Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence St Elizabeth Care Center during CMS and state inspections, most recent first.
A resident with urinary retention, depression, and dependence on renal dialysis, who had an indwelling urinary catheter ordered with care every shift, was observed in the Rehab Room with a visible catheter bag containing red-tinted urine and no dignity cover in place. The DSD and DON both confirmed the absence of a dignity cover, stated that the resident had not refused one, and acknowledged that the cover is necessary for privacy and dignity. Facility policy on resident rights and dignity requires residents to be treated with kindness, dignity, and respect, and for privacy to be maintained during personal care.
A resident with dysphagia, hypothyroidism, and muscle weakness experienced a documented 7.1% weight loss over three months while on a CCHO level 7 diet with fortified foods and variable intake. The RD and IDT identified the weight loss, recommended weekly weights for two weeks, and nursing notes recorded that the MD agreed with these recommendations. However, nursing staff did not enter an order for weekly weights or ensure they were obtained, despite the facility’s policy requiring weekly weights and documentation in the EMR for residents meeting weight‑loss criteria, resulting in missed monitoring of the resident’s nutritional status.
A resident with a periprosthetic knee fracture, DM2, fall history, mobility limitations, and urinary retention was discharged home with an IV and Foley catheter in place without adequate discharge planning or documentation. The NOMNC form showed no signature from the resident or representative, and leadership acknowledged there was no proof the NOMNC was actually provided, despite policy requiring a signed and dated notice so the termination decision could be appealed. Admissions notes claimed a copy was left at bedside and that a family member intended to appeal, but the family later reported they never received appeal information or discharge instructions. The care plan and discharge documentation lacked individualized teaching on Foley and IV care, did not show assessment of caregiver capacity or return demonstration, and the transfer/discharge report omitted key information about the IV and Foley. An LVN confirmed discharging the resident with an IV, and leadership acknowledged that required discharge planning and resident-rights policies, including advance notice and NOMNC procedures, were not followed.
A resident with multiple medical conditions, moderate cognitive impairment, and dependence in ADLs was discharged home with an IV and Foley catheter without an individualized, person-centered discharge care plan or documented education for the resident or responsible party. Despite an order for discharge home with home health, the care plan did not include specific goals, measurable objectives, or interventions addressing catheter or IV care, nor did it reflect family involvement or teaching. An LVN recalled discharging the resident with an IV in place, and the responsible party reported that no discharge instructions were provided and that the discharge was unorganized and unsafe. The ADON and DON acknowledged that the discharge planning process and care plan did not meet facility policy requirements for comprehensive care planning, caregiver assessment, and documented preparation for discharge.
A resident with multiple medical conditions and moderate cognitive impairment was discharged home with home health services without an individualized, person-centered discharge care plan that addressed specific needs or involved the responsible party. The care plan for the resident’s Foley catheter did not include catheter care or family teaching, and there was no documentation that caregiver availability, capacity, or return demonstration of understanding were assessed. At discharge, staff did not provide documented discharge instructions or education to the resident or responsible party, and the resident was sent home with an IV access still in place, which an LVN later acknowledged could lead to infection or bleeding. The ADON and DON confirmed that the discharge order and transfer report omitted key information about the IV and Foley catheter and that staff failed in communication and education, contrary to facility policies on comprehensive care planning, discharge planning, and nursing staff competency in person-centered care and communication.
A resident with multiple medical conditions, including a periprosthetic fracture and T2DM, was issued a Notice of Medicare Non-Coverage (NOMNC) ending SNF coverage and setting a discharge home with home health. Although the NOMNC contained instructions and a phone number for filing an appeal, the form was marked "temporarily incapacitated" and was not signed by the resident or representative, and the representative later reported not receiving appeal information or discharge instructions. An admissions staff note indicated the NOMNC was left at the bedside and that the representative intended to appeal, but the facility failed to obtain the required signature acknowledging receipt, contrary to its NOMNC and resident rights policies, and the admissions director reported being unfamiliar with the 30‑day written notice requirement for involuntary transfer or discharge.
A resident admitted with multiple medical conditions, including a periprosthetic fracture and type 2 DM, had an incomplete Inventory of Personal Effects form at both admission and discharge. Facility policy required staff to document all personal items, obtain signatures from the resident or responsible party and a staff member at admission, and have the resident or responsible party and a nurse sign at discharge to certify receipt of belongings. The DON confirmed that the admission inventory lacked a facility representative’s signature and that, at discharge, the form was not signed by the resident or representative, with the facility signature dated after the actual discharge date, resulting in a failure to properly account for the resident’s personal possessions.
A resident with multiple medical conditions, moderate cognitive impairment, and high ADL assistance needs was discharged home with home health services. After discharge, surveyors found that a SW and ADON entered discharge-related notes into the record on the same day the survey began, but backdated the content to earlier dates and did not identify the entries as late entries as required by facility policy. The SW’s note described family concerns about discharge readiness and their decision to proceed with home discharge, and the ADON’s documentation of a home visit and provision of discharge paperwork was also completed much later than the actual event. The DON and ADON acknowledged that staff failed to timely and properly document these communications in accordance with the facility’s late-entry and addendum procedures, resulting in an inaccurate account of the resident’s record.
A medication pass observation found the facility’s error rate exceeded the 5% threshold, with multiple errors involving one resident who received crushed g-tube medications without an order to crush, without ordered flushes between meds, and without the ordered water amount with potassium chloride, plus another resident who received amlodipine without a prior HR check. Staff interviews and record review confirmed the ordered administration steps were not followed, and the issue was identified as an IJ during survey.
A resident with epilepsy and severe cognitive impairment received multiple meds via g-tube, but an LPN crushed and administered several tablets without a provider order to crush, failed to flush the tube between meds as ordered, and gave potassium chloride without the ordered 8 oz of water. The DON and DSD also noted there was no g-tube med administration care plan or formal competency validation for the LPN. Another resident had a significant med error when aspirin was omitted and omeprazole was given after enteral feeding had already begun.
Licensed nursing staff failed to rotate SQ injection sites for two residents receiving anticoagulants and one resident receiving Humalog insulin, despite physician orders requiring site rotation. One resident had severe cognitive impairment and dependence for care, while the other two residents had orders for heparin or enoxaparin for prophylaxis and insulin for DM2. Review of MAR/LAR documentation and interviews with the ADON and DON confirmed repeated use of the same sites and noncompliance with the prescriber orders and facility policy.
PRN opioid pain management was not carried out according to the ordered numeric pain scales for two residents. One resident with significant mobility and ADL dependence had multiple MAR entries where hydrocodone-acetaminophen doses did not match the documented pain ratings, including missed lower-dose administrations at higher pain levels and higher-dose administrations at lower pain levels. Another resident with cancer-related pain had oxycodone 15 mg documented as given when the pain rating was 0. The DON stated the facility process was to use the pain scale and follow the MD’s orders, and that the incorrect doses were administered for the reported pain levels.
Controlled medication handling was not accurately documented for a resident receiving Norco and pregabalin for pain and neuropathic pain. Surveyors found mismatches between the MAR, controlled drug count sheets, and the physical inventory, including doses removed without MAR documentation and pregabalin doses documented as given without being signed out on the count sheet. The shift change narcotic count sheet for the cart was also left unsigned by the incoming and outgoing LNs, and the DON and ADON stated nurses are expected to document controlled meds immediately after administration and complete the narcotic count at each shift change.
Improper food storage and dish handling were observed in the kitchen. A bottle of salad dressing was labeled with an incorrect best-by date after opening, a bag of parsley with brown discoloration remained in storage, a dented can of applesauce was kept with non-dented cans, and clean food containers were stacked while still wet. The DS and DON stated the facility’s labeling, storage, and dishwashing guidelines required proper dating, removal of spoiled or dented items, and complete air drying before stacking.
Food brought in by family or visitors was not consistently stored in a way that was separate or easily distinguishable from facility food when there was no designated refrigerator space for residents’ leftover foods. The DS and DON stated that only sealed items in original packaging could be kept in the kitchen refrigerator, while opened or leftover outside food had to be consumed within 2 hours or discarded due to cross-contamination concerns and the lack of a refrigerator at the nurses’ station. The facility policy also allowed outside food as an intervention for residents with low intake or cultural food preferences, but storage was limited to manufacturer-sealed items.
A facility failed to maintain infection control when a resident’s personal bag was stored on the laundry room floor, an EBP sign was not posted outside a resident’s room despite a PICC line and EBP order, and an ice scooper was left in an open container exposed to contaminants. Staff and the IP acknowledged the bag should have been kept off the floor, the EBP sign should have been in place for high-contact care, and the ice scoop should have been covered per policy.
Antibiotic stewardship failed for four residents when antibiotic orders were not fully supported by required criteria or were not properly monitored. One resident received Bactrim DS for UTI despite not meeting Loeb criteria and had no documented adverse-effect monitoring on multiple shifts. Another resident had an Amoxicillin order with an unspecified indication and no monitoring documented for Amoxicillin or Diflucan. A third resident had Methenamine Hippurate for UTI prophylaxis with no end date and no adverse-effect monitoring, and a fourth resident had Bactrim DS without documented monitoring for adverse effects.
An LVN left a medication cart computer screen open in a hallway, exposing a resident’s name, photo, DOB, vital signs, weight, allergies, code status, and MAR to public view. The same LVN also gave another resident’s scheduled morning meds in the activity room while the resident was seated at a table facing other residents, even though the resident said he usually takes meds in his room and prefers privacy. The DON and ADON referenced facility confidentiality and privacy expectations, including use of privacy screens and bedside medication administration.
A resident with impaired cognition, weakness, difficulty walking, and high fall risk had a bed pad alarm used as a restraint without a physician order, informed consent from the responsible party, or a restraint assessment. The ADON and DON both confirmed the alarm was treated as a restraint and that the required documentation was not in place before it was applied.
Baseline Care Plan Missing PRN Opioid Intervention: A resident with hemiplegia, hemiparesis, metabolic encephalopathy, polyneuropathy, and PVD was admitted with PRN hydrocodone-acetaminophen orders for pain. The care plan addressed pain generally, but it did not include the opioid medication as a resident-specific intervention, even though the LVN and DON stated baseline care plans should include physician orders and opioid use for pain management. The resident stated he often had pain and that the pain medication caused constipation.
Failure to Assess, Notify, and Document Urinary Symptoms: A resident with impaired cognition, dependence for care, and urinary incontinence reported discomfort and tingling with urination, but the licensed nurses did not complete a documented assessment or change-of-condition record, did not ensure the physician was notified, and did not complete the lab requisition for the ordered UA C&S. Staff also reported confusion about who was responsible for the SBAR, physician follow-up, and care plan for the urinary symptoms.
Feeding Tube Water Flush Bag Not Properly Labeled A resident with dysphagia, a gastrostomy tube, and severe cognitive impairment had a water flush bag observed with only the date and time it was changed. The TN stated the bag should also include the resident’s name, room number, infusion rate, and the LPN’s initials. The ADON confirmed the bag was not labeled per facility policy for closed-system enteral products, which requires those identifiers on the container.
Suction Canister Not Dated: A resident with gastrostomy, dysphagia, pneumonitis, and severely impaired cognition had an order for PRN oral suction for excess secretions. During observation, the resident’s suction canister was labeled with the resident’s name but not the date it was last changed. The TN stated suction canisters should be labeled with the resident’s name and date when provided or changed, and the ADON stated staff did not follow the facility’s suction machine policy requiring canisters and catheters to be dated when replaced weekly and as needed.
Missing CNA Performance Evaluation Documentation: The facility failed to keep required performance evaluation documentation in a CNA’s personnel file. The DSD stated the CNA’s file was missing after the prior DSD left, and no evaluation was on file. The DSD and ADON stated performance evaluations are used to assess competency, identify weaknesses, and support resident care, and the facility policy required annual evaluations to be retained in the employee file.
A resident with hemiplegia, hemiparesis, DM, and dysphagia on a CCHO soft and bite-sized diet requested a salad with lunch, then agreed to cauliflower instead when salad was not allowed. CNA documented the request on the alternative menu, but the lunch tray arrived without either item. The DSA said the kitchen forgot the cauliflower, and the DS and DON confirmed the resident’s food preference was not followed.
Facility Assessment Did Not Include G-Tube Care Competencies: The DON stated the facility’s 2025 Facility Assessment did not reflect enteral tube care or g-tube medication administration for two residents with g-tubes. The assessment listed general medication routes and competencies, but did not identify the resident population’s enteral tube needs or staff competency requirements, despite the facility having residents with diagnoses including attention to gastrostomy and related complex medical conditions.
Inaccurate Pain Medication Documentation: Two residents had MAR entries that did not match the documented pain assessments or ordered PRN opioid parameters. One resident received hydrocodone-acetaminophen despite a recorded pain level of 0, and another resident received oxycodone 15 mg with pain documented as 0 out of 10. The DON, ADON, and LPNs stated the documentation was inaccurate and did not follow the facility’s pain management and medication administration procedures.
CNA training records showed one CNA did not complete required abuse prevention and dementia management education. The DSD confirmed the CNA attended only three of five abuse in-services and did not attend either dementia management session, despite facility requirements for abuse training every 2 years and dementia training annually.
Resident rooms did not meet the required square footage standard in 17 of 25 rooms. A resident council interview stated there was enough room space, and observations found residents in the variance rooms could move freely with adequate space for wheelchairs, walkers, and canes. A review of the room variance waiver showed multiple rooms with two, three, or four residents had actual square footage below the federal minimum, despite the facility policy requiring at least 80 sq ft per resident in multiple-occupancy rooms.
A resident room that was converted from a physical therapy space to a four-bed room did not meet the required 80 square feet per resident, and no waiver was obtained for this deficiency. The room's limited space contributed to a resident tripping and falling while moving toward the bathroom, and staff confirmed the room was not included in the facility's approved waiver list.
Surveyors found that discontinued controlled medications were not removed from the medication cart and that accurate Controlled Drug Administration Records were not maintained for two residents. Nursing staff confirmed that discontinued narcotics remained accessible and that one resident's scheduled oxycodone was not properly tracked due to a documentation error, leading to inaccurate medication records.
RN failed to assess a resident after a CNA reported overhearing the resident say he would hurt himself if he could not leave, and also failed to timely notify the MD of the change in condition. The resident had hepatic encephalopathy, CKD stage 4, muscle weakness, and documented cognitive disorganization/transient confusion. The RN contacted family and emergency personnel, but did not directly assess for self-harm or notify the MD until hours later.
Two residents in a LTC facility did not receive their prescribed medications on time due to the facility's failure to reorder medications five days in advance as per policy. Critical medications for managing hypertension, edema, blood clots, glaucoma, and BPH were unavailable, leading to missed doses. Additionally, one resident received medication from another resident's supply, violating facility policy. The DON acknowledged the lack of a consistent system for timely reordering and follow-up, contributing to these deficiencies.
The facility experienced a medication error rate of 26.92%, affecting two residents who did not receive their prescribed medications due to unavailability. The errors were linked to the failure of licensed nurses to reorder medications in a timely manner, as required by facility policy. The DON acknowledged the lack of a consistent system for medication reordering and follow-up, contributing to the errors.
The facility failed to inform residents of their rights to accept or refuse treatment and to formulate an advance directive (AD). Three residents were not provided with necessary information or assistance to create an AD, and one resident's AD was not maintained in their chart. This oversight could result in residents' medical wishes not being respected.
A resident with heart failure and emphysema required as-needed oxygen therapy, but the facility failed to document its administration in the MAR. Despite observations of the resident using oxygen, staff did not consistently record this, leading to potential delays in care. The facility's policies emphasized the importance of documentation, which was not adhered to in this case.
A long-term care facility failed to administer critical medications to residents, resulting in significant medication errors. A resident did not receive metoprolol due to unavailability, another received expired insulin, and a third missed doses of Eliquis and brimonidine. The facility lacked a consistent system for timely medication reordering and follow-up, leading to these deficiencies.
A facility failed to manage medications properly, leading to the administration of expired insulin to a resident with diabetes and improper storage of an Aplisol vial used for tuberculosis testing. The insulin was used beyond its expiration date, and the Aplisol vial lacked proper labeling, increasing the risk of inaccurate test results.
The facility failed to follow its established menu, omitting cornbread and substituting green beans for seasoned peas, affecting 42 residents. A resident with a history of significant weight loss and medical conditions expressed dissatisfaction with the menu changes. The Dietary Supervisor and Registered Dietician acknowledged the oversight, and the facility's policy requires menu changes to be documented and communicated.
The facility failed to maintain safe food storage and preparation practices, affecting 42 residents. Numerous food items in the kitchen and resident refrigerator were found unlabeled or improperly stored, posing a risk of contamination. The Dietary Supervisor, Director of Nursing, and Registered Dietician confirmed that facility policies were not followed, necessitating the disposal of improperly labeled items.
A LTC facility failed to implement Enhanced Barrier Precautions for a resident with a gastrostomy tube, did not ensure nasal cannulas and humidifier bottles were changed and labeled weekly for a resident on oxygen therapy, and allowed a urinary catheter bag to touch the floor, increasing infection risks. The facility's policies were not updated to reflect current CDC guidelines, leading to potential health risks for residents.
The facility did not ensure residents knew where to find the most recent survey results, as confirmed by interviews with three residents. An observation showed the survey binder was not updated with 2023 results, and the Minimum Data Nurse acknowledged this oversight. The facility's policy states residents have the right to examine survey results, which was not being met.
A resident in a LTC facility experienced a deficiency in their living environment due to an unsecured ceiling light screen and the absence of a chain or cord for the wall light, preventing them from controlling the lighting. The resident, with intact cognition and requiring assistance with walking, expressed concern about the potential for the screen to fall. The Maintenance Supervisor and DON confirmed these issues, which contradicted the facility's policy to ensure a safe and comfortable environment.
A facility failed to notify the ombudsman of a resident's discharge to a hospital, as required. The resident, capable of making decisions, was transferred due to altered mental status. The Social Services Director confirmed the omission, noting that weekend notifications were the responsibility of LVNs or RNs. The facility's policy required ombudsman notification during unplanned hospitalizations, but this was not completed.
A resident was transferred to a GACH without being provided a seven-day bed hold agreement, despite being capable of understanding and making decisions. The facility's policy requires informing residents of the bed hold option upon admission and transfer, but this was not adhered to, as confirmed by the Medical Record Director and Social Services Director.
The facility failed to develop a care plan for a resident's use of Eliquis, an anticoagulant, and did not implement the care plan for another resident's urinary catheter, leading to deficiencies in care. The absence of a care plan for Eliquis left staff without guidance on monitoring for adverse effects, while the improper handling of a urinary catheter bag posed an infection risk. These issues highlight lapses in care planning and implementation, as confirmed by facility staff.
A resident experienced significant weight loss due to the facility's failure to update the care plan with current nutritional interventions recommended by the registered dietitian. Despite the resident's dissatisfaction with meals and the need for revised dietary measures, the care plan remained unchanged, placing the resident at risk for further weight loss. The Director of Nursing acknowledged the oversight, which was contrary to the facility's policy on care plan review.
A resident with a history of dementia and other medical conditions was found with medications unattended in the activities room, despite being assessed as incapable of self-administration. The MDSN attempted to remove the medications but was unsuccessful, and the DON was informed but did not follow up, leaving the medications accessible to other residents.
A resident experienced significant weight loss due to the facility's failure to follow physician orders for weekly weight documentation and revise the care plan. Despite the resident's dissatisfaction with meals and low intake, the facility did not complete an SBAR form or conduct an IDT care plan meeting. The facility's dietary supervisor and MDS nurse did not consider the weight loss significant, leading to a lack of communication with the resident's physician and RD.
A resident was prescribed Eliquis without a specified indication for use, contrary to the facility's policy requiring medication orders to include a diagnosis or indication. The resident, who lacked decision-making capacity and required significant assistance, was at risk of delayed care due to this oversight.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a resident with an indwelling urinary catheter was observed in the facility’s Rehab Room without a dignity cover on the external urine collection bag. The resident had been admitted with diagnoses including urinary retention, depression, and dependency on renal dialysis, and had physician orders for an indwelling catheter with care every shift. The resident’s MDS indicated that he had an indwelling catheter and had the ability to understand and be understood. During the observation, the urinary catheter bag contained red-tinted urine and was not covered by any dignity cover. During concurrent and subsequent interviews, the Director of Staff Development acknowledged that the resident did not have a dignity cover on his catheter and stated that a dignity cover is for the resident’s privacy and dignity, and that without it residents would not have privacy and it would affect their dignity. The DON also stated that the resident should have been provided with a dignity cover, that she was not aware of any refusal by the resident to use one, and that lack of a dignity cover created potential dignity and privacy issues, including the resident possibly not feeling comfortable showing what was in his catheter bag. Review of the facility’s Resident Rights, Dignity and Privacy policy indicated that all residents are to be treated with kindness, dignity, and respect, and that privacy of a resident’s body shall be maintained during toileting, bathing, and other personal hygiene activities.
Failure to Implement RD and Physician Orders for Weekly Weights After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care for a resident with documented weight loss and nutritional risk. The resident was admitted with diagnoses including dysphagia, hypothyroidism, and generalized muscle weakness, and had a care plan identifying risk for nutritional compromise related to dysphagia, chronic disease, and metabolic demands, with increased risk for malnutrition, aspiration, weight loss, and poor healing if not managed properly. Weight records from early January through early April showed a decline from 137 lbs. to 129 lbs., including a 7.1% loss over three months and a 4 lb. loss in one month. On review of the resident’s orders and assessments, the resident was on a CCHO level 7 (easy to chew) diet with thin liquids, fortified cereal at breakfast, and fortified soup at lunch and dinner, with variable intake. An RD note dated in early March documented the 7.1% three‑month weight loss and 4 lb. one‑month loss, and recommended weekly weights for two weeks. A Nutrition IDT review shortly thereafter reiterated the same weight loss data and the recommendation for weekly weights for two weeks. Nursing notes documented that the resident was seen by the RD, that new recommendations including weekly weights for two weeks were made, and that the physician was made aware and agreed, with the note stating “noted and carried out.” Despite these recommendations and physician agreement, weekly weights were not implemented. The COC documentation identified a 4 lb. weight loss in one month and variable oral intake of 25–100% of meals, and recommended an RD consult. The subsequent care plan for weight loss cited diuretic use and variable oral intake, and included interventions to monitor and evaluate any weight loss and obtain an RD consult, but there was no order entered for weekly weights. During interviews, the RNA stated she performs weekly and monthly weights and that the DON inputs weights into the computer, while the DON acknowledged that the nurse should have entered an order for weekly weights and communicated with the RNA, but this was not done. The facility’s own Nutrition Status Management policy required that residents meeting criteria for weight loss be weighed weekly with weights entered into the electronic record and reviewed by the RD, which did not occur for this resident.
Failure to Provide NOMNC, Adequate Discharge Planning, and Safe IV/Foley Management at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to follow its own discharge planning and Medicare Notice of Non-Coverage (NOMNC) policies for a resident discharged home. The resident was originally admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A history and physical indicated the resident had capacity to understand and make decisions, while an MDS assessment documented moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order directed discharge home with home health services, and a NOMNC dated two days before the last covered day stated that Medicare coverage for the SNF stay would end and provided instructions and a phone number for filing an appeal. The NOMNC form itself showed that the resident did not sign because she was documented as “Temporarily incapacitated,” and there was no signature from a representative. Admissions staff progress notes stated that a responsible party was informed by phone of the last covered day, the planned discharge date, options including discharge home and caregiver resources, and the right to appeal, and that the responsible party said she would appeal. The same note stated that a copy of the NOMNC and the appeal number was left at the resident’s bedside. However, the responsible party later reported that no information on how to appeal was received, and the Admissions Director and ADON acknowledged that there was no signed documentation from the resident or responsible party to demonstrate receipt of the NOMNC. The ADON stated that, because the family never received the NOMNC letter, they could not dispute the termination decision or attempt to extend the resident’s stay and coverage. The facility also failed to provide and document adequate discharge instructions and individualized care planning. The responsible party reported that no discharge instructions were given to anyone and described the discharge as unorganized and unsafe. The ADON’s review of the record found that discharge documentation focused only on Foley catheter teaching on the day of discharge, with no documentation of IV-related teaching, no evidence that the resident or family understood any teaching, and no documentation that caregiver capacity and availability were assessed as required by the discharge planning policy. The resident’s care plan for Foley catheter use included monitoring for UTI signs and symptoms but did not address catheter care or family teaching, and the discharge care plan noting the resident’s wish to return home did not include education or involvement of the family to prepare them for discharge. In addition, the facility discharged the resident home with an IV still in place. An LVN who performed the discharge recalled sending the resident home with an IV and acknowledged that an IV access site could lead to infection or bleeding requiring emergency care. The discharge order summary did not include that the resident was being discharged with an IV or with a Foley catheter, and the transfer/discharge report lacked information about the Foley catheter and IV. The ADON stated there was no documentation to show that the discharge planning process considered caregiver/support person capacity, or that return demonstration and understanding of required care were obtained, despite policy requirements. The facility’s Resident Rights policy also required appropriate advance written notice, usually 30 days, for any involuntary transfer or discharge, and the Admissions Director stated unfamiliarity with the 30-day notice requirement. Overall, the survey findings show that the facility did not implement its NOMNC, comprehensive care plan, resident rights, and discharge planning policies for this resident’s discharge. The facility’s own policies required that the NOMNC be delivered in a way that ensures the beneficiary or representative signs and dates the notice to demonstrate receipt and understanding that the termination decision can be disputed. The ADON and Admissions Director both confirmed that this did not occur for the resident, and that the lack of a signed NOMNC meant the resident and family effectively could not file an appeal. The discharge planning policy required sufficient preparation and orientation in a form and manner the resident can understand, identification and timely development of a discharge plan, regular reevaluation and updating of the plan, consideration of caregiver capacity, involvement of the resident and representative, and documentation that the resident was asked about interest in returning to the community. The ADON stated there was no documentation to prove caregiver capacity assessment, return demonstration, or understanding, and that the resident and family were not provided enough instructions to prepare them for discharge. These documented inactions and omissions formed the basis of the cited deficiency.
Failure to Provide Comprehensive, Person-Centered Discharge Planning and Education
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered discharge care plan for a resident, including measurable objectives and timeframes, and to involve the resident’s responsible party. The resident was originally admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s MDS showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order indicated the resident was to be discharged home with home health services, but the discharge care plan did not specify goals, interventions, or family involvement needed to prepare the resident and responsible party for discharge. The facility did not provide an individualized discharge care plan that addressed the resident’s specific needs, including management of a Foley catheter and IV access, nor did it document that the resident or responsible party received or understood discharge teaching. The ADON acknowledged that the discharge care plan only reflected a wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The care plan for the Foley catheter included monitoring for signs and symptoms of UTI but did not address catheter care or teaching for the resident or family. The facility’s own policies required that the IDT develop a comprehensive person-centered care plan with measurable objectives and timeframes, and that the discharge planning process involve the resident and representative, consider caregiver capacity, and provide sufficient preparation and orientation for a safe and orderly discharge, but these elements were not documented or implemented for this resident. The resident was discharged home with an IV still intact, and there was no documentation in the discharge order or transfer/discharge report that the resident was being discharged with an IV or Foley catheter, nor any related instructions. An LVN who discharged the resident recalled that the resident left with an IV in place and recognized that an IV access site could lead to infection or bleeding. The resident’s responsible party reported repeatedly stating that the resident was not ready for discharge and described the discharge as unorganized and unsafe, noting that the resident went home with an IV port and that no discharge instructions were given to anyone. The DON and ADON both confirmed that the facility failed to conduct a comprehensive, person-centered discharge care plan specific to the resident’s needs and did not show family involvement or the types of education needed for discharge, and that there was no documentation of caregiver capacity, return demonstration, or understanding as required by facility policy.
Failure to Provide Competent, Person-Centered Discharge Planning and Education
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had and applied appropriate competencies in discharge planning and resident/family communication for one resident. The resident was admitted with multiple medical conditions, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had the capacity to understand and make decisions, while an MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and dressing below the waist. A physician’s order directed that the resident be discharged home with home health services. The facility did not develop an individualized, person-centered care plan addressing the resident’s discharge needs, including the involvement of the responsible party. The Assistant Director of Nursing (ADON) acknowledged that the discharge care plan only reflected the resident’s wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The ADON also noted that the care plan for the resident’s Foley catheter, which had been reinserted during the stay, included monitoring for signs and symptoms of UTI but did not address catheter care or resident/family teaching on interventions. There was no documentation that the discharge planning process considered caregiver/support person availability or capacity to perform required care, nor documentation of return demonstration or understanding by the resident or family. At the time of discharge, the facility failed to provide discharge instructions and teaching to the resident or responsible party. The responsible party reported repeatedly telling staff that the resident was not ready for discharge and described the discharge as unorganized and unsafe, stating that no discharge instructions were given and that no information was provided on how to appeal the discharge. The resident was discharged home with an IV access still intact, which was later confirmed by an LVN who recalled discharging the resident with an IV and recognized that an IV access site could lead to infection or bleeding requiring emergency care. The ADON and DON both acknowledged that the discharge order and transfer/discharge report did not include information about the IV or Foley catheter, and that the facility failed in communication and education of the resident and family regarding the resident’s needs, demonstrating a lack of nursing staff competency in person-centered care and communication as required by facility policy. The facility’s written policies required development of a comprehensive, person-centered care plan by the interdisciplinary team, with measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs, and required advance notice and involvement of the resident and representative in care planning conferences. The discharge planning policy required identification of discharge needs on admission, timely development and implementation of a discharge plan, regular reevaluation and updating of the plan, consideration of caregiver availability and capability, involvement of the resident and representative in the discharge plan, and documentation of preparation and orientation to ensure a safe and orderly transfer or discharge. The nursing staff competency policy required sufficient nursing staff with appropriate competencies, including resident rights, person-centered care, and communication. The events surrounding this resident’s discharge, including the lack of individualized discharge care planning, lack of documented teaching and understanding, and discharge with an IV still in place, demonstrate that these policies were not implemented for this resident.
Failure to Provide and Document NOMNC and Appeal Rights for Medicare Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s responsible party, as required by facility policy and federal guidance. The resident was originally admitted with multiple diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had capacity to understand and make decisions, and a Minimum Data Set showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order documented a planned discharge home with home health services. The facility received a NOMNC dated 12/22/2025 stating that Medicare coverage for the resident’s skilled nursing stay would end on 12/24/2025, with discharge scheduled for 12/25/2025. The NOMNC included instructions and a contact number for requesting an immediate appeal, and required that the beneficiary or representative sign and date the form to demonstrate receipt and understanding of appeal rights. However, the NOMNC form for this resident was marked “Temporarily incapacitated” in the signature section, and there was no signature from the resident or responsible party. The resident’s responsible party later reported not receiving any information on how to appeal and described the discharge as unorganized and unsafe, stating that the resident was discharged home with an IV port and that no discharge instructions were given to anyone. An administrative progress note by the Admissions Coordinator documented a phone conversation with the responsible party explaining that insurance had issued a last covered day and a discharge date, outlining options such as discharge home, caregiver resources, and the right to appeal if the resident was felt not ready for a lower level of care. The note stated that the responsible party said she would appeal and that a copy of the NOMNC and the appeal number were left at the resident’s bedside. In a subsequent interview, the Admissions Coordinator acknowledged that the facility failed to obtain a signature from the resident or responsible party confirming receipt of the NOMNC. The Admissions Director confirmed that residents or responsible parties are required to sign the NOMNC to acknowledge receipt and that the notice contains the information and phone number needed to file an appeal, and also stated unfamiliarity with the policy requirement for 30 days’ written notice for involuntary transfer or discharge, despite the facility’s Resident Rights policy referencing such notice.
Failure to Complete and Verify Resident Personal Effects Inventory at Admission and Discharge
Penalty
Summary
The facility failed to properly complete and maintain an accurate inventory of personal effects for one resident, resulting in a deficient practice related to residents' rights to retain and use personal possessions. The resident was originally admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s History and Physical indicated capacity to understand and make decisions, and the MDS documented moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. The facility’s policy required that, on admission, a staff member complete an Inventory of Personal Effects form, record all personal items brought in, and obtain signatures from the resident or responsible party and a staff member, with the original kept in the health record and a copy provided to the resident or representative. During an interview and concurrent record review, the DON acknowledged that the resident’s Inventory of Personal Effects form was not complete. On admission, the form was not signed by a facility representative as required by policy. On discharge, the form was again not properly completed, as it lacked the resident or responsible party’s signature to certify that the personal effects were received, and the facility representative’s signature was dated after the resident’s discharge date. The DON stated that, on discharge, residents or responsible parties are supposed to receive a copy of the discharge summary, medication list, follow-up orders, and the inventory, and that the inventory is important to show if any items are missing and to ensure important items go home with the resident and family. Despite this, the required signatures and completion of the inventory form were not obtained at admission or discharge for this resident, contrary to the facility’s written policy and procedure on personal effects.
Failure to Follow Late-Entry Documentation Policy for Discharge Communications
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for timely and accurate documentation in a resident’s medical record. The resident was admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical indicated the resident had capacity to understand and make decisions, while an MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order directed discharge home with home health services. Following the resident’s discharge home, the State Survey Agency identified documentation that had been newly added to the resident’s record on the same date the surveyors were onsite. A social worker acknowledged entering a progress note on that date with an “effective date” several weeks earlier, describing a family discussion about concerns regarding the resident’s readiness for discharge and the family’s decision to proceed with home discharge after declining alternative placement options. The social worker stated this was not the facility’s standard practice, admitted failing to document the interaction when it occurred, and expressed concern that the timing of the note’s creation coincided with the start of the State’s investigation. The note was not identified as a late entry as required by facility policy. The Assistant DON and DON both confirmed that staff did not document key discharge-related communications with the resident and family in a timely or policy-compliant manner. The Assistant DON stated that, per policy, late entries must be clearly identified as such, use the current date and time, and not give the appearance of having been written earlier, but acknowledged documenting a home visit and provision of discharge paperwork many days later without labeling it as a late entry. The DON stated that staff failed to timely document communication to the resident and family. The facility’s written policy on corrections, errors, omissions, and late entries requires that missed or delayed documentation be clearly identified as late entries or addenda, with current date and time and reference to the original incident, which was not followed in this case, resulting in an inaccurate account of the resident’s record.
Medication Administration Errors Exceeded the Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent during the 9 a.m. medication pass, with 7 errors out of 29 observed opportunities. Two residents were involved in the cited deficiency: one resident with epilepsy, hemiplegia, hemiparesis following cerebral infarction, severe cognitive impairment, and a feeding tube; and another resident who received amlodipine without a documented heart rate check before administration. For the resident with the feeding tube, the medication administration observation showed the nurse crushed acetaminophen, methocarbamol, a multiple vitamins-minerals tablet, and phenobarbital, mixed medications in cups, and administered them through the g-tube. The nurse did not obtain an order to crush the medications for g-tube administration. The nurse also did not flush the g-tube with at least 15 ml of purified water between each medication as ordered, and did not administer the potassium chloride solution with at least 8 oz of water as ordered. The resident’s orders included flushing the feeding tube between each medication and giving potassium chloride with water, and the record review showed these directions were not followed during the observed pass. For the second resident, the nurse administered amlodipine without measuring the resident’s heart rate first, despite the medication pass requiring that assessment before administration. Interviews with staff confirmed that the g-tube medication administration practices were not followed as ordered and that the heart rate was not obtained before the amlodipine dose. The report also states that the facility identified the situation as an Immediate Jeopardy during the annual recertification survey and later documented a removal plan, which was verified by surveyors as fully implemented.
Significant Medication Errors During G-Tube Administration
Penalty
Summary
Resident 1, who was admitted with epilepsy, hemiplegia, and hemiparesis following cerebral infarction and was documented as lacking capacity to understand and make decisions, was receiving medications through a gastrostomy tube. The resident’s physician orders included acetaminophen, methocarbamol, multiple vitamins-minerals, potassium chloride solution, phenobarbital, and polyethylene glycol via g-tube, along with an order to flush the feeding tube with at least 15 ml of purified water between each medication and a final flush after all medications were given. The record reviewed on 12/30/2025 did not show a physician order to crush medications for g-tube administration. During the medication pass observation, LVN 1 crushed and prepared acetaminophen, methocarbamol, multiple vitamins-minerals, and phenobarbital for g-tube administration, mixed Miralax with water, and administered the medications through the tube. LVN 1 flushed the tube before the first medication and after all medications were given, but did not flush the g-tube with at least 15 ml of purified water between each medication as ordered. LVN 1 also administered the potassium chloride solution through the g-tube without giving the ordered at least 8 oz. of water with it. LVN 1 stated she forgot to perform the flushes between medications and acknowledged that not following the order for potassium chloride could cause gastric irritation. The Director of Staff Development stated there was no medication pass skills checklist in LVN 1’s file for g-tube medication administration and that LVN 1 had not been formally observed performing g-tube medication administration. The DON stated the facility had no care plan developed and implemented for g-tube medication administration for Resident 1. The Medical Director and pharmacy consultant both stated that the failure to flush between medications and the failure to administer potassium chloride with the ordered amount of water constituted medication errors. Resident 74 was also identified during medication administration review as having a significant medication error when aspirin was not administered as ordered and omeprazole was given after enteral feeding had already started.
Failure to Rotate Injection Sites for Anticoagulants and Insulin
Penalty
Summary
Licensed nursing staff failed to follow physician orders and accepted standards of practice for subcutaneous anticoagulant and insulin administration for three sampled residents. The deficiency involved failure to rotate injection sites for heparin, enoxaparin, and Humalog, despite orders and facility guidance requiring site rotation. Resident 1 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, quadriplegia, and circulatory system disorders. The resident lacked capacity to understand and make decisions, had severely impaired cognition, and was dependent to needing maximal assistance for mobility and ADLs. The resident had an order for heparin sodium 5000 units/ml, 1 ml subcutaneously every 12 hours for CVA prophylaxis, with instructions to rotate injection sites. Review of the location of administration report showed multiple instances where the licensed nurses did not rotate the heparin administration sites. The ADON stated the sites were not rotated and that this did not follow the physician order or the resident’s care plan for anticoagulant therapy. Resident 33 was admitted with diagnoses including a closed fracture, difficulty walking, and pulmonary fibrosis. The resident had capacity to understand and make decisions and intact cognition. The resident had an order for enoxaparin sodium 40 mg/0.4 ml subcutaneously daily for DVT prophylaxis, with instructions to rotate injection sites. Review of the location of administration report showed the medication was administered without site rotation. Resident 12 had a diagnosis of DM2 and received Humalog insulin by sliding scale before meals and at bedtime, with an order to rotate injection sites. Review of the administration record showed repeated injections in the same locations, including the left arm and RLQ on multiple occasions. The ADON and DON stated the insulin sites were not rotated as ordered and that the facility’s standards, manufacturer guidance, and policy were not followed.
PRN opioid pain medications were not administered according to ordered pain scales
Penalty
Summary
Pain management was not provided in accordance with the physician’s orders and the residents’ assessed pain levels for two residents. For one resident, the record showed admission with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, polyneuropathy, and peripheral vascular disease. The resident’s MDS indicated he could understand others and make himself understood, but required substantial to maximal assistance with toileting, bathing, dressing, and mobility, and he was receiving opioids. The physician ordered hydrocodone-acetaminophen 5/325 mg, one tablet for pain rated 1-6 and two tablets for pain rated 7-10. Review of the MAR and progress notes showed multiple instances where the documented pain rating did not match the dose administered. The resident was documented as having pain ratings of 7, 8, or 10 on several occasions when one tablet was not administered as ordered, and there were also occasions when two tablets were not administered as ordered when the documented pain rating was 4 or 0. During interview, nursing staff stated the numeric pain level determines the amount of PRN pain medication administered, and the DON stated the facility process is to use the numeric pain scale and follow the physician’s orders. The DON stated the facility P&P was not followed when the resident was not administered narcotic pain medication per the physician’s orders when the resident was administered the incorrect dose for the reported numeric pain level. A second resident was admitted with diagnoses including sepsis, malignant neoplasm of the ovaries, and generalized muscle weakness. The H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated intact cognition and need for assistance with multiple ADLs; the resident was also on opioids. The physician ordered oxycodone 10 mg for pain rated 4-6 and oxycodone 15 mg for pain rated 7-10, with instructions not to give if RR was less than 12 or the resident was drowsy. The MAR showed oxycodone 15 mg was administered when the pain level was documented as 0. Nursing staff stated this was a documentation error and that the medication would not be administered unless the pain level was between 7 and 10. The DON stated the facility process for PRN pain medication administration is to use the numeric pain scale and follow the physician’s orders, and that the incorrect dose was administered for the reported numeric pain level.
Controlled Medication Documentation and Count Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring and administering of controlled medications for a resident admitted with type 2 diabetes mellitus, diabetic neuropathy, polyarthritis, and generalized muscle weakness. The resident’s record showed intact cognition and that she required assistance with multiple activities of daily living. Her physician’s orders included hydrocodone-acetaminophen 5-325 mg every 4 hours as needed for pain and pregabalin 75 mg twice daily for neuropathic pain. During review of Medication Cart 1, surveyors found discrepancies between the controlled medication count sheets, the medication cards, and the physical inventory for the resident’s hydrocodone-acetaminophen and pregabalin. The hydrocodone-acetaminophen count sheet showed 52 tablets dispensed, while 41 tablets remained in inventory. The pregabalin count sheet showed 28 capsules dispensed, while seven capsules were present. The Assistant DON stated that two hydrocodone-acetaminophen tablets were removed on one date and one tablet on another date by an LVN but were not documented in the MAR. The Assistant DON also stated pregabalin was documented as administered on two occasions by another LVN, but the medication was not signed out on the controlled medication count sheet, and the expected inventory should have been five capsules remaining instead of seven. Surveyors also found that the Shift Change Narcotic Count Sheet for Cart 1 was not signed by the incoming and outgoing licensed nurses for the shift change reviewed. The DON stated the nurses are supposed to count narcotics and sign the shift change narcotic count sheet, and that failure to do so means the count may not have been completed. The DON and Assistant DON both stated nurses are supposed to compare the MAR, bubble pack, and physician’s order, remove the medication, and sign the MAR and controlled medication count sheet immediately after administration. The facility’s policies on medication administration and controlled substances stated that controlled drugs require accurate accountability and that the administering nurse must immediately enter the administration information on the accountability record and MAR.
Improper Food Labeling, Spoiled Food, and Wet Dish Storage
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen. During an initial kitchen tour, a bottle of salad dressing in Refrigerator two was observed with an open date of 12/23/2025 and a best by date of 2/23/2026. In the dry storage room, a sealed plastic bag containing parsley leaves was observed with brownish discoloration, and a can of applesauce with a dent was placed on the shelf for non-dented cans. During concurrent interviews, the Dietary Supervisor stated the facility’s Dry Good Storage Guidelines required opened bottled salad dressing to be refrigerated and used within 1 month after opening, and stated the salad dressing should have been labeled with a best by date of 1/23/2026 instead of 2/23/2026. The DS also stated the parsley leaves had moisture and discoloration and could be spoiled, and that the dented can should have been removed from the shelf because the seal was compromised. The DS stated the parsley should have been discarded timely and that the dented can could not be used anymore. During a later follow-up observation, one round-shaped and one square-shaped clean food container were observed still wet and stacked in the clean and dried dishes/utensils section of the kitchen. The DS stated the containers were not completely dried before being placed on the shelf. Record review showed the facility’s Labeling and Dating of Food policy required food items to be labeled and dated according to established procedures, and the Dishwashing policy required dishes to be air dried in racks before stacking and storing.
Food Brought by Family Not Properly Stored
Penalty
Summary
The facility failed to enforce its policy for food brought in by family or visitors when there was no designated refrigerator space for residents’ leftover foods from home or outside sources. During a kitchen tour, the Dietary Supervisor showed a transparent bin with a lid inside Refrigerator 2 labeled Resident Food and stated it was for residents’ food items that required refrigeration, but only if the food was in a sealed container in its original packaging. The Dietary Supervisor also stated that opened items or leftover food from outside sources brought in by family or visitors were not allowed to be stored in the kitchen refrigerator because of possible cross contamination, and that if such food was not consumed within two hours it would be discarded because there was no designated refrigerator for residents’ leftover foods in the kitchen or at the nurses’ station. During interview, the DON stated the facility policy allowed family or visitors to bring requested food items for residents only if they were in sealed containers and original packaging, and that these items were stored in the kitchen refrigerator. The DON also stated that if food brought in by family or visitors was not consumed within two hours, it would be discarded because the facility did not have a refrigerator at the nurses’ station and leftovers could not be stored in the kitchen refrigerator due to cross contamination concerns. Review of the facility policy titled Food Brought by Family or Visitor showed that outside food could be used as an intervention for residents with low intake or distinct food preferences, but the kitchen would only store food sealed in manufacturer packaging and prepared foods would be discarded after two hours.
Infection Control Failures With Laundry Storage, EBP Signage, and Ice Scoop Handling
Penalty
Summary
The facility failed to maintain an infection prevention and control program when Resident 73’s personal green bag was observed placed directly on the floor in the clean linen area of the laundry room behind a door. The resident was admitted with COPD, acute on chronic respiratory failure with hypoxia, pulmonary fibrosis, and breast cancer, and the history and physical indicated the resident had the capacity to understand and make decisions. Laundry staff stated the bag was being temporarily stored on the floor until the resident’s clothing inside the bag could be labeled, and staff acknowledged that nothing should be placed on the floor in the laundry area and that all items should be elevated off the floor. The Infection Preventionist stated the bag belonged to Resident 73 and should not have been stored on the floor because the floor is dirty. The Infection Preventionist stated this created a cross-contamination issue because the dirty bag could be placed on a clean surface and contaminate it with bacteria that could spread to a resident. The DON reviewed the facility policy and stated resident personal items should be kept off the floor for infection control practices, and that the facility policy was not followed. The facility’s laundry and personal belongings policies stated personal belongings shall not be placed or stored on the floor in resident rooms, the laundry room, or common areas. The facility also failed to ensure Enhanced Barrier Precautions were implemented for Resident 21. Resident 21 was admitted with sepsis, ovarian cancer, and generalized muscle weakness, and the record showed intact cognition and ability to understand others and make needs known. The resident had a PICC line in the right upper arm, physician orders for Enhanced Barrier Precautions, and a care plan directing use of EBP to keep the resident free of complications. During observation, disposable gowns and gloves were present in the room, but no EBP sign was posted outside the door until the Infection Preventionist placed one after being notified. Staff and leadership stated the sign should have been posted when the resident was admitted and that it was not in place outside the room when observed. The facility further failed to keep the ice scooper protected from environmental contamination. During observation, the ice scooper was placed inside an open container beside the ice chest near the kitchen door hallway. The Infection Preventionist stated the scooper should be covered because leaving it open to air exposes it to environmental contaminants such as bacteria and viruses that can cause gastric infections when ingested by residents. The ADON stated the scoopers should be protected inside a plastic container and that staff did not follow the ice procedures policy, which required a covered plastic or stainless-steel container to hold the scoop.
Antibiotic orders lacked required criteria and adverse-effect monitoring
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control program for four residents by not ensuring antibiotic use met required criteria and by not ensuring monitoring for adverse effects was documented. The report states these failures involved Resident 12, Resident 1, Resident 33, and Resident 41, and that the facility’s policy required appropriate antibiotic use, review of antibiotic orders, and monitoring for adverse effects during treatment. For Resident 12, the record showed an order for Bactrim DS for UTI after the resident had increased confusion and an abnormal urinalysis, but the Loeb’s Minimum Criteria form indicated the resident did not meet criteria for suspected UTI without a catheter and did not meet the fever criteria. The report also states the resident did not have documented monitoring for adverse side effects of Bactrim DS on two shifts after the medication was started. The Infection Preventionist and ADON both stated the resident did not meet the minimum criteria for the antibiotic and that monitoring for adverse effects should have been documented every shift. For Resident 1, the record showed orders for Amoxicillin-Pot Clavulanate for bacterial infection and Diflucan for oral thrush. The ADON and Infection Preventionist stated the Amoxicillin order did not have a specific enough indication and should have been clarified, and the record did not show monitoring for adverse effects for either the Amoxicillin or Diflucan orders. For Resident 33, the record showed Methenamine Hippurate for UTI prophylaxis with no end date and no documented monitoring for adverse effects. For Resident 41, the record showed Bactrim DS for UTI, and the ADON and Infection Preventionist stated there was no monitoring for adverse effects documented for that antibiotic.
Privacy and Confidentiality Breaches During Medication Pass
Penalty
Summary
The facility failed to maintain resident privacy and confidentiality when an LVN left a medication cart computer screen unattended in a hallway outside a resident room with the monitor turned on. While the screen was visible from the hallway, it displayed a resident’s full name, photo, date of birth, age, allergies, code status, most recent vital signs, weight, and MAR. The LVN stated she had left the monitor on while she was inside another resident’s room and acknowledged that she should not have left the screen open to the resident’s MAR. The resident whose information was visible was admitted with diagnoses including morbid obesity, pulmonary fibrosis, and DM. The resident’s MDS indicated she was able to understand others and make herself understood, and her H&P indicated she had the capacity to understand and make decisions. The DON reviewed the facility policy and stated resident personal information is protected, that privacy screens can be used on medication cart computers, and that the LVN could also have turned off the monitor screen but did not. The facility also failed to provide privacy when the same LVN administered another resident’s scheduled morning medications in the activity room. The resident was seated in a wheelchair at a table facing two other residents when the medications were given. The resident stated he usually takes his medications in his room, prefers to take them there, and that this was the first time he had taken them in the dining/activity room. The resident’s record showed diagnoses including a wedge compression fracture, dysphagia, and immunodeficiency, and his H&P indicated he had the capacity to understand and make decisions. The ADON stated medications should be provided at the bedside for privacy and confidentiality and that the licensed nurse should ask the resident his preferences and follow them.
Bed Pad Alarm Used Without Required Order, Consent, or Assessment
Penalty
Summary
The facility failed to ensure Resident 12 was free from the use of a physical restraint when a bed pad alarm was used without a physician's order, informed consent, or a completed restraint assessment. Resident 12 was admitted with diagnoses including type 2 diabetes mellitus, generalized muscle weakness, and difficulty walking. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and dependence on staff for all ADLs. The record review showed no physician's order for the bed pad alarm in the Order Summary Report, and the paper and electronic health records did not show consent from the resident's responsible party for its use. The fall risk evaluation identified Resident 12 as high risk for falls, and the care plan included a bed alarm as an intervention to remind the resident or staff of unassisted transfers from bed. During observation, the Infection Preventionist confirmed the bed alarm was present and functioning, and it sounded when the buttons were pressed. During interview and record review, the ADON stated a device that the resident cannot freely remove can be considered a restraint and should have a physician's order, informed consent, and a restraint assessment before use. The ADON stated Resident 12 did not have those items prior to application of the bed pad alarm. The DON also stated the prior order had been discontinued, and if the family wanted the alarm continued, it should have been care planned, a new physician's order obtained, informed consent obtained, and a restraint assessment completed before reapplying the alarm.
Baseline Care Plan Missing PRN Opioid Intervention
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 44 within 48 hours of admission that included resident-centered interventions for pain management and the resident’s PRN hydrocodone-acetaminophen orders. Resident 44 was admitted with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, polyneuropathy, and peripheral vascular disease. The MDS dated 11/20/2025 indicated the resident could understand others and make himself understood, required substantial to maximal assistance with toileting, bathing, upper and lower body dressing, and mobility, and was taking opioids. The physician order summary showed PRN hydrocodone-acetaminophen orders for pain, including one tablet every 4 hours for pain 1-6/10 and two tablets every 4 hours for pain 7-10/10. The care plan titled acute/chronic pain, initiated 11/15/2025, included goals and interventions such as anticipating pain relief needs, assessing pain every shift, and reporting changes in routine or refusal of activities related to pain, but it did not include an intervention for the administration of opioid pain medication. During interview, LVN 3 stated baseline care plans are completed when a resident is readmitted and should include the use of opioid medication as a resident-specific intervention for pain relief, but Resident 44’s care plan did not. The DON reviewed the facility policy and procedures for care planning and pain management and stated baseline care plans include minimum healthcare information needed to provide basic care upon admission or readmission, including physician orders. The DON stated Resident 44’s PRN hydrocodone-acetaminophen order should have been included in the baseline care plan because it was an important intervention for pain management, but it was not. The report also noted Resident 44 was hospitalized and later readmitted, and during observation the resident stated he often had pain and was given pain medication that caused constipation.
Failure to Assess, Notify, and Document Urinary Symptoms
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided for one resident who had urinary symptoms. The resident had been admitted with diagnoses including encephalopathy, generalized muscle weakness, and sepsis, and the MDS indicated moderately impaired cognition, substantial to maximal assistance needs for several ADLs, dependence on staff for transfers and mobility, and urinary incontinence. During interviews, the resident stated she had discomfort and tingling when urinating and had reported the symptoms to staff. On review of the resident’s record, a physician order dated 12/28/2025 directed a UA C&S to be performed in the morning, one time only for one day. The MAR reflected the order, and one LVN’s initials were recorded at 10:10 p.m., but the facility did not complete the laboratory requisition needed for the specimen to be processed. The DON stated there was no assessment performed for the resident’s urinary complaints and no change-of-condition documentation in the record. The DON also stated that when residents complain of abnormal urinary symptoms, the licensed nurse is expected to assess the resident, document findings, inform the physician, and carry out physician orders, including obtaining and sending urine to the laboratory if ordered. Interviews with nursing staff showed confusion about responsibility for the resident’s urinary complaint, the SBAR, the physician notification, and the care plan. One LVN stated he collected the urine but did not enter the laboratory request because he was told that was not his responsibility, and he did not develop a care plan because he believed the nurse who completed the change of condition and SBAR would do so. Another LVN stated she told him the resident needed a urine sample, but she did not have direct contact with the resident that shift. The ADON stated that when a resident presents with urinary symptoms, the licensed nurse must conduct a thorough assessment, initiate a change of condition, notify the physician, carry out physician orders, notify the family, and develop a care plan, and that the laboratory requisition should have been completed when the urine was obtained.
Feeding Tube Water Flush Bag Not Properly Labeled
Penalty
Summary
The facility failed to ensure staff caring for a resident with a feeding tube followed the facility protocol for labeling the resident’s water flush bag. Resident 1 was admitted with diagnoses including dysphagia, gastrostomy, and pneumonitis due to inhalation of food and vomit. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, dependence for mobility and ADLs, and the presence of a feeding tube. The resident’s orders included enteral feedings during every shift and flushing the feeding tube with 30 mL/hr for 20 hours. The care plan identified the resident as dependent on tube feeding and water flushes and directed staff to follow the MD orders for current feeding orders. During observation, the resident’s water flush bag was labeled only with the date and time it was changed. The treatment nurse stated the bag should also have the resident’s name, room number, rate of infusion, and the initials of the licensed nurse who hung the bag. The ADON confirmed that the water flush bag should be treated like a closed container for enteral feeding and should be labeled with the resident’s name, room number, date and time hung, rate of infusion, and the initials of the licensed staff who hung it. Review of the facility’s policy and procedure for Enteral Formulas, Administration of Closed System, showed that formula containers should be labeled with the resident’s name, room number, date, starting time, rate, and initials. The ADON stated the licensed staff did not follow the policy because the bag was labeled only with the date and time it was hung.
Suction Canister Not Dated
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one resident who had diagnoses including gastrostomy, dysphagia, and pneumonitis due to inhalation of food and vomit. The resident’s record also showed severely impaired cognition, inability to understand and make decisions, and dependence to maximal assistance for mobility and ADLs. An order was in place for oral suction as needed for excessive secretions every six hours as needed. During observation, the resident’s suction canister contained whitish fluid and was labeled only with the resident’s name; it was not labeled with the date it was last changed. The treatment nurse stated the canister should be labeled with the resident’s name and the date it was provided or changed, and that canisters are changed weekly and as needed. The ADON later stated licensed staff should have labeled the suction canister with the date it was last changed, and that staff did not follow the facility’s suction machine policy, which required suction canisters and catheters to be dated when replaced weekly and as needed.
Missing CNA Performance Evaluation Documentation
Penalty
Summary
The facility failed to ensure that employee files contained documentation of a required performance evaluation for one of two sampled CNAs. During an interview, CNA 2 stated she had been working in the facility for two years. In a concurrent interview and record review, the DSD stated CNA 2’s original hire date was 11/4/2024, but there was no performance evaluation on file for her. The DSD also stated that all employee files, including CNA 2’s, went missing after the previous DSD left employment in September 2025. The DSD stated he became responsible for CNA performance evaluations effective 9/3/2025 and that evaluations are completed annually in the month the CNA was hired. He stated CNA 2’s hire date under new facility ownership was 6/1/2025 and that her performance evaluation would be completed in June 2026. The DSD stated performance evaluations assess staff performance, identify weaknesses, and determine training needs, and that they ensure a CNA is competent in providing resident care. The ADON stated employee performance evaluations assess competency and that completing evaluations as required is critical to resident safety. The facility assessment dated 9/2025 stated regular performance evaluations should be conducted to assess staff effectiveness and identify areas of improvement, and the facility policy required annual evaluations and retention of the completed form in the employee’s personnel file.
Failure to Provide Requested Menu Substitute
Penalty
Summary
The facility failed to follow the established and alternative menu per resident preferences and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, type 2 DM, and dysphagia following CVA. The resident’s MDS indicated he could understand others and make himself understood, but required substantial to maximal assistance with toileting, bathing, dressing, and mobility. His physician orders included a controlled consistent carbohydrate diet, soft and bite-sized texture, thin liquids, and aspiration precautions. The care plan included offering substitutes for foods not eaten, and the nutrition evaluation directed staff to provide the weekly menu and alternative menu for daily reference. During observation and interview, Resident 44 stated he did not like the facility food and requested a fruit plate with cottage cheese and a salad for lunch. CNA 2 wrote salad and circled fruit plate with cottage cheese on the alternative menu. At lunch, the resident had a fruit plate with cottage cheese, but no salad was on the tray. The resident stated someone told him he could not have a salad. CNA 2 later reviewed the alternative menu and stated salad had been crossed off and replaced with cauliflower, but there was no salad or cauliflower on the tray. The DSA stated the resident had agreed to cauliflower in place of salad because his specialized diet did not allow salad, but the kitchen forgot to add it. The DSA then brought chopped cauliflower to the resident’s room. The DS and DON both stated the cauliflower should have been provided and that the resident’s food preferences were not followed. The facility policy stated resident food preferences would be adhered to within reason and substitutes for disliked foods would be given from the appropriate food group.
Facility Assessment Did Not Reflect G-Tube Care Needs or Competencies
Penalty
Summary
The facility failed to accurately update the 2025 Facility Assessment to reflect the care needs and staff competency requirements for gastrostomy tube medication administration for two sampled residents. The assessment, dated 9/2025, listed general medication administration competencies for injectable, oral, subcutaneous, and topical medications, but it did not identify enteral tube care or enteral tube medication administration as part of the resident population’s needs or staff competencies. Resident 74 was admitted on 6/1/2023 and later readmitted, with diagnoses including encounter attention to gastrostomy, acute respiratory failure with hypoxia, and unspecified Alzheimer’s disease. Resident 1 was admitted on 12/2/2025, with diagnoses including spastic quadriplegic cerebral palsy, atelectasis, and attention to gastrostomy. The Director of Nursing stated the facility had issues with g-tube medication administration and acknowledged that the Facility Assessment did not indicate general care of residents with enteral tube. During interview and record review, the DON stated the Facility Assessment should have been updated because the facility had two residents on g-tube and that the assessment did not contain staff competencies on g-tube medication administration. The DON also stated the assessment should have been updated annually and as needed, and that the facility had two opportunities to update it when Resident 74 was admitted and readmitted, and another opportunity when Resident 1 was admitted, but it was not updated on those occasions.
Inaccurate Pain Medication Documentation
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents reviewed for pain management. For one resident, the record showed an order for hydrocodone-acetaminophen 5/325 mg, one tablet for pain rated 1 to 6 out of 10 and two tablets for pain rated 7 to 10 out of 10. On 12/17/2025 at 11:00 a.m., the MAR documented that two tablets were administered when the pain level was recorded as 0. During interview, LVN 4 stated he administered the medication for a pain level of 7/10 and that the MAR entry showing 0 was a documentation error. LVN 3 and the DON stated the MAR documentation did not accurately reflect the resident’s pain assessment and that the facility’s pain management and documentation procedures were not followed. The first resident had diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, polyneuropathy, and peripheral vascular disease. The resident’s MDS indicated he could understand others and make himself understood, but required substantial to maximal assistance with toileting, bathing, dressing, and mobility. The resident was taking opioids. Facility policy required pain to be identified and documented in the EHR, and PRN medication documentation to include the reason for giving the medication and a complete account of the resident’s care and treatment. For the second resident, the record showed physician orders for oxycodone hydrochloride 10 mg for pain rated 4 to 6 out of 10 and oxycodone hydrochloride 15 mg for pain rated 7 to 10 out of 10. The MAR documented that oxycodone 15 mg was given on 12/18/2025 at 9:26 a.m. for pain level 0 out of 10. The ADON and LVN 3 stated the medication was not administered according to the physician’s order and that the pain level was not documented accurately. The resident had diagnoses including sepsis, malignant neoplasm of the ovaries, and generalized muscle weakness, and the H&P and MDS indicated intact cognition and the ability to understand and make decisions. Facility policy required PRN medications to be administered as prescribed and documented with the symptoms or complaints for which the medication was given.
CNA Did Not Complete Required Abuse and Dementia Training
Penalty
Summary
The facility failed to ensure that one of two sampled CNAs completed required dementia management and abuse prevention training. During a concurrent interview and record review, the Director of Staff Development stated the CNA’s original hire date was 11/02/2024 and that there was no documentation showing the CNA attended any in-service training on abuse or dementia management prior to June 2025. The DSD also stated that abuse in-service trainings were provided on 7/25/2025, 9/5/2025, 9/26/2025, 11/20/2025, and 12/29/2025, each lasting one hour. Attendance records showed the CNA attended the sessions on 7/25/2025, 9/26/2025, and 12/29/2025, but the CNA’s name and signature were absent from the records for the 9/5/2025 and 11/20/2025 sessions. The DSD confirmed the CNA attended three of the five abuse in-service trainings. The DSD further stated dementia management trainings were provided on 10/14/2025 and 12/01/2025, and attendance records for both sessions did not include the CNA’s name or signature; the DSD confirmed the CNA did not attend either session. The DSD stated CNAs are required to complete four hours of abuse training every two years and five hours of dementia training annually, and confirmed this CNA did not meet those requirements.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 17 of 25 resident rooms met the required square footage standard of at least 80 square feet per resident in multiple resident rooms. The affected rooms were Rooms 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 25, and 26. During a resident council group interview, attendees stated they had enough room space. During observation from 12/29/2025 to 1/2/2026, residents in rooms with an application for variance had enough space to move freely inside the rooms, and there was adequate room for wheelchairs, walkers, and canes. A review of the letter titled, Re: Request for Room Variance Waiver, dated 12/30/2025, showed the Administrator submitted an application for a room variance waiver for 17 resident rooms. The letter listed multiple rooms with actual square footage below the federal requirement for the number of residents in the room, including rooms with two, three, and four residents. A review of the facility policy titled, Resident Rooms, stated that resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy, accommodate no more than four residents, and measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in a single resident room.
Resident Room Fails to Meet Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that one of its resident rooms, Room A, met the required minimum size of 80 square feet per resident in a multiple occupancy room or to obtain an approved waiver for the deficiency. Room A, previously used as a physical therapy room, was converted to accommodate four residents, but measured only approximately 284.75 square feet, which is less than the required 320 square feet for four residents. The facility's documentation and interviews confirmed that Room A was not included in the list of rooms with approved size waivers, and no waiver request had been submitted for this room in the current year. The facility's policy also requires that resident rooms meet the minimum square footage per resident. During interviews and observations, it was noted that the limited space in Room A contributed to challenges in resident mobility and safety. One resident described an incident where she tripped over a rolling tray table while navigating the cramped space between beds and the bathroom, resulting in a fall. Staff interviews further confirmed that the room's size was insufficient for its current use, and the Director of Nursing acknowledged the importance of adequate space for residents to perform activities of daily living safely and comfortably.
Failure to Remove Discontinued Controlled Medications and Maintain Accurate Drug Records
Penalty
Summary
The facility failed to properly manage controlled substances by not removing discontinued medications from the medication cart and by not maintaining accurate Controlled Drug Administration Records. Specifically, after physician orders for morphine sulfate and oxycodone/APAP were discontinued for two residents, the medications remained in the medication cart instead of being removed and surrendered to the Director of Nursing for secure storage. This was confirmed during observations and interviews with nursing staff, who acknowledged that discontinued controlled medications should be immediately removed to prevent confusion and potential medication errors. Additionally, the facility did not create a Controlled Drug Administration Record for one of two supplies of oxycodone prescribed to another resident. The pharmacy provided two supplies of oxycodone with different administration instructions—one scheduled and one PRN (as needed)—but only created records for the PRN supply, resulting in the scheduled supply not being accurately tracked. Facility staff failed to identify this discrepancy upon receipt of the medications, leading to incorrect documentation of medication administration. The residents involved had significant medical histories, including prostate cancer with collapsed vertebrae, heart failure with pulmonary edema, and hemiplegia following a stroke. The deficiencies were identified through observation, record review, and staff interviews, which confirmed that the facility's practices did not align with its own policies for the immediate removal of discontinued medications and the preparation of controlled medication accountability records.
RN Failed to Assess and Timely Notify Physician After Resident Threatened Self-Harm
Penalty
Summary
The facility failed to ensure a resident received care in accordance with professional standards of practice when the RN did not complete an assessment after a CNA reported overhearing the resident say he was going to hurt himself if he was not allowed to leave the facility. The resident had been admitted with hepatic encephalopathy, chronic kidney disease stage 4, and muscle weakness. His H&P stated he could make needs known but could not make medical decisions, and the MDS showed he required moderate to maximal assistance with several activities of daily living. A physician progress note also described mild cognitive disorganization and transient confusion related to his liver condition. According to the RN, the resident repeatedly wanted to leave the facility during the night, and staff contacted the resident’s family and police before the CNA reported the statement about self-harm. When the CNA reported what she overheard, the RN went to the room but did not specifically ask the resident whether he wanted to hurt himself. The RN stated she did not use the word hurt because she did not want the resident to know she was frightened by what he was saying. The DON stated that when a CNA reports that a resident wants to harm himself or herself, the licensed nurse must assess the resident’s mentation and well-being and verify what was reported. The facility also failed to timely notify the physician of the resident’s change in condition involving possible self-harm. The change of condition documentation indicated the doctor was not notified, and the SBAR did not show that the primary care clinician was notified after the resident expressed that he would hurt himself. The RN stated she notified the family member and later contacted emergency personnel, but did not notify the doctor at the same time. The physician was contacted several hours later, after emergency personnel had already transported the resident to an acute hospital, and an order for transfer was then obtained.
Medication Management Deficiency
Penalty
Summary
The facility failed to reorder medications five days in advance as per their policy, resulting in two residents not receiving their prescribed medications on time. Resident 5 did not receive doses of metoprolol and bumetanide, which are critical for managing hypertension and edema, respectively. The medications were not available in the medication carts or emergency kits, and the licensed nurses did not follow up on the reordering process, leading to missed doses. Resident 31 also experienced medication omissions, including Eliquis, brimonidine, finasteride, folic acid, and tamsulosin. These medications are essential for preventing conditions such as blood clots, glaucoma, and benign prostatic hyperplasia. The medications were not available in the facility, and the staff failed to reorder them in a timely manner, resulting in missed doses. Additionally, Resident 31 received Eliquis from another resident's supply, which is against facility policy. The Director of Nursing acknowledged the lack of a consistent system for timely reordering and follow-up of medications, which contributed to the unavailability of medications for both residents. The facility's policies were not adhered to, leading to medication errors and the use of another resident's medication supply. These deficiencies highlight a systemic breakdown in the facility's medication management processes.
Removal Plan
- Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered.
- Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1).
- LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1).
- P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31.
- Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions.
- The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31.
- The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 to reconcile medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand.
- MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31. No untoward findings or side effects related to medication omission have been noted for either Resident 5 or 31.
- The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications.
- The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered.
- A Root Cause Analysis (RCA) was initiated by the ADMIN and the DON to determine causative factors for the systemic breakdown.
- The DON conducted in-service for the licensed nursing staff regarding the following: Daily review of resident medication supply for availability, ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, ensuring all licensed nurses are following facility policy and procedures on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, following through daily with the dispensing pharmacy for timely delivery of all ordered medications, how to utilize the Medication Refill Audit Tool.
- The DON or designee will track the following during the Daily Nursing Huddles: Timely (5 days) Ordering of Medications, Timely Delivery of Medication, Timely Administration of Medication.
- The DON or designee will present findings at the Daily Stand-Up Meeting for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
- The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
- The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at Quality Assurance Performance Improvement (QAPI) meetings with modifications to the process as warranted.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 26.92% error rate during a survey. This deficiency affected two residents, who did not receive their prescribed medications as ordered by their physicians. Resident 5 missed doses of metoprolol and bumetanide, while Resident 31 missed doses of Eliquis, brimonidine, finasteride, folic acid, and tamsulosin. These omissions were observed during a medication administration task. The errors were attributed to the unavailability of medications in the facility's medication carts and emergency kits. Licensed nurses, including LVN 1, failed to reorder medications from the pharmacy within the required three to five-day timeframe before the last available dose. This led to the medications not being available for administration at the scheduled times, as confirmed by interviews with the DON and LVN 1. The facility's policies and procedures for medication administration and reordering were not consistently followed. The DON acknowledged the lack of a consistent system for timely reordering and follow-up of medications, which contributed to the medication errors. The failure to administer critical medications as prescribed posed a risk to the residents' health and safety.
Removal Plan
- Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered.
- Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1).
- LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1).
- P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31.
- Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions.
- The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31.
- The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 to reconcile medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand.
- MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31. No untoward findings or side effects related to medication omission have been noted for either Resident 5 or 31.
- The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications.
- The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered.
- A Root Cause Analysis (RCA) was initiated by the ADMIN and the DON to determine causative factors for the systemic breakdown.
- The DON conducted in-service for the licensed nursing staff regarding the following: Daily review of resident medication supply for availability, ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, ensuring all licensed nurses are following facility policy and procedures on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, following through daily with the dispensing pharmacy for timely delivery of all ordered medications, how to utilize the Medication Refill Audit Tool.
- The DON or designee will track the following during the Daily Nursing Huddles: Timely (5 days) Ordering of Medications, Timely Delivery of Medication, Timely Administration of Medication.
- The DON or designee will present findings at the Daily Stand-Up Meeting for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
- The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved.
- The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at Quality Assurance Performance Improvement (QAPI) meetings with modifications to the process as warranted.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive (AD). This deficiency was identified for three residents, who were not provided with the necessary information or assistance to create an AD. The facility's policy requires that residents be informed of their rights and offered assistance in creating an AD upon admission, but this was not consistently followed. Resident 3 was readmitted to the facility with significant medical conditions and lacked the capacity to make decisions. The Social Services Director (SSD) confirmed that neither the resident nor their responsible party signed the consent to treatment form, which should have included information about ADs. This oversight meant that Resident 3's wishes regarding end-of-life care might not be respected. Similarly, Resident 11's responsible person did not sign the consent to treatment form, and the SSD failed to follow up after sending an email with the form attached. Resident 1's AD was not maintained in the resident's chart, and there was no documented evidence that the AD was discussed during admission. The facility's failure to maintain and provide access to ADs could result in the residents' medical wishes not being followed.
Failure to Document and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required supplemental oxygen. The resident, who was admitted with diagnoses including heart failure, emphysema, and anxiety disorder, had a physician's order for as-needed oxygen therapy to be administered when oxygen saturation levels fell below 92%. However, there was no documentation in the Medication Administration Record (MAR) indicating that oxygen was administered, despite observations of the resident using oxygen at various times. Observations and interviews revealed that the resident was frequently on oxygen via nasal cannula, yet this was not consistently documented in the MAR. Certified Nursing Assistant 3 and the Minimum Data Set Nurse both observed the resident using oxygen, but the MAR lacked entries for these instances. The Director of Staff Development admitted to not documenting the oxygen administration, mistakenly believing the resident was on continuous oxygen rather than as-needed. The Director of Nursing confirmed that oxygen use should be documented and monitored according to the physician's orders. The facility's policies on oxygen therapy and chart documentation emphasized the importance of recording oxygen therapy and maintaining accurate medical records. The lack of documentation could lead to a delay in care, as it prevents proper communication and planning for the resident's care needs.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of missed or improperly administered medications. Resident 5 did not receive two doses of metoprolol, a medication for hypertension, due to the medication not being available in the facility. The Licensed Vocational Nurse (LVN) responsible for administering the medication confirmed that it was not available in the medication carts or the facility, and the Director of Nursing (DON) acknowledged that there was no consistent system in place to ensure timely reordering and follow-up of medications. Resident 19 received 24 doses of expired insulin, administered by several LVNs and the DON, over a period of time. The insulin was stored at room temperature beyond the manufacturer's recommended period, and the Director of Staff Development (DSD) confirmed that the expired insulin should have been removed and replaced with a new pen from the pharmacy. The DON admitted that the expired insulin was not removed from the medication cart, leading to its administration to Resident 19. Resident 31 did not receive scheduled doses of Eliquis and brimonidine due to the medications not being available. LVN 1 and the DON both confirmed that these medications were not available in the medication carts or emergency kits, and the DON admitted to failing to follow up on the status of the re-ordered medications. The facility's policies and procedures were not followed, resulting in significant medication errors and a lack of continuity in medication therapy for the residents involved.
Expired Medications Administered and Improperly Stored
Penalty
Summary
The facility failed to properly manage medications, leading to the use of expired drugs. Specifically, an expired insulin Lispro Kwikpen was found in Medication Cart 2, which was used for Resident 19. The insulin was opened and stored at room temperature beyond the manufacturer's recommended 28-day period. Despite the expiration, several doses were administered to Resident 19, who has type 2 diabetes mellitus, potentially compromising the effectiveness of the medication in managing blood sugar levels. Additionally, an open Aplisol vial, used for tuberculosis testing, was found in the medication room refrigerator without a label indicating when it was opened. This lack of labeling made it impossible to determine the expiration date, as the manufacturer's guidelines require the vial to be used or discarded within 30 days of opening. The absence of proper labeling and storage practices increased the risk of using expired medication, which could lead to inaccurate tuberculosis test results. Interviews with the Director of Staff Development and the Director of Nursing confirmed these deficiencies. They acknowledged that the expired insulin should have been removed and replaced, and that the Aplisol vial should have been labeled with the date of opening. The facility's policies and procedures were not followed, as they require medications to be stored and labeled according to the manufacturer's recommendations, and expired medications to be promptly removed and disposed of.
Failure to Follow Established Menu
Penalty
Summary
The facility failed to adhere to the established menu designed to meet the nutritional needs of its residents. On October 1, 2024, during lunch, the facility did not serve cornbread and substituted green beans for seasoned peas, affecting 42 out of 45 residents, including a specific resident who was part of the sample review. This deviation from the menu was observed during a kitchen tray line preparation, where it was noted that green beans were prepared for all diet types, and cornbread was neither prepared nor served. Resident 10, who was affected by this menu change, has a medical history that includes sepsis, metabolic encephalopathy, dysphagia, anxiety disorder, and unspecified dementia. The resident was admitted to the facility on May 24, 2022, and readmitted on June 16, 2022. The resident's Minimum Data Set (MDS) indicated that he required assistance with daily activities and had experienced significant weight loss in the past three months, putting him at risk for malnutrition. During an interview, Resident 10 expressed dissatisfaction with the facility's failure to follow the menu, stating that it was a common occurrence. The Dietary Supervisor confirmed that the menu was not followed and acknowledged that the cornbread was omitted due to an oversight. The Registered Dietician explained that the menus are planned to meet nutritional guidelines and that cornbread, as a grain, provides essential calories. The facility's policy requires that any menu changes be documented and communicated to residents, which did not occur in this instance. The Director of Nursing emphasized the importance of following the menu to meet residents' nutritional expectations.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, affecting 42 of 45 residents. During a kitchen observation, it was noted that numerous food items in the kitchen refrigerator were not labeled according to facility policy. These included various prepared food items such as whipped cream, chocolate pudding, apple sauce, salads, watermelon, egg salad, cut fruits, tofu, margarine cubes, and several opened containers of condiments and bases. Additionally, an open carton of almond milk was found without a cap, and a zucchini with a mold-like substance was discovered in an outside fridge. In the dry storage area, several food items were found without open dates, and two large food storage bins were not properly secured, leaving their contents exposed. The report also highlighted the presence of a staff member's personal cup in the kitchen preparation area, which is against the facility's policy to prevent cross-contamination. The Dietary Supervisor acknowledged these issues and stated that all improperly labeled and stored food items would need to be discarded to prevent potential illness in residents. The facility's policies on food storage, labeling, and handling were not adhered to, as confirmed by the Dietary Supervisor, Director of Nursing, and Registered Dietician during interviews. Furthermore, the resident refrigerator in the employee lounge contained several food items that were not labeled per facility policy. These included water bottles, cultured milk, carrot juice, yogurt, soda bottles, take-out meals, and various containers of food, all lacking proper resident identifiers and dates. The Infection Preventionist and Director of Nursing confirmed that nursing staff were responsible for monitoring this refrigerator and ensuring proper labeling. The failure to label and date these items posed a risk of serving expired or contaminated food to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (GT), which is considered an indwelling device. During an observation, a Licensed Vocational Nurse (LVN) did not wear a gown while providing GT care, despite the resident having an indwelling device that increases the risk of infection. The Infection Preventionist (IP) acknowledged that the facility's policy was not aligned with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend EBP for residents with indwelling devices. The facility's policy had not been updated to reflect current standards, and the IP was unaware of the CDC guidance, leading to an increased risk of infection for the resident. The facility also failed to ensure that nasal cannulas and humidifier bottles were changed weekly and labeled with the date last changed for a resident receiving oxygen therapy. During an observation, the nasal cannula and humidifier bottle were not labeled, and the Certified Nursing Assistant (CNA) stated that hospice staff were responsible for labeling them, but they had not done so. The Infection Preventionist and Director of Nursing (DON) confirmed that facility nurses were responsible for ensuring the equipment was labeled and changed weekly to prevent bacterial growth and potential respiratory infections. Additionally, the facility did not prevent a urinary catheter bag from touching the floor for a resident with a urinary catheter. During an observation, the catheter bag was seen touching the floor, which was confirmed by the resident and the Director of Staff Development (DSD). The facility's policy stated that catheter bags should not touch the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections (CAUTI). The Administrator acknowledged that allowing the catheter bag to touch the floor could lead to infection due to germ transmission.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to uphold resident rights by not ensuring that residents were aware of where to find the most recent survey results. During an interview, three residents attending a resident council group stated they did not know where to locate the state inspection results. This indicates a lack of communication and accessibility regarding the survey results, which are meant to be available for residents, family members, and legal representatives to review. Additionally, an observation revealed that the survey binder was posted on a wall-mounted holder by the information board, but it did not contain the most recent survey results from 2023. The Minimum Data Nurse confirmed that the survey results were not updated and acknowledged that the information should be publicly accessible to inform the public about the facility's operations and any complaints related to resident care. The facility's policy on Resident Rights, last approved in July 2024, states that residents have the right to examine facility survey results, which was not being fulfilled.
Failure to Provide Homelike Environment Due to Lighting Issues
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not properly securing the ceiling light's screen and not ensuring a chain or cord was attached to the wall light. The ceiling light screen was observed to be not fully clipped in place, which concerned the resident as it might fall. Additionally, the resident was unable to turn the wall light on and off due to the absence of a chain or cord, which limited their ability to control the lighting in their living space. The resident, who was admitted with conditions including osteomyelitis and cellulitis, was noted to have intact cognition and required supervision or assistance with walking. During observations, the Maintenance Supervisor confirmed the ceiling light screen was unsecured and the chain or cord for the wall light was missing. The Director of Nursing acknowledged the importance of allowing residents to control their lighting for safety and dignity. The facility's policy emphasized providing adequate lighting to promote a safe and comfortable environment, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of the notification of discharge to the ombudsman for a resident who was reviewed under closed record review. The resident was admitted with diagnoses including orthopedic aftercare and generalized weakness and was discharged to a hospital for further evaluation due to altered mental status. The resident was capable of understanding and making decisions, as indicated in the Minimum Data Set and Internal Medicine Initial Evaluation. However, the Notice of Transfer/Discharge did not indicate that a copy was sent to the state long-term care ombudsman office. During an interview, the Social Services Director confirmed that the checkbox for notifying the ombudsman was left unchecked, and no fax transmittal was attached to the notice. The responsibility for sending the notification on weekends fell to the licensed vocational nurses or registered nurses, but the process was not completed. The facility's policy indicated that ombudsman notification should occur during unplanned hospitalizations and be sent when practical, but not less than monthly. The failure to notify the ombudsman was acknowledged by both the Social Services Director and the Administrator, who emphasized the importance of protecting the resident's rights regarding a safe discharge.
Failure to Provide Bed Hold Agreement Upon Hospital Transfer
Penalty
Summary
The facility failed to ensure that residents were informed of the bed-hold policy upon transfer to a general acute care hospital (GACH), as evidenced by the case of a resident who was not provided with a seven-day bed hold agreement. The resident, who was admitted with diagnoses including orthopedic aftercare and generalized weakness, was transferred to the hospital for further evaluation due to altered mental status. Despite the resident's ability to understand and make decisions, as indicated in their medical records, the facility did not complete or provide the necessary bed hold agreement upon the resident's transfer. Interviews with the Medical Record Director and the Social Services Director confirmed the absence of the bed hold agreement in the resident's medical record. The Social Services Director acknowledged that the facility's process involves informing residents and their representatives about the bed hold policy upon admission and again when a transfer occurs. The Administrator also confirmed that the facility discusses the bed hold policy with residents upon admission and when they are transferred, emphasizing the importance of safeguarding residents' rights to their home. However, in this case, the facility did not adhere to its policy, resulting in the resident and their representative not being informed about the bed hold option.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For Resident 3, the facility did not create a care plan for the use of Eliquis, an anticoagulant medication prescribed to prevent blood clots. Despite the resident's lack of capacity to understand and make decisions, as indicated in the Minimum Data Set and History and Physical, the care plan was not developed. This omission was confirmed by the MDS Nurse, who acknowledged that the absence of a care plan meant staff lacked guidance on interventions and monitoring for adverse side effects. For Resident 148, the facility failed to implement the existing care plan related to the resident's urinary catheter. The care plan included interventions to prevent infection or injury from catheter use, yet during an observation, the resident's urinary catheter bag was found touching the floor, which poses an infection control risk. This was confirmed by the Director of Staff Development, who stated that the catheter bag should not be in contact with the floor. The resident's care plan was not effectively followed, compromising the standard of care outlined in the facility's policy. The deficiencies in care planning and implementation for both residents were identified through observation, interview, and record review. The facility's policy emphasizes the importance of care plans as communication tools to ensure consistent and appropriate nursing care based on resident needs. However, the failure to develop and implement these plans for Residents 3 and 148 indicates a lapse in adhering to these standards, potentially delaying necessary care.
Failure to Update Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to update the care plan for Resident 34, who was at risk for further weight loss. The resident was admitted with diagnoses including unilateral primary osteoarthritis and gastro-esophageal reflux disease. The Minimum Data Set indicated the resident was independent with eating but had experienced a 5% weight loss without being on a physician-prescribed weight-loss program. Despite the resident's capacity to understand and make decisions, the care plan was not revised to include current nutritional interventions recommended by the registered dietitian. Observations revealed that Resident 34 frequently left meals untouched or partially eaten, expressing dissatisfaction with the food provided. The resident's care plan, dated prior to the registered dietitian's recommendations, did not reflect the updated interventions such as providing soup with meals, updating snack options, and including prune juice with breakfast. Interviews with staff confirmed that the care plan was not revised to incorporate these recommendations, placing the resident at risk for further weight loss. The Director of Nursing acknowledged that the care plan should have been updated to reflect the registered dietitian's recommendations. The facility's policy on weight change protocol and care plan review emphasized the need for revising care plans as goals and interventions change. However, the failure to update the care plan in a timely manner resulted in a significant weight loss for the resident, which was not addressed adequately by the interdisciplinary team.
Failure to Prevent Medication Access in Activities Room
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards for a resident, identified as Resident 10, by allowing medications to be accessible for self-administration without staff supervision. Resident 10, who had a history of sepsis, metabolic encephalopathy, dysphagia, anxiety disorder, and unspecified dementia, was observed with a bottle of Refresh eyedrops and a bottle of clindamycin phosphate topical solution on a table in the activities room. The resident was assessed as not capable of self-administering medications, yet these medications were left unattended and accessible to other residents. During observations, it was noted that the medications remained on the table in front of Resident 10, despite the resident's care plan indicating periods of confusion and disorientation. The Minimum Data Set Nurse (MDSN) acknowledged the presence of the medications and attempted to remove them, but the resident refused to relinquish them. The MDSN informed the Director of Nursing (DON) about the situation but did not follow up, leaving the medications accessible. The facility's policy on self-administration of medications requires an assessment by the interdisciplinary team to ensure safety for the resident and others. However, this policy was not adhered to, as the medications were not authorized for self-administration by Resident 10. The DON confirmed that medications should not be left unattended with residents, as it poses a risk of improper handling and potential ingestion by other residents, which could lead to adverse reactions.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident, leading to significant weight loss. The resident, who was admitted with diagnoses including osteoarthritis and GERD, had severe impaired cognition but was able to make herself understood and was independent with eating. Despite physician orders for weekly weight documentation and a care plan goal of gaining one to two pounds per month, the facility did not consistently record the resident's weight, missing a crucial week when the resident experienced a significant weight loss. The resident's care plan was not revised to address the weight loss, and the facility failed to complete an SBAR form for the weight loss incidents. Observations revealed that the resident often left meals untouched, indicating a lack of adherence to food preferences. The resident expressed dissatisfaction with the meals provided, and despite attempts by staff to offer alternatives, the resident's intake remained low. The facility's dietary supervisor and MDS nurse did not consider the weight loss significant due to the resident being within her ideal body weight, and thus did not adjust the care plan or notify the resident's physician and RD. Interviews with facility staff, including the DON, revealed that the facility's weight protocol was not followed, and the IDT care plan meeting was not conducted to address the resident's weight loss. The facility's policies required significant weight changes to be addressed with revised care plans and communication with the resident's physician and family, which did not occur. The failure to adhere to these protocols and communicate effectively placed the resident at risk for further weight loss.
Failure to Specify Indication for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically for a resident who was prescribed Eliquis, an anticoagulant medication. The deficiency was identified during a review of the resident's physician orders, which indicated that Eliquis was prescribed without specifying the indication or diagnosis for its use. This omission was confirmed during an interview with the MDS Nurse, who acknowledged that the lack of indication in the physician order could lead to staff not knowing the purpose of the medication, potentially causing a delay in care. The resident in question was originally admitted to the facility in 2015 and readmitted in 2024 with diagnoses including acute respiratory failure with hypoxia and generalized muscle weakness. The resident's Minimum Data Set (MDS) assessment indicated that the resident lacked the capacity to understand and make decisions and required maximal assistance with activities of daily living. The facility's policy and procedure for medication orders, last approved in 2024, required that medication orders specify the diagnosis or indication for use, which was not adhered to in this case.
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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 North Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineland Post Acute | 1.2 mi | ★★★★★ | 22 | 0 |
| Valley Vista Nursing And Transitional Care Llc | 1.3 mi | ★★★★★ | 50 | 0 |
| Studio City Rehabilitation Center | 2.1 mi | ★★★★★ | 7 | 0 |
| Imperial Care Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Four Seasons Healthcare & Wellness Center, Lp | 2.3 mi | ★★★★★ | 24 | 0 |
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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 October 2026) and official state health department websites.