The facility's policy, dated 2019, mandates that all food items be stored, thawed, and prepared according to good sanitary practices, including proper labeling and dating.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. During an observation, it was noted that the call light was hanging on the side of the bed and not accessible to the resident. The resident, who has chronic obstructive pulmonary disease, diabetes mellitus, and gastro-esophageal reflux disease, was dependent on staff for various activities of daily living. The resident's care plan specifically indicated that the call light should always be within reach to prevent falls and encourage the resident to use it for assistance. Interviews with staff, including a Certified Nursing Assistant and the Director of Staff Development, confirmed the importance of having the call light within reach as it serves as a critical communication tool for residents to alert staff when they need assistance. The facility's policy and procedure also mandated that call cords be placed within reach in residents' rooms. Despite these guidelines, the call light was not positioned correctly, placing the resident at risk for accidents and potentially delaying the meeting of their physical and emotional needs.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to inform the physician about a resident's persistent refusal to take trazodone, a medication prescribed for major depressive disorder. The resident, who was admitted with diagnoses including major depressive disorder, diabetes mellitus, and muscle weakness, had a physician's order for trazodone to be taken six days a week. Despite the resident's capacity to understand and make decisions, as noted in their History and Physical, the Minimum Data Set indicated moderately impaired cognitive skills for daily decision-making. The resident refused the medication on 19 occasions throughout October, but there was no documentation that the physician was notified of these refusals. The Director of Nursing confirmed that the facility's process for medication refusal includes notifying the physician and documenting the refusal in the progress notes. However, there was no evidence that the physician was informed of the resident's continued refusal, which was necessary for evaluating the reason for refusal and considering alternative treatments. The facility's policies on refusal of treatment and medication administration require documentation of the physician's notification and response, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident Receiving Dialysis
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, leading to incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS). The deficiency was identified during a review of the resident's records, which revealed discrepancies between the resident's documented medical needs and the information recorded in the MDS. Specifically, the MDS indicated that the resident's cognitive skills for daily decision-making were moderately impaired, and that they required maximum assistance with toileting hygiene and dressing. However, the MDS Nurse acknowledged that there was an error in the MDS section regarding the resident's dialysis treatment, which was not accurately marked despite the resident receiving dialysis three times a week. The resident involved had been admitted with diagnoses including End Stage Renal Disease (ESRD) and congestive heart failure (CHF), and had the capacity to understand and make decisions according to their History and Physical (H&P) report. The facility's policy and procedure for the Resident Assessment Instrument (RAI) process emphasized the importance of accurate resident assessments to meet state and federal guidelines. The MDS Nurse confirmed that the inaccurate MDS assessment did not reflect the resident's actual condition and care needs, which is a mandated requirement for proper care planning and service delivery.
Failure to Monitor Resident's Diet and Outside Food Intake
Penalty
Summary
The facility failed to ensure that a care plan was in place for a resident, identified as Resident 26, to monitor the frequency and type of outside food brought in by family members. This deficiency was observed when surveyors found an empty box of a burger, a large bag of potato chips, crackers, and cans of soda in the resident's room. Despite the resident being on a prescribed pureed texture diet due to medical conditions such as COPD, diabetes mellitus, and GERD, there was no documentation or care plan addressing the monitoring of food brought by family members. The resident reported that certain foods brought by family caused coughing, and staff did not check on her ability to tolerate these foods. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) revealed a lack of awareness and documentation regarding the resident's consumption of non-prescribed food. The DON acknowledged the absence of a care plan to monitor the resident's intake of regular textured food, which could lead to issues such as choking or aspiration. The RD confirmed that the resident should have been monitored for the types of food and textures being brought in by the family, and a care plan should have been developed to prevent potential risks during mealtimes.
Failure to Revise Care Plan for Aspiration Precautions
Penalty
Summary
The facility failed to revise the care plan for one of the residents, identified as Resident 26, who was at risk of aspiration. Resident 26 had a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and gastro-esophageal reflux disease (GERD). The resident was on a pureed textured diet and required oxygen therapy, as well as assistance with toileting hygiene, showering, and dressing. During a Multidisciplinary Care Conference, it was noted that Resident 26 needed monitoring for medical management and observation due to complex medical conditions, including the need to keep the head of the bed elevated to prevent shortness of breath and to observe aspiration precautions. Despite these identified needs, the care plan for Resident 26 was not revised to include the necessary aspiration precaution interventions. This oversight was confirmed during interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged that the care plan should have been updated following the care conference. The facility's policy on Comprehensive Person-Centered Care Planning, which mandates periodic review and revision of care plans by the Interdisciplinary Team (IDT), was not adhered to in this instance, leading to the deficiency.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a stage 4 pressure ulcer was turned and repositioned every two hours, as required for proper care and prevention of further deterioration. The resident, who was admitted with multiple diagnoses including anxiety, COPD, muscle weakness, major depressive disorder, and schizoaffective disorder, was observed multiple times over two days lying in a supine position without evidence of repositioning. The resident's Minimum Data Set indicated severe cognitive impairment and a dependency on two or more helpers for activities, highlighting the need for diligent care. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, revealed a lack of documentation and clarity regarding the resident's repositioning schedule. The facility's policy on pressure injury prevention required interventions such as repositioning, but there was no specific documentation in the electronic health record to confirm that the resident was being repositioned every two hours. This oversight in care and documentation had the potential to worsen the resident's condition and delay wound healing.
Failure to Provide Timely Podiatry Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 36, who had long, thick, and elongated toenails. Despite the resident's repeated requests to see a podiatrist, no action was taken by the facility staff. The resident's toenails were observed to be causing discomfort and hindering mobility, as they hurt when touching the linen and prevented walking. The resident was admitted with diagnoses including muscle weakness, iron deficiency anemia, and protein calorie malnutrition, and was noted to have moderately impaired cognitive skills requiring moderate assistance with personal hygiene. Certified Nurse Assistant 2 acknowledged awareness of the resident's condition but did not report it to the Social Service Director, considering it not serious. The Social Service Director, responsible for referring residents to podiatry services, stated that residents with such toenail conditions should be referred immediately due to the risk of ingrown toenails and potential infections. The facility's policies on foot care and grooming indicated that high-risk residents should be referred to a podiatrist, but this protocol was not followed for Resident 36.
Failure to Maintain Bed in Lowest Position for Fall Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's bed was placed in the lowest position to prevent injuries during a fall. This deficiency was identified for one of the three sampled residents, who was at high risk for falls. The resident, who had been diagnosed with chronic obstructive pulmonary disease, diabetes mellitus, and gastro-esophageal reflux disease, was dependent on staff for toileting hygiene, showering, and dressing. The resident's care plan specifically indicated that the bed should be in the lowest position as a preventive measure against falls. During an observation and interview, a Certified Nursing Assistant (CNA) confirmed that the bed was too high and should have been lowered to prevent potential injuries. The Director of Staff Development also acknowledged that the resident was at high risk for falls and that the bed should have been in the lowest position to avoid injury. The facility's policies on fall management and resident safety emphasized providing a safe environment and implementing a fall management program to minimize fall hazards, which were not adhered to in this instance.
Failure to Implement Scheduled Toileting Plan for Resident
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident, identified as Resident 146, who was admitted with diagnoses including muscle weakness, a nondisplaced fracture of the left femur, and chronic obstructive pulmonary disease. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for toileting hygiene and lower body dressing. Despite being a candidate for scheduled toileting, as indicated by a Bowel and Bladder Program Screener score of 7, there was no documented evidence of a scheduled toileting plan being implemented for the resident. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed that a scheduled toileting plan is essential for managing incontinence and preventing complications such as skin breakdown. The facility's policy requires that each resident who is incontinent be assessed and provided with appropriate treatment and services, including an individualized scheduled toileting program. However, the facility did not adhere to this policy for Resident 146, as there was no evidence of such a plan in the resident's clinical records.
Failure to Communicate Dietitian's Recommendation for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis treatment received care in accordance with standards of practice. The resident, who was admitted with diagnoses including End Stage Renal Disease and congestive heart failure, had a recommendation from a Registered Dietitian to receive a high-calorie nutritional supplement, Novasource, due to variable oral intake. However, there was no documentation indicating that the resident's physician was notified of this recommendation. The Director of Nursing confirmed that the licensed nurses did not communicate the dietitian's recommendation to the physician within the required 72-hour timeframe because the facility did not have the Novasource supplement available. This lack of communication and failure to provide the recommended nutritional supplement put the resident at risk for weight loss and dehydration, potentially leading to a decline in health condition. The facility's policy required regular collaboration between nursing staff, dialysis provider staff, and the attending physician concerning the resident's care, which was not adhered to in this case.
Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label and date medications for two residents, leading to potential harm. For Resident 34, who has glaucoma, muscle weakness, and hypertension, the facility did not label the open date on ketorolac and prednisolone acetate ophthalmic solutions. These medications are crucial for reducing inflammation after eye surgery. The Licensed Vocational Nurse (LVN) acknowledged the absence of open dates and stated it was the responsibility of the nurse who opened the medication to label it. The facility's policy requires medications to be labeled according to state and federal laws. For Resident 40, who suffers from chronic obstructive pulmonary disease (COPD) and anxiety disorder, the facility failed to label and remove an expired pouch of ipratropium with albuterol inhalation solution. This medication is essential for treating shortness of breath. The LVN found the expired medication in the medication cart without an open date, and it was unknown when it was opened. The Director of Nursing (DON) confirmed that all medications should be labeled with open and expiration dates to ensure efficacy. The report highlights the facility's non-compliance with medication labeling and storage requirements, which could lead to ineffective treatment and potential harm to residents. The manufacturer's guidelines for ipratropium with albuterol specify that opened vials should be used within one week, emphasizing the importance of proper labeling and timely usage.
Failure to Date and Label Nasal Cannula
Penalty
Summary
The facility failed to ensure that a nasal cannula used by one of the residents was properly dated and labeled, which is a requirement for maintaining sanitary conditions and preventing respiratory infections. During observations on multiple occasions, it was noted that the nasal cannula in the resident's room was neither dated nor labeled. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the nasal cannula should be changed weekly and dated to prevent the risk of respiratory infections. The facility's policy on oxygen therapy, dated November 2017, also indicated that the tubing should be changed every seven days and labeled with the date of change. The resident involved had a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, and gastro-esophageal reflux disease (GERD). The resident required oxygen therapy and was dependent on staff for various activities of daily living. The failure to date and label the nasal cannula placed the resident at risk for respiratory infection, as confirmed by both the DSD and the DON during their interviews. The facility's oversight in adhering to its own policy and procedure for oxygen therapy contributed to this deficiency.
Facility Exceeds Resident Capacity in Two Rooms
Penalty
Summary
The facility failed to ensure that two of the sampled resident rooms accommodated no more than four residents per room, as required by regulations. Observations conducted over several days revealed that room [ROOM NUMBER] had beds labeled A, B, C, D, and E, and room [ROOM NUMBER] also had beds labeled A, B, C, D, and E, indicating that each room accommodated five residents. Although some beds were empty during the observations, the facility's Client Accommodations Analysis confirmed the presence of five beds in each room. This situation was further documented in a Request for Waiver/Variance to Section 483.70, where the Administrator sought a renewal for a variation of the existing variance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Centinela Skilled Nursing & Wellness Centre West | 0 mi | ★★★★★ | 18 | 0 |
| Inglewood Health Care Center | 0.8 mi | ★★★★★ | 32 | 0 |
| Century Villa, Inc | 1.3 mi | ★★★★★ | 12 | 0 |
| Hawthorne Healthcare & Wellness Centre, Lp | 1.5 mi | ★★★★★ | 17 | 0 |
| Primrose Post-acute | 1.5 mi | ★★★★★ | 7 | 0 |
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