Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River City Post Acute during CMS and state inspections, most recent first.
Inadequate supervision during a shower led to a resident fall when a CNA left a resident unattended in the shower room. The resident had paroxysmal atrial fibrillation, major depressive disorder, moderate cognitive impairment (BIMS 9/15), and was assessed as high risk for falls due to unsafe self-transfer, poor coordination, and lower-extremity weakness. The resident was found on the shower room floor after slipping from the shower chair, and the DON stated a CNA cannot leave a resident unattended in the shower room.
A resident with morbid obesity, generalized weakness, and a history of falls had a care plan requiring a Hoyer lift with 2-person assist for transfers. The resident fell with head injury when a CNA transferred the resident from bed to wheelchair without following the ordered transfer instructions, and the DON confirmed the CNA did not follow the resident's transfer requirements.
The facility failed to prevent physical abuse when an argument between two residents escalated into one resident standing and repeatedly punching another resident who was seated and attempting to block the blows. One resident, with muscle weakness and mobility difficulties but intact cognition, sustained a small laceration near the eye and a hematoma on the back of the head, with mild tenderness reported. The other resident, who also had intact cognition and diagnoses including a bone infection and anxiety disorder, was documented as the aggressor. An LN responded after hearing a staff call for help and witnessed the ongoing assault. The DON later confirmed the incident, and facility policy in place prohibited abuse and defined physical abuse as willful infliction of injury such as hitting.
A resident with a PICC line and a history of MRSA infection had an IV central line dressing that was not changed on the ordered weekly schedule. Surveyors observed that the dressing was dated more than a week earlier, and an LPN acknowledged it should have been changed and confirmed she did not perform the dressing change as ordered. The DON stated that PICC dressings must be changed per physician orders and that failure to do so places the resident at risk for infection, and facility policy required at least weekly transparent dressing changes.
Unnecessary quetiapine use was identified for two residents. One resident with dementia-related behaviors, impaired hearing and vision, and no documented psychosis was given quetiapine for unspecified psychosis despite MDS findings showing no hallucinations, delusions, or disorganized thinking, and staff described the behaviors as yelling, cursing, and occasional refusal of care rather than danger to self or others. Another resident received quetiapine for aggressive outburst related to bipolar even though MDS assessments showed no psychosis, the daily behavior monitoring was left blank, and the MD stated the bipolar diagnosis was unclear and the dose was not even effective for bipolar treatment.
Failure to Follow Ordered Bowel Care, Therapy, and Wound Treatment: A resident did not receive ordered bowel care and reported constipation with abdominal discomfort; another resident did not receive ordered PT for ROM despite significant mobility needs; and a treatment nurse did not follow wound care orders by omitting betadine from toe wound care even though the wounds were wet and draining.
Failure to Provide Timely Podiatry Foot Care: A resident with DM and moderate cognitive impairment had long, yellow, sharp toenails and reported needing them cut. The chart showed a podiatry order for diabetic foot/nail care, but the resident had not been seen by podiatry for several months, and staff confirmed shower sheets documented the need for nail clipping while the resident remained without the ordered foot care.
Failure to implement an ONS recommendation contributed to significant unplanned weight loss for a resident with CVA, hemiplegia, dysphagia, urinary retention, and schizophrenia. The resident required 1:1 feeding and extra time to swallow, but weight records showed a marked decline, and the IDT documented that the resident was not meeting EER due to the weight loss trend. Although the RD recommended adding a daily ONS, it was not ordered or implemented, and the resident continued to lose weight.
Medication administration errors exceeded the 5% threshold, with 3 errors in 31 opportunities. An LPN failed to give one resident an ordered multivitamin because it was unavailable, and for another resident gave the wrong strength of folic acid and omitted ordered calcium because only different house-supply products were available. The ADON stated the ordered medications should have been available and that medications are to be administered safely and as prescribed.
Improper Storage and Dating of Medications: Three bottles of atropine 1% eye drops were stored in a refrigerator instead of at the labeled room-temperature range, and two opened budesonide/formoterol inhalers in a med cart were found without open-date labels. An LN confirmed the storage and labeling issues, and the ADON stated that eye drop potency could be affected and that open dates are needed to track inhaler expiration.
Improper storage of dishware and food was observed in the kitchen and activities refrigerator. Cups, mixing bowls, and a colander were stored upright and exposed to air, dust, and splatter, while open chocolate sauce containers were not dated, the refrigerator thermometer was not working, and a container of chocolate ice cream had no open date with debris and smears in the freezer.
Infection control practices were not consistently followed for resident care, equipment, and hand hygiene. A resident with an AVF had a blood-soiled dressing left in place after dialysis, shower rooms had visible buildup and residue, a resident’s nebulizer equipment was stored uncovered with used tissues, another resident’s enteral feeding pump and suction equipment were soiled, and residents were observed eating without being prompted or assisted with hand hygiene before meals.
A whiteboard at the nursing station identified two resident rooms as FEEDERS, and LNs confirmed the label referred to residents needing one-on-one feeding assistance. An ADON agreed the label was demeaning, reduced a person to a task rather than recognizing them as an individual, and was inappropriate to post in a visible area because it exposed residents’ health information.
A resident was not offered or assisted to eat breakfast in the dining room and instead ate in bed, despite stating he wanted to dine there and had asked for help getting there. Another cognitively intact resident had sealed snacks and drinks removed from his room, even though staff said residents could keep nonperishable snacks at bedside in drawers or closets. Interviews with CNA, LN, SSA, and the ADM confirmed the snacks were allowed and that the resident should have been able to keep them.
A discharge MDS assessment was not completed for a resident after discharge. MDS staff confirmed the assessment was missed, and the RAI requires discharge assessments to be completed within 14 days of discharge. The facility policy states assessments must be completed and submitted according to current federal and state timeframes.
Failure to Complete Required PASRR Level II Evaluation: A resident admitted with bipolar disorder had a PASRR Level I screening that was positive and required a Level II evaluation, but the record showed no Level II was completed. The SSD stated residents with mental diagnoses and/or psychotropic meds need DHS evaluation, and later confirmed the facility did not follow up, leaving the resident without assessment for special services tied to the mental illness.
A resident with communication barriers did not have the communication board available at the bedside even though it was listed in the care plan, and staff communicated with him using yes/no answers or Google Translate. Another resident with a history of brain injury, severe cognitive impairment, and an order to wear a helmet when OOB did not have that requirement included in the care plan before later documentation, and was observed without the helmet while in a wheelchair and at the bedside.
Failure to Arrange Neuro Follow-Up: A resident with a hx of ICH, CVA, hemiplegia, hemiparesis, and severe cognitive impairment did not have the recommended neurology or neurosurgery follow-up arranged after admission. Hospital discharge paperwork and SNF admit orders listed neurosurgery and neurology follow-up, and later MD notes also referenced neuro follow-up, but staff interviews confirmed no neurology referral had been initiated and no appointment was located.
Failure to provide needed oral care assistance: A resident with TIA, CVA, DM2, CKD, HF, and severe UE contractures was cognitively intact but dependent for oral care and ADLs. The resident was observed with missing, decayed, discolored teeth and foul oral odor, and stated staff did not help with tooth brushing despite repeated requests. Staff interviews showed the resident needed total assist, oral care was not being documented daily, and the family sometimes had to brush the resident’s teeth.
Failure to Provide Scheduled Resident Activities: A cognitively intact resident stated she wanted to get out of bed earlier to attend activities and said coffee hour was no longer offered as before. Staff did not start the scheduled coffee social on time, did not go to residents’ rooms to invite them, and no puzzles were observed during the posted activity time. The AD stated recreation staff were expected to provide activities according to the schedule, and the resident’s care plan called for meaningful daily routines and involvement in meaningful activities.
A resident with severe cognitive impairment, hemiplegia, and a history of intracranial hemorrhage and decompressive hemicraniectomy was ordered to wear a helmet whenever out of bed. Records showed repeated shifts where the helmet was not worn, the care plan did not list helmet use as an intervention, and staff interviews confirmed the resident often removed the helmet and was asked to replace it himself. Observations found him out of bed and transferring without the helmet, and he stated he wore it only occasionally and had not been told to wear it.
A resident with CHF, pulmonary edema, and COPD was observed wearing an unlabeled NC while receiving oxygen at 2 LPM. Staff stated the NC should be labeled with the date applied so they could determine when it should be changed and whether it was clogged or dirty, but the resident said it had never been labeled and the ADM stated the facility had no specific policy for labeling the NC upon application.
A deficiency was identified when used prescription medications, including two blister packs of apremilast, were found in a medication cart drawer without resident-specific pharmacy labels. An LPN confirmed the labels were missing, and the ADON stated medications needed to be properly labeled within 24 hours after receipt. Facility policy required all meds maintained in the facility to be properly labeled.
A resident with multiple chronic conditions and moderate cognitive impairment, whose paid caregiver was also the responsible party, was subjected to repeated episodes of verbal and physical aggression by that caregiver, including yelling, use of profanity, slamming doors and furniture, kicking walls and furniture, and throwing a cup of water that missed. The roommate, also cognitively impaired, reported these behaviors and expressed concern, and CNAs observed the caregiver’s escalating anger and aggressive actions in the room and identified them as potential abuse. An RN documented one incident but did not treat it as abuse because the resident minimized it and the roommate was viewed as unreliable, despite the facility’s abuse prohibition policy defining intimidation and mental abuse through verbal or nonverbal conduct as abuse.
A resident with multiple chronic conditions and moderate cognitive impairment, whose paid caregiver also served as responsible party, was the subject of alleged verbal and potential physical abuse reported by the roommate and CNAs. Staff observed the caregiver becoming angry over missing personal items, yelling, speaking aggressively, and kicking furniture and fixtures, and CNAs reported these concerns to an RN/LVN the same day. The nurse documented the incident but did not initiate required abuse reporting because she had not witnessed it herself and questioned the reliability of the roommate, and the administrator was not informed until two days later. As a result, the formal abuse report to the state agency, ombudsman, and law enforcement was not submitted within the facility’s policy and regulatory timeframes, which required immediate reporting and no later than two hours for alleged abuse.
Surveyors found that staff did not follow enhanced barrier precautions for two residents with indwelling urinary catheters. One CNA adjusted a resident’s urine drainage bag, removed gloves, then obtained new gloves and provided care to another resident without performing hand hygiene, despite the resident’s care plan requiring hand hygiene and PPE use between residents. Another CNA adjusted a different resident’s urine drainage bag without wearing gloves, contrary to the resident’s care plan and facility policy requiring gowns and gloves for device care. Facility leadership and the IPN confirmed that residents with indwelling devices are on enhanced barrier precautions and that staff are required to use PPE and perform hand hygiene between residents.
A resident with hemiplegia, hemiparesis, depression, and intact cognition was care planned to smoke with supervision and valued engaging in meaningful daily routines. During a scheduled smoke break, an LPN cursed at the resident, yelled at him to leave the smoking area, and prevented him from smoking, as later corroborated by another resident. The resident reported feeling humiliated, intimidated, and singled out, subsequently isolating in his room and avoiding usual exercise and socialization to avoid encountering the LPN. Facility leadership and social services staff acknowledged that the LPN verbally abused the resident, and an internal investigation substantiated the abuse despite an existing abuse-prohibition policy.
A resident on hospice with a history of cardiovascular and cerebrovascular disease was found unresponsive, and the ADON administered two doses of intranasal naloxone at the request of a relative but did not document these doses on the MAR or ensure a signed physician telephone order was placed in the medical record or on the physician order summary. Facility policy requiring immediate transcription and maintenance of telephone orders in the chart was not followed, and the ADON also did not call 911 or follow the full opioid overdose response protocol, which required emergency activation and repeated naloxone dosing with rescue measures until EMS arrival.
A resident with dementia, epilepsy, and major depressive disorder was discharged, and their representative repeatedly requested the return of the resident's personal belongings. Facility staff received the request but did not respond or provide updates, and the belongings could not be located in storage. There was no documentation that the items were returned, and required grievance and property return procedures were not followed.
Resident Rights and Admission Consent: A resident with dementia, epilepsy, and major depressive disorder signed the admission agreement, consent for treatment and release of information, and facility service consents while not oriented to person, place, and time and without documented capacity to make medical decisions. The ADON confirmed the resident signed these documents despite lacking capacity, and facility policy stated that the resident or representative must sign the admission agreement and that the patient's representative should be contacted if the patient is incapacitated.
A resident with a seizure disorder and significant neurologic history missed multiple scheduled doses of levetiracetam after the medication was not available as ordered. The MAR showed 10 missed doses, the resident and his sister reported the medication was not being given regularly, and the ADON confirmed there was no documented evidence that the MD was notified or that the pharmacy reorder was followed up until the medication was finally delivered.
Two residents with significant physical and cognitive impairments were found without accessible call lights, as one had the device blocked by a pillow and the other had it stored in a drawer. Staff and care plans confirmed that call lights should be within reach, but observations and interviews revealed this was not consistently maintained.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not consistently answer call lights promptly, as reported by three residents who experienced significant delays—sometimes up to 30 minutes—when requesting assistance for incontinence care, toileting, and mobility. Observations confirmed multiple unanswered call lights, and interviews with leadership acknowledged that these response times did not meet facility expectations or policy.
A resident with a right humerus fracture and shoulder dislocation did not receive care according to physician orders, as the immobilizer sling was not properly applied and supplemental oxygen was not administered or updated as needed. Nursing staff continued to document that these interventions were provided, despite observations and interviews confirming otherwise.
A resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for self-care was found with a call light not within reach while in bed, despite care plan and facility policy requiring accessibility. Staff confirmed the call light was not accessible at the time of observation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with diabetes and severe cognitive impairment had a physician's order requiring notification if blood sugar exceeded a certain level. When the resident's blood sugar was above this threshold, a nurse administered insulin but did not notify the physician as required, and there was no documentation of physician contact. The facility could not provide a policy on following physician orders.
A resident with schizophrenia and moderate cognitive impairment, who required assistance with personal care and was known to remove her wander guard, left the facility unsupervised after staff failed to complete an elopement risk assessment upon admission and did not adequately monitor the resident as required by policy. The resident's care plan noted a tendency to wander and a desire to leave, but these risks were not sufficiently addressed, resulting in the resident's exit without staff knowledge.
A resident with autonomic neuropathy and recent burn injuries was able to leave the facility unsupervised when a staff member failed to secure an exit door. The resident was not found during routine medication rounds, prompting a facility-wide search and code green. The resident later returned to collect belongings and signed out AMA. Facility policy required supervision and safety measures, but these were not effectively followed.
Multiple shower rooms were found with unsanitary conditions, including mold, mildew, and a resident cup left on a sink. Staff interviews confirmed these issues had been ongoing and were known to management, despite facility policies requiring daily cleaning and infection prevention measures.
Staff did not follow physician orders for two residents, including not applying prescribed wound care and not ensuring protective boots were worn as ordered for a resident with diabetes, and pre-pouring and mis-timing medication administration for another resident. These actions were confirmed by staff interviews and were not in accordance with facility policy.
A resident with cognitive impairment sustained a finger fracture after a fall. Swelling and discoloration were noted, and an X-ray confirmed the fracture, but no immediate intervention to stabilize the injury was provided. The PA reviewed the X-ray but did not inform nursing staff or arrange treatment, and there was no documentation of the resident refusing hospital transfer. The fracture was only addressed days later when the resident was sent to the ED and received a splint.
A resident with severe cognitive impairment was struck on the head twice by another resident in an unprovoked incident witnessed by an LPN. The altercation occurred in a hallway near the nursing station, and documentation confirmed the victim did not provoke the aggression. Staff interviews and facility policies affirmed the expectation and right for all residents to be free from abuse.
A resident with moderate cognitive impairment was moved to a different room without the responsible party receiving prior written notification, as required by both federal regulations and facility policy. The DON confirmed that the responsible party was not notified until after the move had occurred, and documentation showed the notification was made by phone with a voicemail left.
A resident with schizoaffective disorder and substance abuse eloped from the facility on two occasions due to staff failing to consistently implement Q 15-minute safety checks as required by the care plan. Documentation of the checks was inconsistent with the resident's actual whereabouts, and the facility was unaware of the resident's location during these incidents.
A resident with a history of heart disease and a deep tissue injury was not provided with soft heel lift boots as ordered by the physician and outlined in the care plan. Observations and staff interviews confirmed the absence of the required pressure-relieving device, despite facility policy and the resident's dependence on staff for mobility and wound prevention. The DON confirmed that physician orders for such devices were not followed.
Staff failed to properly dispose of used disposable razors and allowed a sharps container to become overfilled in a resident shower room, with the door left open and accessible to residents. Both nursing and CNA staff confirmed the issue, and the Infection Preventionist and DON acknowledged that the facility's policy for timely replacement of sharps containers was not followed, resulting in a breach of infection control practices.
A resident did not receive care in accordance with a physician's order for fluid restriction, as the facility failed to limit the resident's daily fluid intake as prescribed.
A resident was not provided with adequate supervision, resulting in a failure to prevent elopement. This deficiency was identified through observation, interview, and record review.
Inadequate Supervision During Shower
Penalty
Summary
The facility failed to provide adequate supervision during a shower when a CNA left a resident unattended in the shower room. The resident had diagnoses including paroxysmal atrial fibrillation and major depressive disorder, and the MDS indicated moderate cognitive impairment with a BIMS score of 9 out of 15. The care plan identified the resident as high risk for falls due to attempted unsafe self-transfer, poor coordination, and weakness of the lower extremities, with interventions to anticipate and meet the resident's needs. During the shower incident, the resident was found lying on the shower room tiles after the CNA left to get the hall nurse. The resident stated she slipped down from the shower chair, and the IDT note documented that the CNA left the resident alone and was educated not to leave the resident alone due to fall risk. The CNA later stated she opened the shower door, spoke with the nurse while the door was open, and within seconds the resident was on the floor. The DON stated that a CNA cannot leave a resident in the shower room unattended.
Failure to Follow Hoyer Lift Transfer Instructions
Penalty
Summary
A resident with diagnoses including morbid obesity and generalized weakness had a care plan that identified the resident as at risk for falls and specified special instructions for a Hoyer lift with a 2-person assist. The resident's MDS indicated that chair/bed-to-chair transfer required substantial to maximal assistance and also noted a history of falls with injury. The resident's physician order later directed that the resident be up in a wheelchair three times a week on the morning shift using Hoyer lift only. The resident fell during a transfer from the bed to the wheelchair when a CNA transferred the resident without following the Hoyer lift instructions. Nursing progress notes documented that the CNA called the licensed nurse after the resident fell in the room during the transfer, and the resident was found lying on the back with the head resting on the base of the nightstand and bleeding from the back of the head. The H&P stated the resident was brought in after a ground-level fall and reported being transferred from the bed to the wheelchair before hitting the head on the side table. The DON confirmed the resident had a fall with injury and that the assigned CNA did not follow the transfer instructions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident punched another in the face and head. Resident 1, admitted in early 2026 with muscle weakness and difficulty with mobility and assessed with a BIMS score of 15/15 indicating no cognitive impairment, was seated in a chair when Resident 2 began throwing punches. Resident 2, also admitted in early 2026 with diagnoses including a bone infection of the right foot and an anxiety disorder and a BIMS score of 14/15 indicating no cognitive impairment, engaged in an argument with Resident 1 that escalated into a physical attack. A progress note for Resident 1 documented that he was struck in the face and back of the head, resulting in a small laceration at the outer corner of his right eye, a small hematoma on the back of his head, and complaints of mild tenderness. A progress note for Resident 2 documented that he attacked Resident 1 by throwing punches while Resident 1 was seated and Resident 2 was standing. A licensed nurse reported hearing another staff member yell for help and, upon arriving at the scene, observed Resident 2 throwing punches at Resident 1, with several punches making contact as Resident 1 attempted to block them while seated. The DON confirmed that the incident occurred between the two residents and stated that her expectation was for residents to be free from any abuse. The facility’s Abuse Prohibition Policy and Procedures, dated 2/21, states that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, including physical abuse such as hitting and slapping. Despite this policy, the incident of resident-to-resident physical abuse occurred, resulting in documented injuries to Resident 1.
Failure to Perform Weekly PICC Dressing Change per Orders and Policy
Penalty
Summary
The facility failed to ensure services met professional standards of quality when nursing staff did not change a resident’s peripherally inserted central catheter (PICC) dressing according to physician orders and facility policy. The resident was admitted in April 2026 with diagnoses including a methicillin-resistant Staphylococcus aureus (MRSA) infection. Physician orders dated 4/14/26 directed that the resident’s IV central line dressing be changed every seven days and as needed, specifically on the evening shift every Sunday. On 4/22/26 at 12:41 p.m., during an observation with a licensed nurse, the resident’s PICC dressing was found labeled with the date 4/13, and the nurse confirmed it should have been replaced on the evening of 4/19/26 and that the dressing should be changed weekly due to the risk of infection. In a subsequent interview on 4/22/26 at 2:42 p.m., another licensed nurse confirmed she did not change the resident’s PICC dressing on 4/19/26 as ordered by the physician. During an interview at 2:47 p.m. the same day, the Director of Nursing stated that PICC line dressings should be changed per physician orders and that failure to do so places the resident at risk for infection. Review of the facility’s policy and procedure titled “PICC DRESSING CHANGE,” dated 6/18, indicated that dressing changes using transparent dressings are to be performed at least weekly. The observed failure to change the PICC dressing as ordered and as required by policy constituted the deficiency.
Unnecessary Quetiapine Use Without Supporting Clinical Evidence
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use when quetiapine was administered without adequate supporting clinical evidence. One resident had diagnoses including stroke-related paralysis, depression, and later dementia, but multiple MDS assessments showed a BIMS score of 15/15 with no delusions, hallucinations, or disorganized thinking. The psychiatrist documented yelling, agitation, mood instability, depression, anxiety, insomnia, frustration, poor hearing, poor eyesight, and isolation, but there was no documented diagnosis of psychosis or another mental disorder supporting use of quetiapine for unspecified psychosis. That resident’s order summary listed quetiapine 100 mg twice daily for unspecified psychosis manifested by agitation, shaking the siderails, cursing, and yelling. During observations, the resident was repeatedly found sleeping in bed and no screaming or yelling was noted. Staff interviews described the resident as having impaired vision and hearing, occasional refusal of care, and yelling or cursing behaviors, but not hallucinations, delusions, aggression, or danger to self or others. The MD stated the resident had no hallucinations or delusions, that the behaviors could be related to unmet physical needs, medical conditions, or dementia-related behaviors, and that the medication did not appear to be helping. The second resident was readmitted with diagnoses including major depressive disorder, anxiety, dementia, and bipolar disorder, and was receiving quetiapine 25 mg twice daily for aggressive outburst related to bipolar. The resident’s MDS assessments showed a BIMS of 15 and no indicators of psychosis, hallucinations, delusions, or behavioral symptoms directed toward others. The daily behavior/cognitive monitoring form was left blank every day during the reviewed period. The MD stated the 25 mg twice-daily dose was not even effective for treating bipolar disorder, was unsure when the bipolar diagnosis was added, and later stated the psychiatric referral report did not indicate bipolar disorder and the diagnosis should have been removed from the chart.
Failure to Follow Ordered Bowel Care, Therapy, and Wound Treatment
Penalty
Summary
Resident 15 did not receive bowel care as ordered. The resident was admitted with multiple diagnoses including COPD, diabetes, peripheral vascular disease, and atrial fibrillation, and had moderately impaired cognition with bowel incontinence. The MAR showed a bowel regimen order for MOM, then Dulcolax suppository, then Fleet enema if constipation persisted, but the record showed no bowel care regimen was provided in March 2026. The resident reported not having a bowel movement in two weeks and stated MOM did not work, with abdominal pain and discomfort. The ADON acknowledged that no bowel care regimen was given between the documented bowel movements and stated the resident should have had bowel care initiated. Resident 90 did not receive ordered physical therapy. The resident was cognitively intact and had significant mobility limitations documented in the MDS, including substantial/maximal assistance for bed mobility and dependent assistance for chair or bed transfers. The order summary showed a physician order for recommended physiotherapy for foot and left shoulder ROM, but therapy records indicated the resident had not been seen by the therapy department since the facility began providing therapy services. The DOR stated the order was entered incorrectly and did not trigger therapy to see the resident, and the record showed no physical therapy was received from the time the order was written through the survey review. Resident 156 did not receive wound care according to physician orders. During observation, the treatment nurse was seen performing wound care to the resident’s lower legs and toes, and the resident’s left and right second toes had drainage and appeared wet. The TAR ordered cleansing with normal saline, pat dry, and application of betadine to the toes with open-to-air treatment every day shift, but the nurse stated betadine was not applied to either toe. The nurse acknowledged the order required betadine and stated it was supposed to be followed. The medical director stated it was her expectation that nursing staff follow wound care orders and that betadine is used to help dry out the wound.
Failure to Provide Timely Podiatry Foot Care
Penalty
Summary
The facility failed to ensure Resident 79 received necessary foot care to maintain her highest practicable physical and psychosocial well-being. Resident 79 was admitted with multiple diagnoses including DM and generalized weakness, and her most recent MDS indicated moderate cognitive impairment. The clinical record included a physician order dated 12/18/25 for Social Services to arrange podiatry for diabetic foot/nail care, and a later order dated 2/3/26 for podiatry services for treatment of toenails and other foot problems every 61 days as needed. The record showed Resident 79’s last podiatry visit for toenail care was on 10/21/25, and the document from that visit described her nails as painful, long, yellow, brittle, and thickened. There was no documented evidence that she was seen by podiatry after the 12/18/25 order. During observation on 3/3/26, Resident 79 was noted in bed with yellow, long toenails with sharp uneven edges, and she stated she did not like them being that long and sharp and needed them cut. She also stated that because of her DM she required a podiatrist and had not seen one for several months. Staff interviews and record review confirmed the delay in care. A CNA stated that shower sheets were used to document when nails needed trimming and that nurses reviewed them daily to either trim nails or notify Social Services for podiatry. An LN confirmed that residents with DM required a podiatrist to trim toenails and agreed Resident 79’s nails were long and sharp. Social Services acknowledged the resident’s name was not on the 2/3/26 podiatry list and that the last toenail care was over 4 months earlier. The ADM reviewed shower sheets dated 2/14/26 and 2/25/26 and acknowledged both indicated the resident’s toenails needed to be clipped. The resident’s family member also stated the resident had been waiting a long time for toenail clipping and had not seen podiatry since October.
Failure to Implement Nutritional Supplement After Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not ensured for one resident with cerebral infarction, hemiplegia, dysphagia, urinary retention, and schizophrenia. The resident was admitted in January 2026 and was unable to complete the BIMS interview. Weight records showed a decline from 137.6 lbs on January 13, 2026 to 124 lbs on February 28, 2026, for a total loss of 13.6 lbs (9.9%) since admission and 12.4 lbs (9.1%) within one month, which was identified as significant unplanned weight loss. The resident was ordered a regular soft bite sized diet with thin liquids and one-to-one feeding with extra time to swallow, and a CNA stated the resident required assistance with every meal and most meals were eaten in the resident's room with staff. The interdisciplinary care conference on February 20, 2026 documented that the resident was not meeting estimated energy requirements due to the recent weight loss trend and recommended adding an oral nutritional supplement to be consumed daily. The RD confirmed the recommendation was made, but the supplement was not ordered or implemented, and the resident continued to lose weight after the conference. The ADON confirmed the expectation was that recommendations discussed during IDT would be ordered and implemented in a timely manner, and the RD stated implementation was expected within 24 hours. The facility's weight management policy stated that for patterned or significant unplanned weight loss of at least 5% in 30 days, the dietetics professional would assess the resident and make recommendations, and orders may be obtained for nutritional supplements or other interventions.
Medication Error Rate Exceeded 5% During Observed Passes
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 3 errors identified out of 31 opportunities for error during medication administration observation, resulting in a 9.68% error rate. For one resident, a licensed nurse administered morning medications without the ordered multivitamin-mineral tablet because the medication was not available on the cart or in the medication room. The resident’s physician order required one tablet by mouth daily, and the MAR later documented the multivitamin-mineral as not available. The ADON stated the medication bottle should have been available before the medication pass. For another resident, a licensed nurse administered folic acid at 400 mcg from a house supply bottle even though the physician order was for folic acid 1 mg daily, and the nurse acknowledged the wrong strength was given. The same resident’s ordered calcium 500 mg was not administered during the observed medication pass because only a higher-strength calcium plus vitamin D product was available, and the nurse stated the physician needed to be contacted. The nurse later stated the order was changed to calcium 600 plus vitamin D so the facility could use its current house supply. The ADON stated the ordered calcium 500 mg medication bottle should have been available for resident use prior to the observation.
Improper Storage and Dating of Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when three bottles of atropine 1% eye drops were found in the medication room refrigerator at 38 degrees F, even though the manufacturer’s label stated the product should be stored at 68 to 77 degrees F. During observation and interview, an LN confirmed the bottles were in the refrigerator, and the ADON stated that the potency of eye drops could be negatively affected. The report also noted that the facility’s census was 162 at the time of the survey. The facility also failed to date opened multidose inhalers stored in medication cart 2 on hall 7. Two opened budesonide/formoterol inhalers were observed without open-date labels, and an LN acknowledged that the boxes did not have dates to determine expiration. The ADON stated that open dates needed to be documented on multidose inhalers to know the products’ expiration dates, and the manufacturer’s label indicated the inhalers should be discarded within 3 months after removal from the foil pouch. The facility policy for administering medications stated that the expiration or beyond-use date is checked before administration and that the date opened is recorded when a multi-dose container is opened.
Improper Storage of Dishware and Food in Kitchen and Activities Refrigerator
Penalty
Summary
Food was not stored in a sanitary manner in the kitchen when multiple cups, a nest of six mixing bowls, and a large colander were observed stored upright on a bottom shelf and left open to air, dust, and splatter. During the observation, Dietary Aid 2 verified the cups were stored upright and stated they were supposed to be turned upside down to protect them from dust. Another staff member also verified the nesting bowls and colander were stored upright and stated they should be turned face down. The Corporate Registered Dietitian later stated that cups and mixing bowls should be stored face down, and the facility policy for warewashing indicated dishware should be air dried and properly stored. The activities refrigerator also had food storage and sanitation issues. Two 20-ounce and two 24-ounce containers of chocolate sauce were open but not labeled with an open date, and the refrigerator thermometer registered 75 degrees. In the freezer, a five-gallon container of chocolate ice cream had no open date and showed brown streaks running down the carton, with brownish smears and additional debris on the bottom and sides of the freezer. The Recreation Director verified the broken thermometer and the freezer condition, and the Dietary Manager stated that items in the refrigerator and freezer should be labeled with open and use-by dates, that working thermometers should be present in both units, and that freezers should be cleaned weekly or sooner if there is spillage. The facility policy for refrigerators and freezers indicated food should be appropriately dated and freezers kept clean and free of debris.
Infection Control Practices Not Followed for Resident Care, Equipment, and Hand Hygiene
Penalty
Summary
The facility failed to ensure infection control practices were implemented for multiple residents and shared areas. Resident 95, who was admitted with end stage renal disease, dependence on kidney dialysis, and heart failure, was observed lying in bed with a blood-soiled dressing on the left upper arm covering the AVF site. Resident 95 stated the dressing had been applied after dialysis the previous afternoon and wanted it changed because it was dirty. Two nurses confirmed the dressing was soiled with blood and should have been changed, and one nurse stated the dressing had been left on since the prior day after dialysis. Unsanitary conditions were also observed in the shower rooms on hallway 6 and hallway 7. A resident stated the shower in hallway 6 was always dirty and that he wrapped his shoes or feet in plastic before using it because he had a wound. During observation, pink residue was seen built up in the corners of the shower room in hallway 7, and pink and black slimy substance was observed on the tile and side skirting in the corners of the shower room in hallway 6. Facility staff confirmed the buildup and stated the showers were expected to be free of debris, mold, odor, and buildup. Resident 56, who had multiple diagnoses including CHF, diabetes, Parkinsonism, and pulmonary hypertension and was severely cognitively impaired, had a nebulizer mask and tubing uncovered in a nightstand drawer and covered with used tissues. A nurse confirmed the equipment should have been stored in a black mesh bag to keep it clean and stated it could not be used if not stored properly. Resident 54, who had diagnoses including respiratory failure, epilepsy, stroke, dysphagia, and gastrostomy, was observed with an enteral feeding pump and the wall behind it splattered with droplets and brown stains resembling tube feeding formula. The resident’s suction machine and cannister were also soiled, and the cannister was dated 12/8/25. In addition, residents in the dining room and in a resident room were observed eating meals without being prompted or assisted with hand hygiene, and residents stated they were not offered hand wipes or sanitizer before meals. Staff interviews confirmed hand hygiene products were not provided on meal trays and that resident hand hygiene before meals was not consistently prompted or assisted.
Dignity Violation: Residents Labeled as “FEEDERS” on Visible Whiteboard
Penalty
Summary
The facility failed to provide care in an environment that maintained and enhanced residents’ dignity and respected their individuality when a white board at the Nursing Station of Hall 6 identified two resident rooms as FEEDERS. During an observation on 3/3/26 at 4:05 p.m., the white board on the wall at the Nursing Station of Hall 6 was observed to have two resident rooms labeled FEEDERS. During a concurrent observation and interview on 3/4/26 at 3:15 p.m., LN 3 and LN 4 confirmed that the whiteboard in Hallway 6 listed two resident rooms as FEEDERS and explained that these were residents who needed assistance with feeding, one-on-one. When asked whether it was appropriate to label and identify residents as feeders, LN 3 and LN 4 did not provide an answer. During a later concurrent observation and interview on 3/4/26 at 3:35 p.m., ADON 1 validated that FEEDERS referred to residents who required help with feeding and agreed that labeling residents as FEEDERS could be demeaning because it reduced a person to a task rather than recognizing them as individuals and undermined residents’ dignity. ADON 1 also stated that posting FEEDERS in a visible area was inappropriate because it exposed residents’ health information.
Failure to Support Resident Choice for Meals and Personal Snacks
Penalty
Summary
The facility failed to support resident choice when it did not offer or assist one resident to eat breakfast in the dining room. During an observation, the resident was sitting in bed with breakfast on the bedside table. The resident stated he ate breakfast in bed but would rather eat in the dining room, and said he had asked for help wheeling himself there but was not assisted and was told he was kicked out of the dining room. On another observation, the resident was again seen in bed while the breakfast cart was in the hallway, and he stated he was not offered the dining room that morning. A nurse stated that residents in the hallway who need assistance to eat are brought to the dining room, while residents who are independent eat in their room. The resident’s care plan stated it was important that he have opportunities to engage in daily routines meaningful to his preferences. The facility also failed to allow another resident to keep snacks in his room. The resident was admitted with diagnoses including left below-knee amputation, anxiety, and depression, and his MDS indicated he was cognitively intact. He stated he was very upset because staff had confiscated his snacks, including cookies, chips, candies, water bottles, other drinks, salt, pepper, and hot sauce, which had been stored in Ziplock bags, original packages, drawers, and a box in the closet. He said the items were not perishable and that he had been told only perishable food could not be kept at bedside. He also stated that the removal of his snacks made him feel that his rights were not respected. Staff interviews conflicted with the removal of the snacks. A CNA stated residents were allowed to keep snacks, chips, candies, and drinks at bedside if stored closed in a drawer or closet. A charge nurse stated that perishable food needed to be dated and refrigerated, but snacks such as cookies, chips, and candies could be kept at bedside if covered and not exposed to air. The social services assistant confirmed the bags contained sealed snacks and drinks and could not explain why they were taken. The administrator stated residents had the right to keep snacks in drawers or containers as long as they were covered and said the resident should have been able to keep them at bedside.
Missed Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment for one of four sampled residents, Resident 142, after the resident was discharged from the facility on 9/22/25. Review of the resident’s facesheet confirmed the discharge date, and a concurrent interview and record review on 3/5/26 with MDS Nurse 2 confirmed that the discharge MDS assessment had not been completed. MDS Nurse 2 stated that the discharge MDS assessment was missed, and that the facility has 14 days from discharge to complete it. Review of the MDS RAI 3.0 indicated that discharge assessments, including discharge return anticipated and discharge return not anticipated, must be completed within 14 days after the discharge date. Review of the facility’s policy titled MDS Completion and Submission Timeframes stated that resident assessments are to be conducted and submitted in accordance with current federal and state submission timeframes.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that Resident 18 received a required mental health evaluation after the resident’s PASRR Level I screening was positive for a mental disorder. Resident 18 was admitted in 2025 with multiple diagnoses, including bipolar disorder, and the PASRR Level I Screening Evaluation dated 12/18/25 indicated the resident had a diagnosed mental disorder and was prescribed psychotropic medications. The screening form stated that a Level II evaluation was required, but the resident’s clinical record did not show that a Level II evaluation was completed. During interviews, the Social Services Director stated that residents with a mental diagnosis and/or psychotropic medication use who screen positive on Level I are required to have a Level II screening through DHS, and that the evaluation guides the plan of care and may identify psychiatric referral or special activities. On follow-up review, the Social Services Director validated that the facility did not follow up with DHS and that Resident 18 was not assessed for the need for special services for the mental illness. The Administrator stated that residents with mental illnesses should receive Level II screening to ensure appropriate care and specialized services.
Incomplete Care Planning for Communication Needs and Helmet Use
Penalty
Summary
The facility failed to develop and/or implement a comprehensive care plan for Resident 46 related to communication needs. Resident 46 was admitted with diagnoses including cerebral infarction, hemiplegia, dysphagia, urinary retention, and schizophrenia, and the care plan dated 1/13/26 stated that he had difficulty communicating verbally, spoke a non-English language, and had a communication board in his room to help him communicate with staff. However, during observation on 3/5/26, staff confirmed there was no communication board at the bedside, and staff were observed providing care and communicating with him without using one. Staff interviews showed that communication was being attempted with yes/no responses or Google Translate, and one CNA stated she knew when he needed help by his behavior rather than by use of the board. The facility also failed to include and implement a care plan intervention for Resident 88 requiring a helmet when out of bed. Resident 88 was admitted with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and intracerebral hemorrhage, and his MDS showed severe cognitive impairment with substantial assistance needed for bed mobility and transfers. His hospital discharge information and physician order stated that he was to wear a helmet when out of bed due to his craniectomy, but the care plans reviewed before 3/4/26 did not identify helmet use as an intervention. The only later care plan, dated 3/4/26, addressed forgetful behavior of taking off the helmet while out of bed. Observations showed Resident 88 sitting in a wheelchair in the dining room without his helmet and later sitting at the edge of the bed with the helmet hanging from the wheelchair. During interview, he stated he wore it only occasionally and that no one had told him to wear it. Staff acknowledged that he was supposed to wear the helmet when out of bed and that whoever assisted him should put it on, but the care plan prior to 3/4/26 addressing helmet use was not provided. The facility policy stated that the interdisciplinary team is responsible for developing an individualized comprehensive care plan, and the fall management policy stated that residents at risk for falls should receive individualized interventions to reduce risk and minimize injury.
Failure to Arrange Neurology and Neurosurgery Follow-Up
Penalty
Summary
The facility failed to arrange needed neurology and neurosurgical follow-up services for one resident after admission. The resident was admitted with multiple diagnoses including cerebral infarction, hemiplegia, hemiparesis, and intracerebral hemorrhage. The resident’s hospital records showed a history of intracranial hemorrhage and cerebrovascular accident, and that the resident had undergone a decompressive hemicraniectomy with hematoma evacuation and had multifocal embolic-appearing strokes. Hospital discharge documents and skilled nursing facility admit orders listed recommended follow-up appointments with neurosurgery and neurology. Facility records later included physician notes referencing the resident’s significant past medical history and outpatient specialty follow-ups with neurology as feasible, along with orders from the facility Medical Director for neuro follow-up and a neurologist consult for cerebrovascular disease and seizure disorder. During interviews, the ADON stated no neurology follow-up appointments had been arranged, the Medical Director stated the resident should have been seen by neurology and that it would have been worthwhile to contact neurology or neurosurgery, and the Social Services Assistant stated she could not locate a referral for neurology consult. The facility policy stated social services staff are responsible for making referrals and obtaining needed services from outside entities.
Failure to Provide Needed Oral Care Assistance
Penalty
Summary
The facility failed to ensure that one resident received necessary assistance with tooth brushing and mouth care in accordance with the resident’s assessed needs, care plan, and facility policy. The resident had a history of TIA, cerebral infarction, diabetes mellitus type 2, chronic kidney disease, heart failure, right below-the-knee amputation, and muscle wasting and atrophy. The resident’s BIMS score was 15, indicating cognitive intactness, and the resident was observed lying in bed with multiple missing teeth, remaining teeth that appeared decayed and discolored, and a noticeable foul oral odor. During the observation, the resident stated he was unable to perform ADLs independently, could not hold a toothbrush because of contractures, and that staff did not assist with oral care. The resident stated he had asked for help with teeth brushing and no one helped, including that morning, and said staff had not brushed his teeth for over a year, with oral care only sometimes performed when his sister visited. The care plan revised 2/6/26 stated the resident required assistance with oral care and would be assisted with current level of functioning in personal hygiene. The MDS Section GG indicated the resident was dependent for oral care. Staff interviews showed inconsistent awareness and documentation of oral care needs. An LN stated the resident was a total assist for ADLs and had no orders for mouth care, while a CNA stated the resident needed total assist with oral care and that there was no place to chart daily performance of oral care. Another LN stated oral hygiene was not being documented daily and that the resident was totally dependent on assistance with ADLs. The family member stated she sometimes brushed the resident’s teeth when visiting and that the teeth were in very poor condition. A CNA later stated she observed tooth discoloration, discolored sputum, and plaque indicating lack of teeth cleaning. The facility policy stated that if a resident refuses mouth care, the reason and intervention should be documented and the supervisor notified.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide activities meaningful to Resident 156 and according to the posted activity schedule. Resident 156 was cognitively intact with a BIMS score of 15 and stated she wished she could get out of bed earlier so she could attend activities. She also stated that activity staff used to offer coffee at 10 a.m. but no longer did, and that she looked at the schedule posted on the wall to see what activities were offered. The activity schedule whiteboard for March 2026 in Hallway 1 showed a Wednesday 10:00 a.m. Coffee Social. During observation at 10:14 a.m., no staff were seen in the dining room and no staff were observed going into residents’ rooms to invite them to the scheduled activity. Recreation Assistant 1 later stated the activity was coffee hour and that he had to get the cups, and at 10:31 a.m. the coffee hour had still not started; four residents were sitting alone in the dining room. The schedule also listed 11:00 a.m. Puzzles, but during observation from 11:09 a.m. to 11:30 a.m., no puzzles were seen in the dining room, the television was on, and RA 1 and RA 2 were speaking with each other rather than with Resident 156. RA 1 stated residents were invited by announcements over the speakers and that he did not go into residents’ rooms to ask them to join activities. The AD stated recreation staff were expected to provide activities according to the schedule. Resident 156’s care plan stated she should have opportunities to engage in meaningful daily routines and self-directed involvement in meaningful activities at least 5 times per week, and the facility policy stated activity programs are designed to meet residents’ interests and support their physical, mental, and psychosocial well-being.
Failure to Ensure Helmet Use During Transfers and Out-of-Bed Activity
Penalty
Summary
The facility failed to provide supervision for one of 36 sampled residents, Resident 88, to ensure he wore a protective helmet when out of bed. Resident 88 was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and intracerebral hemorrhage, and his MDS indicated severe cognitive impairment with a BIMS score of 3 out of 15. His records also showed he required substantial assistance for bed mobility and transfers from bed to chair, and his hospital history documented a decompressive hemicraniectomy with instructions to continue wearing a helmet when out of bed. Resident 88’s orders stated he was to be out of bed with a helmet every shift for craniectomy, and the MARs for January, February, and early March 2026 documented multiple episodes in which he was not wearing the helmet during day and evening shifts. The care plan addressed fall risk, impaired mobility, weakness, and impulsive behavior, but it did not include wearing the helmet as an intervention. During observation, Resident 88 was seen in the dining room sitting in his wheelchair without his helmet, and later was observed sitting on the edge of his bed with the helmet hanging from the back of the wheelchair. During the bedside observation, Resident 88 stood and began turning to sit in the wheelchair while appearing unsteady and with right-sided weakness, then sat back on the bed. When asked, he stated he wore the helmet only occasionally and said no one had told him to wear it. Staff interviews showed CNA 9 and LN 9 knew of the helmet order but described Resident 88 as taking the helmet off and being asked to replace it himself. The ADON stated the resident needed assistance when getting out of bed and that whoever assisted him should put on the helmet, and acknowledged the order was not effective because it only reflected whether the helmet was observed on or off. The medical director stated the resident was missing part of his skull and needed to wear a helmet when out of bed due to imbalance, and that nurses should document whether he was wearing it.
Unlabeled Nasal Cannula Used for Oxygen Therapy
Penalty
Summary
The facility failed to ensure respiratory equipment was maintained in accordance with professional standards of practice for one resident. Resident 193 was admitted with diagnoses including congestive heart failure, pulmonary edema, and COPD. His MDS dated 3/4/26 showed a BIMS score of 10 out of 15, indicating moderately impaired cognitive function. Physician orders dated 3/2/26 directed oxygen tubing changes weekly on Sunday night shift and oxygen at 2 LPM via nasal cannula as needed for shortness of breath. During a concurrent observation and interview on 3/3/26 at 9:05 a.m., Resident 193 was seen sitting in a wheelchair wearing an unlabeled nasal cannula connected to oxygen set at 2 LPM. The resident stated the nasal cannula was never labeled. A nurse stated the nasal cannula should be labeled with the date it was applied, and that if it was left unlabeled staff could not determine when it should be changed or whether it was clogged or dirty. The ADON also stated the nasal cannula should be labeled with the date applied, and the Administrator stated the facility did not have a specific policy on labeling the nasal cannula upon application.
Improperly Labeled Medications Stored in Medication Cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not maintained when prescription medications were found stored in medication cart 2 on hall 7 without resident-specific prescription labels. During observation with LN 11, the bottom drawer of the cart contained used prescription medications, including two blister packs of apremilast, that did not have a resident-specific pharmacy label. During interview, LN 11 stated that the two blister packs did not have a resident-specific pharmacy label. The ADON later stated that prescription medications needed to be properly labeled within 24 hours after being received to prevent medication errors. The facility policy titled, Labeling of Medication Containers, required all medications maintained in the facility to be properly labeled and stated that improperly labeled medication containers are to be returned to the issuing pharmacy.
Failure to Protect Resident From Mental and Emotional Abuse by Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from mental and emotional abuse by his visitor/caregiver. The resident was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, protein calorie malnutrition, dysphagia, and congestive heart failure, and had a BIMS score indicating moderate cognitive impairment. An order documented that the resident did not have capacity to make decisions, and the visitor/caregiver was identified as the responsible party and healthcare decision maker. On one occasion, the resident’s roommate reported to a CNA that the responsible party was physically abusing the resident. When a licensed nurse spoke with the resident, he laughed and said they were just fooling around. Another CNA reported that the responsible party became violent after discovering that a pair of scissors had been removed from the resident’s drawer, kicking the wall and the bedside drawer. Subsequent documentation and interviews described a pattern of verbally and physically aggressive behavior by the caregiver in the resident’s room. A nurse’s note indicated that a Report of Suspected Dependent Adult/Elder Abuse was completed for alleged verbal abuse, and the resident stated that the caregiver had never been physical but did yell and was an angry person. A social worker’s note documented that the caregiver denied physical abuse but admitted to verbal abuse toward the resident, describing frequent arguments and profanity as normal between them. The resident also told the social worker that he did not view their interactions as abuse, although the social worker explained that such conduct in this setting is considered abuse when witnessed as verbally or physically abusive toward a resident. Interviews with staff and the roommate further detailed the caregiver’s conduct. The resident reported that the caregiver became angry when shaving cream was missing, yelled, and slammed the door. The roommate, who also had moderate cognitive impairment, stated that the caregiver had anger issues, yelled when the resident did not do things right or fast enough, pounded on the wall, threw a cup of water at the resident but missed, and slammed the bedside table, and that he was worried about the resident. A CNA described an incident where the caregiver became angry about a missing razor, talked loudly, kicked the closet door and trash can, and appeared to be losing control, which the CNA viewed as potential abuse. The licensed nurse who received the report from the CNA did not recognize the incident as abuse because the resident did not indicate he was being abused and the roommate was considered not always reliable, and she only documented the incident in the chart. These actions and inactions occurred despite a facility abuse prohibition policy that defines abuse to include intimidation and mental abuse through verbal or nonverbal conduct that causes or has the potential to cause mental anguish.
Failure to Timely Report Alleged Verbal Abuse by Resident’s Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse of a resident to the state agency within the required regulatory timeframe. The resident was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, protein calorie malnutrition, dysphagia, and congestive heart failure, and had a BIMS score indicating moderate cognitive impairment. The resident had an order stating he did not have capacity to make decisions, and his visitor/caregiver was identified as his responsible party and healthcare decision maker. On one date, the resident’s roommate reported to a CNA that the responsible party was physically abusing the resident. Nursing documentation indicated that when the nurse spoke with the resident, he laughed and said they were just fooling around. Another CNA reported that the responsible party was violent, having kicked the wall and bedside drawer after discovering that a pair of scissors had been removed from the drawer. A CNA later described that the caregiver became angry when a razor was missing, talked loudly, became aggressive, and kicked the closet door and trash can while the roommate was present, and stated she was afraid the caregiver was losing control and believed the behavior was potential abuse. The roommate also reported to another CNA that the caregiver was becoming verbally aggressive to the resident. Staff interviews showed that CNAs reported the incident to a licensed nurse on the day it occurred, and CNAs understood that suspected abuse should be reported the same day to the nurse and then to the state, though they were not all familiar with exact timeframes. The licensed nurse who received the reports did not complete or file the abuse report at that time, stating she did not witness the incident, the resident did not indicate he was being abused, and she considered the roommate unreliable, so she only documented the incident in the chart. The administrator later acknowledged that the incident occurred on that earlier date but was not brought to her attention until two days later, at which time the abuse reporting form was completed and sent to the Department, ombudsman, and law enforcement. The facility’s policies required that alleged violations involving abuse be reported immediately, and not later than two hours after the allegation is made, but the report for this incident was not submitted until two days after the initial allegation.
Noncompliance With Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control practices, specifically enhanced barrier precautions, for residents with indwelling urinary catheters. Resident 1, admitted with urinary retention and a personal history of infectious disease, had a care plan requiring enhanced standard/barrier precautions, including changing gowns and gloves and performing hand hygiene when moving from contact with one resident to another. During observation, CNA 1 adjusted Resident 1’s urine drainage bag, then removed his gloves, went to another room to obtain new gloves, and proceeded to provide care to another resident without performing hand hygiene in between. In a subsequent interview, CNA 1 acknowledged that he should have washed his hands before putting on new gloves. Resident 2, re-admitted after hospitalization for sepsis, urinary tract infection, and acute kidney failure, also had a care plan requiring enhanced barrier precautions, including wearing gowns and gloves for device care such as urinary catheter care. During observation, CNA 2 adjusted Resident 2’s urine drainage bag without wearing gloves. In an interview, CNA 2 confirmed she did not wear gloves and stated she should have worn them. Review of the facility’s enhanced barrier precautions policy showed that residents with indwelling medical devices, including urinary catheters, were to be on enhanced barrier precautions, and staff were required to wear gowns and gloves and perform hand hygiene between residents. The Infection Preventionist Nurse and the Assistant Director of Nursing both stated that staff were required to wear PPE and perform hand hygiene for residents on enhanced barrier precautions.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a licensed nurse. The resident was admitted with hemiplegia, hemiparesis, and depression, and had a BIMS score of 13/15, indicating he was cognitively intact. His care plan allowed him to smoke with supervision per smoking assessment and facility policy, and he reported that engaging in meaningful daily routines was important to him. During an evening smoke break, the resident went to the designated smoking area as scheduled, but when the licensed nurse saw him approaching the group of smokers, the nurse cursed and yelled at him, telling him to “get the fuck out of here,” and did not allow him to smoke in the designated area. The resident reported this as an alleged verbal abuse incident, and another resident later reported witnessing the nurse cursing, yelling, and preventing him from smoking. Following the incident, the resident stated he felt intimidated, humiliated, scared, discriminated against, and singled out by the nurse. He avoided the evening smoke break so he would not have to deal with the same staff member, and he began staying in his room instead of participating in activities or socializing. Observations showed him lying in bed in a curled-up position in a dark room, and he became agitated and paced while recalling the incident, stating in garbled speech that the facility was his home. Facility staff, including the Administrator and Social Services Director, confirmed that the licensed nurse verbally abused the resident and that the incident affected him mentally and emotionally, leading him to stop walking around the building, exercising, and visiting friends in another hall because he would have to pass the hall where the nurse worked. A completed facility investigation substantiated the alleged verbal abuse incident, despite the facility’s written abuse prohibition policy that states staff must do all within their control to prevent occurrences of abuse and mistreatment.
Failure to Properly Order, Document, and Administer Naloxone During Change in Condition
Penalty
Summary
The facility failed to ensure services met professional standards of quality for one resident related to the ordering, documentation, and administration of naloxone. The resident had a history of hypertension, heart failure, and cerebrovascular disease and was on hospice care. A telephone order for naloxone was reportedly obtained from the physician, but there was no signed physician order in the resident’s medical record, and the order was not entered on the Physician’s Order Summary Report. The Assistant Director of Nursing (ADON) stated that a copy of the telephone order was in her office and acknowledged it had not been recorded in the resident’s chart. Facility policy required that telephone orders be transcribed onto the physician’s order form at the time the order was taken, mailed promptly to the physician for signature, and that a copy be maintained in the medical record until the signed form was returned. The facility also failed to document the administration of naloxone on the resident’s Medication Administration Record (MAR) and did not follow the facility’s opioid overdose response policy. The ADON reported that, upon finding the resident unresponsive with a relative present, she administered naloxone 4 mg nasal spray at 8:32 a.m. and a second 4 mg dose at 8:34 a.m. at the relative’s request, but did not document these doses on the MAR. Progress notes later reflected that naloxone was administered twice with no change in status and described agonal breathing and shallow respirations. The ADON further acknowledged that she did not call 911 as required by the facility’s naloxone policy, which directed staff to call 911, assess for pulse and respirations, initiate rescue breathing or CPR as indicated, and administer additional naloxone doses every two to three minutes until emergency personnel arrived.
Failure to Timely Respond to Request for Resident's Personal Belongings After Discharge
Penalty
Summary
The facility failed to accommodate the exercise of a resident representative's rights by not responding in a timely manner to a request for the resident's personal belongings after discharge. The resident in question had diagnoses including dementia, epilepsy, and major depressive disorder, and was discharged from the facility. Despite multiple requests from the resident's sister for the return of personal belongings, there was no documented response or update provided by facility staff. The Social Services Director (SSD) acknowledged that the request was received but had not contacted the family or confirmed the whereabouts of the belongings. A search of the storage area did not locate the items, and there was no documentation in the resident's record indicating the belongings were returned or received by the family. Interviews with facility staff, including the SSD, Business Office Manager (BOM), and administrator, confirmed that the request for the resident's belongings was communicated internally but not acted upon or followed up with the family. Facility policy requires that grievances be acknowledged and updates provided within 72 hours, and that personal property be returned and documented at discharge. These procedures were not followed, resulting in the resident's representative not receiving the requested belongings or communication regarding their status.
Resident Rights and Admission Consent
Penalty
Summary
The facility failed to exercise the resident representative's right for one sampled resident when Resident 5 signed the admission agreement, consent for treatment and release of information, and consents for facility services while not oriented to person, place, date, and time and without documented capacity to make medical decisions. Resident 5's clinical record showed diagnoses of dementia, epilepsy, and major depressive disorder. A progress note dated 5/5/25 indicated Resident 5 was not oriented to person, place, and time, and the physician's orders did not indicate that Resident 5 had the capacity to make medical decisions on that date. The record review showed Resident 5 signed the consent for treatment and release of information on 5/5/25, the admission agreement with no resident sign date, and informed consents for bed hold, influenza vaccine, and pneumococcal vaccine on 5/5/25. Facility staff confirmed during interview that Resident 5 signed these documents while not oriented and without capacity to make medical decisions, and stated that if a resident lacks capacity, the facility should reach out to a family member to sign the admission agreement and consents. The facility's policies stated that residents have the right to exercise rights not delegated to a legal representative, that centers must inquire with the patient's representative if the patient is incapacitated at admission, and that the resident or representative must sign the admission agreement at the time of admission.
Missed Antiseizure Medication Doses
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error when prescribed antiseizure medication was not administered in accordance with the physician’s order and standards of practice. The resident was admitted in January 2025 and had diagnoses including cerebral infarction, cerebrovascular disease, right-sided hemiplegia, and aphasia. The resident’s MDS dated 10/3/25 showed a BIMS score of 13 out of 15, indicating intact cognition. The resident’s active physician’s order dated 7/2/25 directed levetiracetam 1000 mg by mouth three times daily for seizures. The MAR for November 2025 showed the resident did not receive levetiracetam on 10 occasions, including missed doses on 11/13, 11/14, 11/15, 11/16, and 11/18. During an interview, the resident gestured that he was not receiving his antiseizure medication regularly, and the resident’s sister stated she was told by facility staff that the resident had not received the medication since 11/13/25. Record review showed a provider communication log entry on 11/13/25 stating the pharmacy was called to order the medication and delivery was pending, and a DON-signed notice of non-covered/high-cost drug was dated 11/14/25. A progress note on 11/18/25 stated the resident had not received levetiracetam for more than 3 days. The medication was delivered to the facility on 11/18/25 at 5:29 p.m. During interview and record review, the ADON confirmed the resident missed 10 doses and that there was no documented evidence the doctor was notified or that the medication reorder was followed up with the pharmacy between 11/13/25 and 11/18/25. The DON stated staff should reorder medications before they ran out and notify the doctor if the medication was not available.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of five sampled residents, resulting in the potential for unmet care needs. One resident, admitted with multiple sclerosis, muscle weakness, and moderate cognitive impairment, was observed unable to access her call light due to it being blocked by a pillow. Despite attempts to reach it, she was unsuccessful, and both a CNA and a licensed nurse confirmed the call light was out of reach. The resident expressed a desire to have the call light accessible. The care plan for this resident specifically indicated that the call light should be within reach due to her risk for falls and limited mobility. Another resident, with a history of cerebral infarction, muscle weakness, dysphagia, and severe cognitive impairment, was found with the call light stored in a drawer, out of reach. When asked to use the call light, the resident was unaware of its location. Both a licensed nurse and a CNA confirmed the call light was not accessible and stated it should be within reach. The care plan for this resident also required the call light to be accessible due to high fall risk. The facility's policy stated that call lights must be accessible to residents in bed, on the toilet, or in bathing areas. Interviews with staff and the administrator confirmed the expectation that call lights should always be within reach unless staff are present and assisting the resident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
Staff failed to answer call lights in a timely manner for three of four sampled residents. One resident, admitted with acute respiratory failure and protein calorie malnutrition, reported having to wait a long time to be changed after using the call light for incontinence care. This resident was observed to be on continuous oxygen and unable to walk, and stated that delays occurred whenever she needed assistance after incontinence episodes. Another resident, with encephalopathy and cerebrovascular disease, stated that it sometimes took 30 minutes for her call light to be answered, depending on staff busyness. This resident was dependent on staff for toileting, personal hygiene, dressing, and bed mobility. A third resident, with a right humerus fracture and shoulder dislocation, reported that her call light was ignored for 15 minutes late at night before staff responded. This resident required substantial assistance for bed mobility, toileting, and dressing. Observations on the unit revealed multiple unanswered call lights. Interviews with facility leadership confirmed that the expectation was for call lights to be answered within 2 to 3 minutes, and that 30 minutes was considered too long. The facility's policy required timely responses to resident requests, with staff expected to communicate estimated response times and seek assistance if needed. Despite these policies, staff did not consistently respond to call lights promptly, as evidenced by resident reports and direct observation.
Failure to Follow Physician Orders for Immobilizer Sling and Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident admitted with a right humerus fracture and shoulder dislocation. Physician orders were in place for the resident to have a non-weight bearing right upper extremity, use an immobilizer sling on the shoulder, and receive continuous supplemental oxygen at 2L/min via nasal cannula. Despite these orders, observations revealed that the resident was not wearing the immobilizer sling as ordered, with her wrist out of the immobilizer, and was not receiving supplemental oxygen. The resident reported feeling unwell and in pain, and stated that the immobilizer was not effective and that she had only used oxygen a few times. Record reviews showed that licensed nurses had been signing off on the administration of both the immobilizer sling and oxygen orders, even though these interventions were not being provided as ordered. Interviews with nursing staff confirmed that the oxygen order should have been updated and that the immobilizer was not being used as directed. The physical therapist and assistant director of nursing also confirmed the lack of compliance with the physician's orders. Facility policy required that supplies and medications needed to carry out physician orders be provided, but this was not followed in this case.
Call Light Not Accessible to Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for self-care and bed mobility was found to have a call light that was not within reach while lying in bed. The resident's care plan specifically indicated that the call light should be placed within reach due to her risk for falls and self-injury related to impaired balance, limited mobility, and generalized weakness. During an observation, the call light was seen hanging from the side of the bed, out of the resident's reach. This finding was confirmed by both a Certified Nursing Assistant and a Licensed Nurse, who acknowledged that the call light was not accessible and that this was not acceptable practice. The facility's policy, revised in October 2024, requires that the call light be accessible to residents when in bed. The deficiency was identified through observation, interview, and record review, and it was noted that the resident was still able to use her call light despite episodes of confusion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Elevated Blood Sugar per Order
Penalty
Summary
A physician's order for a resident with diabetes, schizophrenia, dementia, and psychotic disturbance was not followed as required by professional standards. The resident had a physician's order for insulin Lispro to be administered according to a sliding scale, with instructions to notify the physician if the blood sugar value exceeded 401. On review of the electronic medication administration record, it was found that the resident's blood sugar was recorded at 411, and the nurse administered six units of Lispro insulin but did not notify the physician as directed in the order. During an interview and record review, a licensed nurse confirmed that the physician was not notified of the elevated blood sugar value, and acknowledged that the nurse did not follow the physician's order. No documentation was found in the nursing progress notes or medication administration record indicating that the physician was contacted. Additionally, when a policy and procedure on following physician orders was requested, the facility was unable to provide one.
Failure to Monitor and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with schizophrenia and moderate cognitive impairment, resulting in the resident leaving the facility without staff knowledge. The resident was admitted with a diagnosis that included the need for assistance with personal care and was determined to lack capacity to make healthcare decisions. Orders indicated the use of a wander guard device due to poor safety awareness, with instructions for staff to check its placement every shift. However, the resident had a known history of removing the wander guard, and staff interviews confirmed that the elopement risk assessment was not completed upon admission as required by facility policy. On the day of the incident, staff discovered the resident missing during routine checks and initiated a search, but the resident could not be found within the facility. The care plan documented the resident's tendency to wander and desire to leave, as well as previous episodes of removing the wander guard. Facility policies required elopement risk assessments for residents with cognitive impairment or a history of wandering upon admission, but this was not completed. The lack of timely assessment and monitoring contributed to the resident's unsupervised exit from the facility.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment when a resident with idiopathic peripheral autonomic neuropathy and significant burn injuries eloped from the facility. According to the resident's routine, they would typically come to the nurse's station early in the morning to request medication, but on the day of the incident, the resident did not appear as expected. The RN searched the resident's room and surrounding areas, and after being unable to locate the resident, initiated a code green to alert staff of a missing resident. Subsequent attempts to contact the resident by phone revealed that the resident had left the facility and did not intend to return. Further review indicated that the resident later returned to collect personal belongings and signed an AMA (Against Medical Advice) form before leaving again. The Administrator acknowledged that the facility was responsible for resident safety and stated that the resident was able to leave unnoticed when a pharmacy technician failed to close the door upon exiting. The facility's policy emphasized the importance of a safe environment and adequate supervision, including addressing risks such as unsafe wandering, but these measures were not effectively implemented in this instance.
Failure to Maintain Infection Control in Shower Rooms
Penalty
Summary
The facility failed to maintain acceptable infection control practices in four shower rooms, as evidenced by multiple observations and staff interviews. In one shower room, a red drinking cup was found on the sink, which a licensed nurse confirmed was unsanitary and should not have been present. Another shower room was observed to have dark brown and black mold and mildew on the walls and flooring, which a certified nurse assistant stated had been an ongoing issue for several months. Additional observations revealed mold and mildew between tiles, dark mildew under a resident shower bed, and cracked tiles in another shower room, with staff confirming these conditions and acknowledging that they should have been addressed through more thorough cleaning. Environmental personnel and the housekeeping supervisor both confirmed the presence of mold and mildew in the shower rooms, noting that housekeeping was responsible for cleaning but that the problem was ongoing and known to facility management. The infection preventionist and administrator also acknowledged awareness of the unsanitary conditions, including the presence of a resident cup and mildew, and stated these could potentially expose residents to infectious diseases. A review of facility policies indicated that infection prevention measures and cleaning protocols were in place, but these were not followed as required, resulting in unsanitary conditions in the shower rooms.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to follow physician orders and professional standards of practice for two residents. For one resident with diabetes and a history of slow wound healing, staff did not implement the physician's order to cleanse and treat both legs and ensure the resident's feet were placed in protective boots while in bed. Observations showed the resident's legs were not off-loaded as required, and the boots were not in use, despite the resident expressing a preference and expectation to wear them for wound protection. A licensed nurse confirmed the order was not followed and acknowledged the potential for the resident's condition to worsen if the treatment was not implemented. For another resident with multiple diagnoses including GERD, a nurse was observed pre-pouring medications into multiple cups and preparing to administer Donepezil before the scheduled time, contrary to physician orders and facility policy. The nurse also left unlabeled medication cups in the medication cart. The RN supervisor confirmed that medications should be prepared and administered for one resident at a time, at the correct time, and that pre-pouring and leaving unlabeled medications was not acceptable. Facility policies reviewed supported these expectations for medication administration.
Delay in Fracture Management Following Resident Fall
Penalty
Summary
A resident with a history of metabolic encephalopathy, bipolar disorder, and dementia, and with moderate cognitive impairment, experienced a fall while attempting to change position in bed. Initially, no injury was noted, but the following day, swelling and discoloration were observed in the resident's right hand and wrist. A STAT X-ray was ordered and performed, revealing an acute fracture at the base of the fourth finger. Despite this finding, no immediate interventions to support or stabilize the fractured finger were implemented. The physician assistant (PA) reviewed the X-ray results but did not communicate the fracture to the nursing staff or discuss treatment options with the resident. The director of nursing (DON) and other staff were unaware of the fracture until several days later, as the PA had cleared the result in the electronic dashboard without notification. There was no documentation of any refusal by the resident to be sent to the hospital, and the PA later confirmed that the resident had not refused transfer and that standard practice would have been to send the resident for treatment. During this period, the only interventions provided were neuro checks and continued pain management, with no specific care for the fracture. The resident was eventually sent to the emergency department at her request, where a splint was applied. The facility's fall management policy required appropriate care for injuries resulting from falls, but timely interventions to manage the fracture were not implemented, resulting in a delay in treatment.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical abuse when a staff member witnessed another resident approach and strike the resident on the head twice—once with a closed fist and once with an open hand. The incident was unprovoked, and the victim did not initiate or provoke the aggression in any manner. The event occurred in a hallway near the nursing station, and was directly observed by a licensed nurse. Documentation in both residents' progress notes and the care plan confirmed the details of the altercation. The resident who was the victim had severe cognitive impairment, including diagnoses of anxiety disorder, dementia, and adult failure to thrive. The aggressor had a history of dementia and traumatic brain injury but was assessed as having intact cognition. Staff interviews confirmed the expectation that all residents should be free from abuse, and facility policies reviewed also emphasized the prohibition of abuse and the right of residents to be treated with respect and dignity.
Failure to Provide Timely Written Notification of Room Change to Responsible Party
Penalty
Summary
A deficiency occurred when a resident was moved from one room to another without the responsible party (RP) receiving prior written notification, as required by federal regulations and the facility's own policy. The resident, who had a moderately impaired mental status as indicated by a Brief Interview for Mental Status (BIMs) score of 8, was determined by the Director of Nursing (DON) to lack the capacity to make decisions, making it necessary for the RP to be notified of significant changes such as a room transfer. Documentation in the resident's medical record showed that the room change took place at 5 p.m. on July 16, 2024. However, the RP was not notified of the move until July 24, 2024, and this notification was made via phone with a voicemail left. The facility's policy required that the resident, the RP, and all affected roommates receive timely advance notice, either orally or in writing, including the reason for the change, prior to any room or roommate assignment change. During interviews and record reviews, the DON confirmed that the RP was not notified before the room change occurred, and that the facility's policy was not followed in this instance. The lack of timely notification to the RP before the room change constituted a violation of the resident's rights under federal regulations and the facility's own procedures.
Failure to Implement Elopement Prevention Care Plan and Supervision
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and psychoactive substance abuse was not adequately supervised, resulting in the resident eloping from the facility. The resident's care plan required Q 15-minute checks for safety and to prevent elopement, but documentation and staff interviews revealed that these checks were not implemented correctly or consistently. On one occasion, the resident was found missing from the facility and was located by staff approximately 30 minutes later down the street with a bag. On another occasion, the resident was found at a bus stop about 20 minutes after being discovered missing. Record reviews showed inconsistencies between the Q 15-minute check documentation and the nurse's progress notes, with the resident documented as "in bed asleep" during times when the resident was actually missing from the facility. The facility's elopement policy required adequate supervision and care in accordance with the resident's person-centered care plan, but this was not followed, resulting in the facility not knowing the resident's whereabouts and failing to prevent the resident from leaving the premises.
Failure to Implement Physician's Order for Pressure-Relieving Devices
Penalty
Summary
A deficiency occurred when a facility failed to implement a physician's order for a resident requiring soft heel lift boots to relieve pressure on the heels. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease and had a deep tissue injury on the right heel and lateral foot, had a physician's order dated 04/14/24 to elevate heels off the bed or apply soft heel lift boots every shift. The care plan also specified the need for these interventions to protect the resident's heels. Despite these orders, observations on 04/16/25 revealed that the resident was not wearing heel boots. Interviews with nursing staff confirmed that the resident should have had at least one boot on, and that the use of wound prevention devices was crucial to prevent wound progression. The resident reported that the heel boots had disappeared and were not available. Further, staff acknowledged the importance of heel boots, especially given the resident's contractures, which made turning difficult and increased the risk of pressure on the heels. The facility's own policies required staff to review care plans for special needs and to implement physician orders promptly. However, these procedures were not followed, as evidenced by the lack of heel boots on the resident during multiple observations and staff interviews. The Director of Nursing confirmed that staff are expected to follow physician orders and that heel boots should have been applied as ordered.
Plan Of Correction
Note: This plan of correction is submitted as required by law. By submitting the plan of correction, Windsor El Camino does not admit that the citations listed on the CMS 2567 exist nor does it admit to any statements, findings, facts or conclusions that form the basis of the alleged deficiencies. This plan of correction represents our written and credible statement of compliance. We reserve the right to challenge in legal and/or regulatory or administrative proceedings the deficiencies, statements, facts, and conclusions that form the basis for the deficiencies. POC F658 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The physician's order was immediately reviewed, and soft heel boots were applied to Resident 2 as ordered. Resident 2 was assessed by nursing staff and the interdisciplinary team to ensure there were no adverse effects due to the delay in reapplying the soft heel boots. No injuries or complications were noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A review of all current physician orders was conducted to ensure compliance with pressure-relief interventions. No other residents were affected by the same deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur; On 4/16/25 a 4/17/25 the DON or designee provided an in-service to Licensed Staff on the importance of timely implementation of physician orders, specifically for pressure-relieving devices. A new protocol was established requiring a second nurse to verify and document that pressure-relief devices are applied within 2 hours of the physician order. The DON or designee will audit new physician orders daily to ensure implementation within the required timeframe. How does the facility plan to monitor its performance to make sure that solutions are sustained? The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The POC is integrated into the quality assurance system; and. The DON or designee will conduct weekly audits of 3-5 random residents with physician orders for assistive or pressure-relieving devices for 4 weeks, then monthly for 2 months. Findings will be reported to the QAPI committee monthly. The committee will evaluate the effectiveness of corrective actions and adjust as necessary. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. COMPLETION DATE: 4/25/25
Improper Sharps Disposal and Infection Control Breach
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when staff did not dispose of used disposable razors appropriately and allowed a sharps container to become overfilled in the resident shower room at nursing station seven. During observations, multiple uncovered disposable razors were found placed on top of an overfilled sharps container, and the shower room door was left open, allowing resident access. Both a licensed nurse and a CNA confirmed the sharps container was full, the razors were not properly discarded, and the room was accessible to residents, which was acknowledged as a safety concern for both staff and residents. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the sharps container should have been replaced when full and that staff should not place used, uncovered razors on top. The facility's policy required sharps containers to be sealed and replaced when 75% to 80% full, but this was not followed. The improper disposal of contaminated razors and failure to secure the shower room created a risk of exposure to sharps and contamination, as confirmed by staff interviews and policy review.
Failure to Follow Physician's Order for Fluid Restriction
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one of three sampled residents. Specifically, the facility did not follow a physician's order for fluid restriction for a resident, as identified through observation, interview, and record review. This lapse resulted in the resident not receiving the prescribed limitation on daily fluid intake as ordered by the physician. The deficiency was identified based on direct evidence that the resident's care did not align with the physician's instructions regarding fluid restriction, which is a diet limiting the amount of daily fluid consumption.
Failure to Provide Adequate Supervision to Prevent Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one of two sampled residents. This deficiency was identified through observation, interview, and record review. The report specifically notes that the facility did not ensure sufficient supervision for Resident 2, which resulted in a failure to prevent the resident from eloping.
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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 Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Pointe Post-acute | 0 mi | ★★★★★ | 35 | 0 |
| Mountain Manor Senior Residence | 0.1 mi | ★★★★★ | 2 | 0 |
| Whitney Oaks Care Center | 1.7 mi | ★★★★★ | 6 | 0 |
| American River Center | 1.8 mi | ★★★★★ | 12 | 0 |
| Casa Coloma Health Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
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