Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accel At Longmont Health And Rehab, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
Staff failed to follow infection prevention protocols, including not changing gloves or performing hand hygiene between catheter care and incontinence care for a resident with wounds and an indwelling device. A shared shower chair was not cleaned after use and was visibly soiled before being used again. Additionally, the facility's main water heater was broken, resulting in laundry being washed at insufficient temperatures and in areas lacking proper infection control measures, with no physical separation from resident spaces.
A resident with chronic respiratory conditions and moderate cognitive impairment was allowed to keep and self-administer an albuterol inhaler without a documented assessment or physician's order authorizing self-administration. Staff interviews confirmed that required assessments and documentation were missing from the medical record, and the care plan did not reflect the resident's ability to self-administer medication.
Surveyors found that two linen storage closets lacked essential clean linens, such as fitted sheets and pillowcases. Two residents reported frequent shortages, and staff—including a CNA and the laundry aide—confirmed that the facility did not maintain an adequate linen supply, requiring them to rotate and prioritize available items to meet resident needs. Facility leadership acknowledged the ongoing linen shortage and its impact on maintaining a safe and comfortable environment.
A resident with a history of behavioral disturbances physically grabbed another resident's arm after a dispute over a sugar packet in the dining room, resulting in visible injuries. Despite a care plan requiring one-to-one supervision, the resident was left unsupervised for several minutes, allowing the incident to occur. Staff and family interviews confirmed lapses in supervision and documentation showed the injuries sustained.
Two residents requiring BiPAP and CPAP therapy did not receive appropriate respiratory care due to lack of proper device setup, missing or incomplete physician's orders, and insufficient staff training. One resident was unable to use his BiPAP machine for an extended period because settings were not adjusted by a physician, and his care plan lacked necessary details. Another resident's CPAP orders were not documented until the time of survey, and staff were not adequately trained on respiratory device care.
A facility failed to manage pain effectively for two residents with chronic pain. One resident’s scheduled opioid pain medication was repeatedly delayed or missed because it was out of stock, and preferred nonpharmacologic interventions were not documented in the care plan. Another resident with quadriplegia was not offered a missed scheduled gabapentin dose and waited over an hour and a half after requesting PRN pain meds while moaning and calling out for help. Staff interviews and MAR review confirmed delayed and omitted pain treatment.
Dialysis Care and Communication Failures: The facility failed to consistently monitor and document dialysis access sites, complete dialysis communication forms, and address dialysis center orders in a timely manner for two residents receiving HD. One resident with ESRD, dementia, and a chest CVC had repeated documentation gaps, untreated skin excoriation, and was later hospitalized with a line infection, bacteremia, and chest wall cellulitis after the dialysis center noted blood, swelling, and pain at the access site. The other resident’s dialysis forms were also frequently incomplete, with missing pre- and post-dialysis details and signatures.
Failure to Invite Residents to Initial Care Conferences: The facility did not ensure that three residents and/or their representatives were invited to participate in initial care conferences for person-centered care planning. Two cognitively intact residents reported they had been in the facility for weeks without a care conference, and a representative for a third resident with Parkinson's disease, dementia, and depression said no initial conference had occurred. The EMR lacked documentation of invitations or completed initial care conferences, and staff acknowledged the conferences had not been held for the residents reviewed.
Failure to Honor Resident Shower Preferences: Multiple residents with varying levels of cognitive and physical impairment did not receive showers according to their preferred days or frequency. Records showed missed or inconsistent bathing opportunities, incomplete documentation, and several instances where residents reported being told showers were unavailable or not offered as preferred. Staff interviews confirmed that shower aides were responsible for bathing and that residents should be able to receive showers on the days they choose.
Failure to Provide Meaningful Activities and Complete Initial Activity Assessment: Multiple residents with dementia, stroke-related deficits, Parkinson’s disease, COPD, and other conditions were not provided meaningful activity programming aligned with their preferences and needs. Interviews and record review showed the facility lacked a regular AD, residents were often left sitting without music, TV, or individualized activities, some residents were not invited or assisted to activities, and one resident did not have an initial activity assessment documented.
Activities Program Not Directed by a Qualified Professional: The facility did not have a qualified AD directing the activities program, and the staff list and contact list did not identify one. The CNO confirmed the AD had resigned and that the facility had no current AD, while surveyors observed no current activity calendars in common areas or a resident room. Staff and a resident representative reported the activities person had not been seen for weeks, and one resident room still displayed an old calendar.
Food Served at Improper Temperatures: Residents reported meals were often cold, bland, late, or served with temperatures reversed for hot and cold items. Surveyors observed a room tray without hot plates, with noodles and ham cool to the palate and cold items such as salad, pudding, and dressing served at warm temperatures. Staff acknowledged tray delivery and food temperature control problems, including limited CNA tray passing and lack of equipment to keep foods at proper temperatures.
A resident with COPD, respiratory failure, and dementia had an order for a minced and moist diet with thin liquids, but staff served a peanut butter and jelly sandwich with the crust cut off and cut in half. Staff interviews confirmed that bread was not allowed on this diet, and the record did not show documentation that the resident could safely eat sandwiches.
Failure to obtain informed consent for psychotropic meds: two residents with cognitive impairment and psychiatric diagnoses received antipsychotic, antidepressant, and antianxiety medications before verbal consent was documented. Records showed the meds were administered prior to consent, even though facility policy required residents or representatives to be informed of the risks, benefits, alternatives, and any black box warnings before psychotropic use.
A resident with CHF, COPD, AFib, and intact cognition choked on mucus while taking meds and became cyanotic, requiring staff to give back blows, abdominal thrusts, oxygen, and an albuterol neb. The RN notified the MD and attempted to call the resident's representative, but there was no documentation that the representative was actually informed, and the representative later said she learned about the event from the resident the next day. Facility leadership agreed the choking episode was a change in condition that should have been reported.
Failure to Document and Resolve a Resident Grievance: The facility did not maintain a complete grievance process for a cognitively intact resident who reported an inappropriate comment by a CNA during care. Although the resident said she had filed multiple grievances and had not received resolution for most of them, the facility could not produce a grievance form or documentation showing investigation or follow-up for this concern. Other grievance forms in the record were also incomplete, with the satisfaction section left blank.
A resident with schizoaffective disorder, stroke, CKD, MDD, and anxiety had a PASRR level II determination requiring specialized services, including case management, psychiatric case consultation, neurocognitive evaluation, and individual therapy. The EMR did not show documentation that these services were provided, and the SSD and CNO could not confirm implementation of the PASRR recommendations.
Failure to Provide Timely Toileting and Incontinence Care: Two residents who were dependent on staff for ADLs were observed going without toileting or incontinence care for two and a half hours. One resident with COPD, dementia, and moderate cognitive impairment was left wet in her recliner after staff brought and removed her breakfast tray without offering toileting. Another resident with bipolar disorder and blindness in both eyes remained in bed with breakfast in front of her while staff did not provide toileting assistance or incontinence care, and she reported long waits for help and said she was wet.
A resident with a toe wound did not receive wound care consistently as ordered, and dressings were observed without dates or initials while the MAR/TAR lacked documentation for several ordered treatments. In a separate event, an RN documented a resident’s morning meds as given before actually administering them, even though the resident said she had not yet received them and was anxious without her meds.
Failure to Provide Pressure Injury Prevention for Left Ankle: A resident with DM, polyneuropathy, impaired mobility, and contractures developed a non-blanchable purple area on the left outer ankle while lying in bed without a pressure-reducing mattress or ankle offloading device. The resident said staff had mentioned a boot, but it had not been provided, and observations showed the ankle resting directly on the mattress for an extended period. Records showed prior ankle skin injury, a care plan listing an air mattress, and later documentation of discoloration, but the needed pressure-relieving interventions were not in place when the area was observed.
Unsafe Hoyer lift transfers led to resident injuries and improper lift use. One resident with quadriplegia reported scratches and a buttock bruise during transfers, including an episode where the lift began to tip during a move to a shower chair. Another resident with aphasia, muscle weakness, and contractures was observed being transferred with the lift brakes applied and the base legs closed because the lift did not fit well under the bed; the lift legs also caught on a cable under the bed during the transfer.
Failure to Set Up and Care Plan BiPAP Use: A resident with quadriplegia and obstructive sleep apnea reported that his BiPAP machine had not been used since admission because it was never set up and he had not received respiratory support. The chart included an order for RT to obtain BiPAP settings from a sleep clinic, but there was no documentation that this was done, and the care plan did not include the BiPAP. Staff interviews showed uncertainty about the device and no awareness that the resident had a BiPAP in his room.
Failure to provide trauma-informed care for a resident with PTSD and a history of childhood abuse. The resident reported that food, the dining area, and his room reminded him of past trauma, but the chart lacked a trauma behavior assessment, did not identify triggers, and did not include resident-specific interventions tied to his abuse history. Staff said they did not know the resident had trauma or what approaches helped him, while the care plan contained only general mood-related interventions.
Two residents with psychiatric diagnoses had incomplete psychotropic monitoring and refusal documentation. One resident with dementia, anxiety, and depression refused Risperdal, Zoloft, and lorazepam multiple times, but the chart did not show physician notification, attempted interventions, or sleep monitoring, and the psychotropic review lacked target behaviors and non-pharmacologic measures. Another resident with schizoaffective disorder, depression, and anxiety refused sertraline and buspirone, but the record did not show physician notification or interventions attempted, and the psychotropic review did not identify non-pharmacologic interventions or responses.
Improper Storage and Labeling of Medications and Wound Supplies: A resident’s bathroom counter contained topical meds, including a jar labeled for another resident, plus ointments and cream that were being used on the resident despite no self-administration assessment and no order for one of the products. Another resident’s bedside table had an unlocked drawer labeled wound supplies containing wound cleanser, saline irrigation, barrier spray, and medicated wound treatments, even though the resident did not know what they were for and had no self-administration assessment. Staff, including an RN and the DON, stated these items should not have been left in the residents’ rooms.
A resident with a suprapubic catheter had missing EMR documentation for catheter care and urine output across multiple shifts. The resident, who was cognitively intact and dependent on staff for several ADLs, reported that the catheter bag was not emptied consistently and sometimes became so full that urine backed up into the tubing and caused discomfort. Staff interviews showed inconsistent understanding of who was responsible for catheter care and when output should be recorded, while the regional director stated the tasks were expected every shift.
Staff failed to perform hand hygiene while serving meals in the dining room. A CNA brought lunch trays from the kitchen to residents and returned for additional plates without sanitizing her hands, even though hand sanitizer was available nearby. The CNA was also observed touching her hair multiple times and continued serving residents without washing or sanitizing her hands. The RDCS stated staff should perform hand hygiene when serving food and that the CNA should have washed her hands after touching her hair before handling residents' meals.
A facility failed to ensure residents, family members, and legal representatives had access to the most recent survey findings, complaint investigations, and plans of correction. Surveyors could not locate the survey results binder in the main lobby, and later found it printed and placed on a desk. Four residents said they did not know what the survey binder was or where it was located, and the RVP of operations stated it should have been available during the survey.
Surveyors found that confidential resident information was left unsecured in open bags at the nurse's station for several weeks due to the lack of shred box containers. Additionally, a medication cart was left unattended in a hallway with its computer screen displaying a resident's medication administration record, visible to anyone passing by. Staff confirmed these lapses in maintaining the privacy and confidentiality of residents' medical records.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
Two residents in the facility developed severe pressure injuries due to the facility's failure to provide timely and necessary treatment. One resident, with diabetes and kidney disease, developed deep tissue injuries and sepsis after the facility did not implement care plan interventions or notify the physician of heel discoloration. Another resident, with a history of vascular disease, developed deep tissue injuries on his foot and heel, leading to cellulitis and sepsis, due to the facility's failure to off-load heels and document skin condition changes. The facility's systemic failure created an immediate jeopardy situation.
The facility failed to employ a qualified infection control preventionist (ICP) with specialized training, affecting all residents. The acting ICP, also the wound care nurse, had not completed her certification, and the regional nurse consultant was unaware of this. This deficiency was identified during a survey.
The facility did not have a full-time RN designated as the Director of Nursing (DON) after the previous DON resigned. Staff interviews revealed that there was no charge nurse on duty, and nursing staff deferred questions to LPNs who were not in management positions. The nursing home administrator confirmed the vacancy and stated that corporate support was assisting until the position could be filled.
The facility reported a medication error rate of 16.67%, exceeding the acceptable threshold. Errors included incorrect application of lidocaine patches, failure to verify vital signs before administering metoprolol, and late administration of Parkinson's medication. Staff interviews confirmed the importance of adhering to prescribed medication guidelines.
The facility failed to follow proper infection prevention practices during medication administration and patient care. An LPN did not perform hand hygiene before or after administering medications and failed to clean a pulse oximeter before and after use. Another LPN prepared medications without hand hygiene, and a staff member disposed of a pill from the floor without performing hand hygiene. The wound care nurse confirmed the importance of hand hygiene and equipment cleaning to prevent infection spread.
The facility failed to properly store and label medications, leaving multi-dose medications unlabeled and a resident's inhaler improperly stored. Medications were left unsecured when an LPN left a cart unattended with keys in the lock. Improper disposal of medications was noted, with unused drugs discarded in trash cans instead of using drugbuster bottles. The medication storage room was cluttered and unclean, with expired medications and a dirty refrigerator. Staff interviews revealed unclear responsibilities for cleaning and medication disposal.
The facility's QAPI program failed to address compliance concerns, leading to repeat deficiencies in medication administration and infection control. A resident developed a wound infection with sepsis due to inadequate pressure injury assessment and treatment. The new NHA was unaware of these issues and could not locate previous documentation, indicating a lack of oversight and continuity.
A resident's electric tricycle was stolen from a locked area in the facility, and the facility failed to replace or reimburse the resident. The tricycle was not listed on the resident's inventory sheet, and the facility lacked a policy for personal property responsibility. The resident filed a grievance, but the facility's corporate management did not authorize reimbursement for the tricycle, valued at $4,000.
A resident with osteomyelitis required IV antibiotics through a PICC line, but the nursing staff removed the line prematurely without a physician's order, leading to missed doses. The error was not reported promptly, delaying the line's replacement. Additionally, the facility failed to change the PICC line dressing as ordered, risking infection. Staff interviews revealed a lack of clarity on PICC line care and the importance of timely reporting and replacement.
The facility did not conduct required annual performance reviews for two CNAs, as identified through record reviews and staff interviews. The HR director and regional nurse consultant confirmed the oversight, acknowledging that the reviews were not completed within the mandated timeframe.
The facility failed to honor the preferences of two residents regarding their care and scheduling. One resident was not assisted in scheduling a wound care appointment at an in-network clinic, leading to financial strain, while another resident's shower preferences were ignored, with no documentation of their requests. Staff interviews revealed a lack of communication and adherence to the facility's policy on residents' rights.
A resident with severe cognitive impairments and multiple diagnoses frequently refused medications and treatments, but the facility failed to update the care plan to address these refusals. Despite known refusals of medications like Aspercreme and Haloperidol, and refusal to be moved to a chair for meals, the care plan lacked person-centered interventions. Staff interviews confirmed awareness of refusals but highlighted a deficiency in care management due to the lack of updated strategies in the care plan.
A resident with multiple diagnoses, including severe cognitive impairments, did not receive showers as per her preference and care plan. Despite her grievance, there was no documentation of showers being offered since her admission. Staff interviews revealed that showers were scheduled by room number, not resident preference, and staff were unaware of the resident's shower status. The regional nurse consultant acknowledged the grievance and the need for timely showers.
The facility failed to ensure two CNAs received required training in abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics, and resident rights. Additionally, there was no documentation of the CNAs completing at least 12 hours of annual in-service training. Interviews with the HRD and RNC confirmed the lack of training completion and documentation.
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Infection Control and Laundry Deficiencies Compromise Resident Safety
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program on two of three units, resulting in lapses in hand hygiene, improper use of personal protective equipment (PPE), and inadequate cleaning of shared equipment. Specifically, a certified nurse aide (CNA) did not change gloves or perform hand hygiene after emptying a resident's indwelling urinary catheter and before providing incontinence care. The same CNA also failed to clean a shared shower chair after use, leaving it visibly soiled with stool before it was placed outside the resident's room for use. The resident involved had an indwelling urinary catheter and wounds, and was on enhanced barrier precautions (EBP), as indicated by signage on the door. Staff interviews confirmed that these actions were contrary to facility policy and infection control expectations. Additionally, the facility's main water heater was broken, resulting in laundry being washed at temperatures significantly below the recommended threshold for effective sanitation. The laundry aide reported that the water temperature during wash cycles was only sixty-eight degrees Fahrenheit, well below the CDC-recommended 160 degrees Fahrenheit for hot-water washing. As a result, the facility resorted to laundering some resident clothing and linens in the rehabilitation area, which was not equipped with industrial washers and dryers and lacked proper infection control or isolation measures. There was also no physical barrier separating the laundry area from resident spaces, further compromising infection prevention. Interviews with staff, including the infection preventionist, director of nursing, nursing home administrator, and laundry aide, confirmed awareness of the deficiencies. Staff acknowledged that the facility's infection control and laundry practices did not meet regulatory standards, and that the lack of functioning equipment and proper procedures contributed to the failure to provide a safe, sanitary, and comfortable environment for residents.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine the clinical appropriateness of self-administration of medications for a resident with multiple chronic conditions, including chronic respiratory failure, COPD, and moderate cognitive impairment. The resident was observed with an albuterol inhaler at his bedside and reported that staff allowed him to keep and use the inhaler as needed. However, there was no documentation in the electronic medical record of a self-administration assessment or a physician's order permitting the resident to self-administer the inhaler or to keep it at the bedside. The resident's care plan did not reflect the ability to self-administer medication, and the physician's order only specified the medication and dosage, not self-administration privileges. Interviews with staff, including an LPN, RN, and the DON, confirmed that an assessment should have been completed and documented before allowing the resident to self-administer medication. Staff were unable to locate any such assessment in the resident's record, and the DON acknowledged uncertainty about whether the assessment had been completed. The lack of assessment, physician's order, and care plan documentation led to the deficiency in ensuring safe and clinically appropriate self-administration of medication for the resident.
Insufficient Clean Linen Supply for Resident Care
Penalty
Summary
The facility failed to provide clean linens in sufficient quantities for residents, as evidenced by observations of two out of three linen storage closets lacking essential items. Specifically, one closet contained only flat sheets, comforter sheets, pillowcases, and blankets, but no fitted sheets, while another closet had flat sheets, comforter sheets, and blankets, but no pillowcases or fitted sheets. These shortages were directly observed during facility rounds. Interviews with residents confirmed that clean linens were often unavailable or insufficient, with one resident describing the issue as ongoing. Staff interviews further corroborated the deficiency, with a CNA and the laundry aide both stating that the facility did not maintain an adequate supply of linens, requiring staff to rotate and prioritize available items. The maintenance director and the NHA also acknowledged awareness of the linen shortage, noting that it affected the facility's ability to meet regulatory requirements for a safe, sanitary, and comfortable environment.
Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident during a meal service. The incident involved one resident taking a sugar packet from another resident's dining table, which led to the second resident approaching and physically grabbing the first resident's right arm. This altercation was witnessed by the dietary manager, who reported the event to nursing staff. The affected resident was found to have a pinch mark, bruising, and redness on her right arm, as well as a redness mark at the base of her posterior head. The incident and resulting injuries were documented in the resident's medical record, including photographs and a detailed skin assessment. The resident who initiated the physical contact had a history of behavioral disturbances, including yelling, cursing, and throwing objects when served an inappropriate diet texture. However, prior assessments did not document physical or verbal behaviors directed at others. The resident was cognitively impaired and required behavioral interventions as outlined in her care plan. Despite these interventions, the resident was able to approach and physically harm another resident in the dining room. Interviews with staff and the resident's family revealed that the resident responsible for the altercation had previously entered the dining room unattended, even after being placed on one-to-one supervision following the incident. Observations confirmed that the resident was left unsupervised in the dining area for several minutes before staff intervened. The failure to provide continuous supervision as required contributed to the occurrence of the abuse and the resulting injury to the other resident.
Failure to Provide Appropriate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required the use of BiPAP and CPAP machines. One resident, who had diagnoses including quadriplegia and sleep apnea, reported not using his BiPAP machine for approximately two months due to incorrect settings and lack of physician adjustment. He stated that he had only seen a respiratory therapist once during his stay, and the settings were not corrected at that time. The resident also indicated that staff asked him for the correct settings, which caused frustration as he expected the facility to have this information. The care plan for this resident did not include specific interventions or settings for the BiPAP machine, and there was no documentation of a follow-up pulmonology appointment as recommended by the physician. Another resident, with chronic respiratory failure and sleep apnea, reported independently managing his CPAP machine and receiving minimal assistance from staff. The care plan referenced the use of CPAP and oxygen, but there were no detailed physician's orders for the CPAP machine in the electronic medical record until the time of the survey. This lack of documented orders meant that staff did not have clear guidance on the application and management of the resident's CPAP therapy prior to the survey. Staff interviews revealed that certified nurse aides had not received training on the care of CPAP or BiPAP machines and were unfamiliar with facility policies regarding these devices. The infection preventionist confirmed that staff education on respiratory devices had not yet been provided and emphasized the need for physician's orders with specific settings in the electronic medical record. The director of nursing acknowledged that nurses were responsible for following up on missed pulmonology appointments and ensuring that physician's orders for respiratory devices were in place, but these actions had not occurred prior to the survey.
Failure to Provide Timely and Ordered Pain Medications
Penalty
Summary
The facility failed to provide effective pain management for two residents with chronic pain. Resident #15, who had diagnoses including acute and chronic respiratory failure, schizoaffective disorder, bipolar disorder, muscle weakness, frequent pain, and limited range of motion, was prescribed Belbuca 75 mcg twice daily for chronic pain. The resident reported that pain medication was often given late, that pain affected sleep and mobility, and that she had not slept in two days. She also stated that ROM exercises and massages had helped her pain in the past, but those interventions were not documented in her care plan as preferred non-pharmacological measures. Record review showed Resident #15’s Belbuca doses were repeatedly delayed or missed. The resident received the 6:00 p.m. dose late on 9/2/25 and 9/5/25, and then missed scheduled doses on 9/9/25, 9/10/25, and the morning of 9/11/25 because the medication was out of stock or unavailable. Nursing notes documented the medication was pending delivery from the pharmacy and later unavailable, and staff interviews confirmed the medication should have been ordered before it ran out. The resident was observed being transported by EMS to the hospital for severe leg pain, and the hospital record documented left leg pain and chest pain. Resident #42, who had quadriplegia, neurogenic bowel, neuromuscular dysfunction of the bladder, and narcissistic personality disorder, had chronic pain related to quadriplegia, a left humerus fracture, and decreased mobility. His orders included scheduled gabapentin and PRN ibuprofen and methocarbamol. On 9/10/25, RN #2 documented that a scheduled gabapentin dose was not given because the resident was out of the building, but the resident was not offered the missed dose later despite reporting pain and yelling in the common area. On 9/11/25, the resident rated his pain as 8 out of 10 and requested PRN ibuprofen and methocarbamol, but after the LPN said she would return with the medication, the resident was heard moaning and calling out for help for more than an hour and a half without staff entering the room or providing the medication during the observation period.
Dialysis Care and Communication Failures
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for two residents who required hemodialysis. Resident #8 had diagnoses including end-stage renal disease, dependence on renal dialysis, diabetes mellitus, vascular dementia, and cellulitis of the chest wall. The resident’s dialysis access was a central venous catheter in the chest. A 6/3/25 dialysis communication form documented that the catheter dressing was bloody, the site had bloody trauma, and the resident appeared to have pulled on the catheter line; the dialysis center asked the facility to contact the clinic, but there was no documentation that the facility did so. Weekly skin assessments also failed to consistently identify the dialysis access site or the resident’s skin problems, including dry skin, scratch marks, and later scattered linear scabs. Resident #8’s record showed repeated failures to monitor and document the condition of the dialysis access site and to address dialysis-related communication in a timely manner. The resident was noted by a physician to have widespread excoriation from scratching, with itching and skin breakdown involving the arms, legs, and chest. The record did not show administration of ordered medications such as Atarax or doxepin, and the weekly skin assessments did not consistently reflect the extent of the skin issues. On 6/28/25, the resident was sent from the dialysis center to the hospital because there was blood around the CVC site, swelling, and pain; the resident was hospitalized for five days with recurrent hemodialysis line infection, gram-positive cocci bacteremia, and chest wall cellulitis. The facility also did not timely address dialysis center orders for Resident #8, including scheduling arteriovenous fistula placement and starting cephalexin after the dialysis center noted a yellowish CVC site. Dialysis communication forms for Resident #8 and Resident #7 were inconsistently and incompletely completed, with many pre-dialysis and post-dialysis sections left blank or missing required information such as dialysis time, catheter status, meals and snacks, medications, vital signs, signatures, and other details. Resident #7 had end-stage renal disease and received dialysis on Tuesdays, Thursdays, and Saturdays, but his dialysis communication forms also contained numerous omissions, including blank post-dialysis sections and missing pre-dialysis documentation. The record and staff interviews showed that the facility’s dialysis-related documentation and communication processes were not consistently carried out for either resident.
Failure to Invite Residents to Initial Care Conferences
Penalty
Summary
The facility failed to ensure that residents and their representatives were invited to participate in the development and implementation of their person-centered plans of care for three residents. The facility policy stated that residents would be informed of and encouraged to participate in care planning, including initial decisions about treatment, and that care plan conferences would be discussed with the resident and/or representative. However, for the three residents reviewed, the record did not show documentation that they were invited to initial care conferences, and staff acknowledged that the conferences had not yet occurred for two of the residents and were still being scheduled for the third. Resident #13 was admitted with chronic kidney disease stage IV, chronic pain syndrome, obesity, major depressive disorder, and chronic diastolic congestive heart failure. Her MDS showed she was cognitively intact with a BIMS of 15 out of 15 and required partial/moderate assistance with several activities of daily living. She told surveyors she had been in the facility for about three weeks and had not had an initial care conference, though she would attend if invited. She also said she would have liked a care conference within the first few days of admission to learn what care she would receive and about ancillary services such as dental and hearing. Resident #18 was admitted with acute ischemic heart disease, sequelae of unspecified cerebrovascular disease, depression, anxiety, and muscle weakness. His MDS showed he was cognitively intact with a BIMS of 15 out of 15 and needed partial/moderate assistance with dressing and footwear. He reported that he had not had an initial care conference after about three weeks in the facility and would attend if invited. Resident #46 was admitted with Parkinson's disease without dyskinesia, dementia, and depression, and had mild cognitive impairment with a BIMS of 12 out of 15. His representative stated he had not yet had an initial care conference, and the EMR contained no documentation of one; staff said his care conference was scheduled for the week after the survey.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor resident choices for shower days and/or the preferred number of showers per week for five residents. The cited policy stated that each resident has the right to choose schedules, including bathing times, consistent with their interests, assessments, and plans of care. Surveyors reviewed records, observed shower documentation, and interviewed residents and staff, and found that bathing schedules were not consistently carried out as preferred or documented as refused or otherwise unavailable. One resident with moderate vascular dementia and dependence on staff for bathing and other ADLs had preferred evening showers on specific days, but the record showed showers were often provided in the daytime and there was no documentation for part of the review period. Another cognitively intact resident with diabetes, neuropathy, impaired mobility, and hand contractures said he was told which days were assigned for showers and wanted at least two showers weekly, but the record showed he received showers on only some scheduled days and there was no documentation for part of the period reviewed. A third resident with quadriplegia, neurogenic bowel and bladder dysfunction, and intact cognition said he preferred showers three times weekly but often received only one or two; the record showed he received showers on all but one preferred day, but only met his preferred frequency during one week, and there was no documentation for part of the review period. A fourth resident with hemiplegia, anxiety, and other diagnoses said she had not received a shower in a while and preferred showers twice weekly. Her care plan and shower documentation showed she received only one shower out of 11 opportunities, and refusals were documented on several dates without documentation that staff followed up to offer another shower or determine why she was refusing. A fifth resident with Parkinson’s disease, schizoaffective disorder, anxiety, weakness, and pain said she had gone over a week without a shower and was told there were no shower aides. Her hair was described as greasy in appearance, and the record showed she received bathing on only part of the bathing opportunities in August and September, with no documentation explaining the missed showers. Staff interviews indicated shower aides were responsible for bathing, that documentation should reflect completion or refusal, and that residents should be able to get baths or showers on any day they chose.
Failure to Provide Meaningful Activities and Complete Initial Activity Assessment
Penalty
Summary
The facility failed to ensure meaningful activities designed to support residents’ physical, mental, and psychosocial well-being were provided for six residents, and it also failed to complete an initial activity assessment for one resident. The facility policy stated that residents should receive an ongoing program of group, individual, and independent activities based on comprehensive assessment, care plan, and preferences, with staff assisting residents to and from activities when necessary. Interviews and record review showed that the facility had been without a regular activities director for an extended period, and a temporary activities director was only brought in during the survey period. Resident #1 had diagnoses including moderate vascular dementia with mood disturbance, heart disease, muscle wasting, and lack of coordination, and was dependent on staff for multiple activities of daily living and used a wheelchair. The resident’s representative said the facility had not had an activities director for about six months, that a CNA had briefly planned activities without training, and that after those staff left the facility only occasionally offered bingo, which the resident could not participate in because of cognitive impairment. The care plan listed preferences such as watching sports, television, visiting with family, birdwatching, sitting outside, and tinkering with tools, but the report did not show meaningful activities being provided to match those preferences. Resident #32 had hemiplegia and hemiparesis following a cerebral infarction, depression, and narcolepsy, with moderate cognitive impairment and substantial assistance needs for hygiene, toileting, bathing, transfers, and wheelchair mobility. Her representative said she tended to isolate herself, did not know activities were available unless cued, and had never attended activities to the representative’s knowledge. The care plan noted little to no activity involvement due to physical limitation and included a physician order for CNA assistance with getting ready for church service, but documentation was missing for some dates. Resident #42 was cognitively intact but had quadriplegia, neurogenic bowel and bladder dysfunction, and required substantial assistance with eating, hygiene, bathing, toileting, dressing, and transfers. He reported that since admission he had not attended any activities, that by the time staff were available to transfer him the activity was usually over, and that no staff provided individual activities in his room. His care plan did not include a specific activity focus, although it referenced meaningful activities without identifying them. Resident #29 had COPD, dementia, and acute and chronic respiratory failure with hypoxia, with moderate cognitive impairment and partial to moderate assistance needs for toileting, showering, dressing, and hygiene. During observation, the resident sat in a recliner for more than two hours with no music, television, or meaningful activity available, and staff did not offer activities when they passed by the room. The resident’s representative said the resident was routinely found sitting in the recliner without activities unless the representative helped provide them. Resident #38 had Parkinson’s disease, schizoaffective disorder, anxiety, muscle weakness, and right hip pain, was cognitively intact, and required assistance with showers, toileting, hygiene, and eating. She stated that the activity department had been nonexistent since the activity staff quit, that there had been no activities in the facility, and that residents were mostly limited to eating meals in the dining room. Her care plan did not include an activity focus or interventions, and the record did not show an activity participation log. Resident #18 had acute ischemic heart disease, sequelae of unspecified cerebrovascular disease, depression, anxiety, and muscle weakness, and was cognitively intact with impairment on one side and functional limitation in range of motion. He said he had not been invited to activities since admission and had not had an activity assessment completed. The record showed a care plan addressing emotional, intellectual, physical, and social needs related to cognitive deficits, but it did not contain a resident-specific activity care plan or an initial activity assessment. Staff interviews confirmed that an initial activity assessment should be completed within 48 hours of admission and that residents should be invited to activities, but the resident’s record did not show that this occurred.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. The report states that the facility did not employ a qualified activities director to provide a program of activities for residents who required activity and recreational support. The facility policy required the activities director to meet specified qualifications, including certification, education, experience, or approved training, and to direct the development, implementation, supervision, and ongoing evaluation of the activities program. During the survey, the key personnel contact list and the staff list did not identify an activities director. The chief nursing officer confirmed there was currently no activities director for the facility and said the qualified activities director had resigned sometime in August 2025. She also stated the facility had tried to replace the position, but the person offered the job accepted another position elsewhere. She said an activities director from another facility was working in the building on 9/10/25 and 9/11/25 to help provide activities. Observations and interviews showed a lack of consistent activities coverage. Surveyors observed no calendars in the hallways, main living area, dining area, or in a resident room showing activities for the day, week, or month of September 2025. In one resident room, an August 2025 activities calendar was still posted, and later no current or prior month calendar was visible. A resident representative said she visited Resident #8 almost every day and last saw the activities director around 8/15/25. Staff members reported they had not seen activities being conducted in the facility since the last time they saw the activities person, until 9/10/25, and said activities were important because they helped residents stay engaged and prevented boredom.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature. The facility policy stated that foods and drinks should be prepared to preserve and enhance nutrition and hydration status, and that hot foods should be served hot and cold foods cold. During a group interview, four interviewable residents said meals were served cold, and one resident said it did not matter whether meals were eaten in the room or dining room. One resident reported the food was bland and usually inedible because it was cold, while another said warm foods were delivered cold and cold foods were usually warm. Additional resident interviews reflected similar concerns, with residents stating the food was always served cold unless they ate early when the kitchen opened, that the food tasted horrible, and that meals were served cold and late all the time. During a lunch observation, a regular diet test tray delivered to room trays did not have hot plates to keep food warm. Surveyors measured the noodles at 112 degrees F, the ham at 114 degrees F, the ranch dressing at 55 degrees F, the pudding at 72 degrees F, and the salad at 66.4 degrees F; surveyors noted the noodles and ham were cool to the palate, while the dressing, pudding, and salad were warm to the palate. Staff interviews indicated room trays were often passed by only one CNA per hall, residents frequently complained of cold food, and the nutrition services manager stated the facility did not have equipment to keep cold items cold and was behind in preparing cold foods to maintain proper temperature.
Improper Food Texture Served to a Resident on a Minced and Moist Diet
Penalty
Summary
The facility failed to ensure that Resident #29 received food prepared in a form designed to meet the resident’s needs and physician orders. Resident #29, who had diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and dementia, had a physician order for a minced and moist texture diet with thin liquids. The resident’s record also showed dentures and a care plan directing staff to serve the diet as ordered and consult the dietitian if chewing or swallowing problems were identified. During a continuous observation, Resident #29 was served a peanut butter and jelly sandwich with the crust cut off and the sandwich cut diagonally in half, and the resident ate it. The resident’s representative stated the resident was at risk of choking. Staff interviews confirmed that a minced and moist diet meant food should be chopped into tiny pieces and moistened, and that residents on this diet could not have bread. The social service director, CNA staff, and regional director of clinical services all stated Resident #29 should not have received a sandwich, and the EMR did not show documentation that the resident could safely consume sandwiches.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to two residents. The facility policy stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, alternatives, and any black box warnings, and that this information must be documented before treatment begins or is increased. Resident #47 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, vascular dementia, anxiety disorder, and depression. The resident’s MDS showed cognitive impairment with a BIMS score of 8, dependence on staff for several activities of daily living, and receipt of an antipsychotic and an antidepressant. The record showed orders for Risperdal, Zoloft, and lorazepam for dementia with behaviors and anxiety. Consent forms later showed verbal consent was obtained on 9/10/25, but the MARs showed the medications were administered before that consent was documented. Resident #3 was admitted and readmitted with diagnoses including schizoaffective disorder, atherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and anxiety disorder. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4, dependence on staff for several ADLs, and receipt of antianxiety and antidepressant medications. The record showed orders for sertraline, trazodone, and buspirone, with diagnosis changes documented for sertraline and trazodone. Consent forms showed verbal consent was obtained on 8/26/25, but the MARs showed the medications were administered before consent was documented. Staff interviews confirmed that consent was required before psychotropic medications were administered, and the chief nursing officer stated that neither resident had provided consent before receiving the medications.
Failure to Notify Resident Representative After Choking Episode
Penalty
Summary
The facility failed to immediately notify the resident's representative when a resident had a significant change in condition involving a choking episode that required staff to perform the Heimlich maneuver. The report states that the facility also failed to ensure notification when the resident experienced an accident with injury, and that this deficiency involved 1 of 17 residents reviewed out of a sample of 36. Resident #16 was admitted and readmitted with diagnoses including acute on chronic diastolic CHF, acute respiratory failure with hypoxia, COPD, paroxysmal atrial fibrillation, and morbid obesity. The resident's MDS showed intact cognition with a BIMS score of 14 out of 15 and no swallowing disorder. During the choking event, the resident was swallowing medications when she choked on mucus, began coughing and wheezing, became cyanotic, and was in respiratory distress. Staff increased oxygen, repositioned the resident, gave back blows, and the CNA performed abdominal thrusts while the RN obtained and administered an albuterol nebulizer treatment. The resident's oxygen saturation improved to baseline, and she reported stomach pain and redness from the Heimlich maneuver. The RN reported the event to the physician and attempted to call the resident's representative twice in the early morning hours, but neither call was answered. The choking event was discussed with the oncoming nurse, who was to inform the representative, but there was no documentation in the EMR showing that the representative was notified. During interview, the resident's representative stated she was not told about the choking episode or the Heimlich maneuver and learned of it from the resident the next day. The NHA and regional clinical staff reviewed the record and agreed the representative should have been notified, and they could not find documentation that notification occurred.
Failure to Document and Resolve a Resident Grievance
Penalty
Summary
The facility failed to maintain a system for documenting grievances and demonstrating prompt action for one resident’s grievance. The grievance policy stated that the grievance officer was responsible for overseeing the grievance process, tracking grievances to conclusion, leading investigations as needed, maintaining confidentiality, issuing written decisions, and coordinating with agencies as necessary. Surveyors found that the facility could not provide documentation showing that a grievance form was completed for Resident #37’s concern about a staff member’s inappropriate comment during care, or that the concern was followed up on. Resident #37 was admitted with diagnoses including Ehlers-Danlos syndrome, acute respiratory failure with hypoxia, encephalopathy, acute kidney failure, muscle weakness, and depression. Her MDS assessment showed she was cognitively intact with a BIMS score of 15 out of 15 and required substantial to maximal assistance with toileting, showers, and personal hygiene. During interview, she said she had filed several grievances since admission, that most had not been resolved, and that she was not notified of the resolution of her concern about a CNA’s comment. She said she felt uncomfortable with the staff member and requested that the staff member not be assigned to care for her anymore, but believed the concern was not investigated. Record review showed grievance documentation for other concerns, including delayed PRN medication and cold, inedible food, but the satisfaction portion of those forms was not completed. For the CNA comment concern, the facility had no grievance form, investigation record, or documented resolution. Staff interviews indicated the DON and SSD discussed the issue with the resident, and an LPN spoke with the CNA and asked that the CNA not be assigned to the resident, but the SSD did not complete any documentation in social services notes. The NHA stated he could not confirm that a grievance form had been completed and could not find grievance information regarding the incident.
Failure to Implement PASRR Level II Specialized Services
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR level II determination and evaluation report into the assessment, care planning, and transition of care for one resident. Resident #3 was admitted and later readmitted with diagnoses including schizoaffective disorder, cerebral infarction affecting the right dominant side, chronic kidney disease, major depressive disorder, and anxiety disorder. The 9/8/25 MDS showed the resident was cognitively impaired with a BIMS score of 4 out of 15, required partial assistance with eating, was dependent on staff for oral hygiene, toileting, and showering, and had verbal behavior symptoms directed toward others during the look-back period. Resident #3's PASRR level II report, dated 2/17/25, identified a PASRR condition and required specialized services including case management, psychiatric case consultation, neurocognitive evaluation, and individual therapy. Review of the EMR from 7/8/25 to 9/11/25 did not show documentation that these services were being provided. The social services director stated she was responsible for carrying out PASRR recommendations and ensuring services were provided, but she did not know whether Resident #3 had PASRR level II recommendations. The chief nursing officer stated the facility care planned and implemented PASRR recommendations, but she could not find documentation showing the specialized services recommendations for Resident #3 had been implemented.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary assistance with bathing and toileting. The deficiency involved two residents who were dependent on staff for ADL support and who were observed not receiving timely incontinence care during a continuous observation period. The facility policy stated that residents unable to perform ADLs would receive the necessary services to maintain personal and oral hygiene, and that toileting assistance would be provided based on the resident’s needs and care plan. Resident #29 had diagnoses including COPD, dementia, and acute and chronic respiratory failure with hypoxia. Her MDS showed moderate cognitive impairment and need for partial or moderate assistance with toileting, showering, dressing, and personal hygiene. During observation, she was seen sitting in her recliner while staff brought breakfast and later removed the tray without offering toileting assistance. Two CNAs were observed outside her room and did not offer toileting before leaving to another resident’s room. At the end of the observation period, her pants were wet with urine, and she had not been offered toileting or incontinence care assistance for two and a half hours. Her representative stated she routinely found her sitting in her recliner wet with urine and that staff were not toileting her in a timely manner. Her care plan directed staff to assist with toileting and to toilet her every two hours. Resident #33 had diagnoses including bipolar disorder, blindness in both eyes, and anxiety. Her MDS showed mild cognitive impairment and substantial to maximal assistance needed for toileting. During observation, she was lying in bed when breakfast was delivered, and no toileting assistance or incontinence care was offered. Two and a half hours later, she remained in bed with her breakfast tray in front of her, and no staff had entered her room to provide toileting or incontinence care. She stated staff often took a long time to come and change her, that the longest she had waited was two and a half hours, and that she was wet and felt like a loser because she was not important enough for staff to come check on and change her. Her care plan identified her as totally dependent for personal hygiene and needing help from two staff members for transfers.
Wound Care Not Followed and Medications Documented Before Administration
Penalty
Summary
The facility failed to ensure Resident #32 received wound care in accordance with physician orders for a left great toe wound. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, depression, and narcolepsy, had moderate cognitive impairment and required substantial assistance with hygiene, toileting, bathing, transfers, and wheelchair mobility. The resident’s representative reported that the left great toe dressing remained unchanged after admission, including a bandage dated 7/26/25 that was still present on 7/29/25 and 7/30/25, and that the dressing later appeared soiled and had an odor. Observation of the resident showed a dressing on the left great toe on 9/9/25 and again on 9/11/25, but neither dressing had a date or initials to show when it had last been changed. Record review showed multiple wound care orders for the left toes and left great toe, including orders for cleansing and applying Aquacel AG, Hydrofera blue, Medihoney gel, and betadine, with several treatment administration record entries showing no documentation that the ordered wound care was completed on specific dates in August and September 2025. An LPN stated she placed a dressing on the resident’s left great toe on 9/8/25 but forgot to date it, and said the only way to verify the dressing change was through her TAR signature. The facility also failed to ensure medications were not documented as administered before they were actually given to Resident #33. The resident had diagnoses including bipolar disorder, blindness in both eyes, and anxiety, and had mild cognitive impairment. During the morning medication pass, the resident told staff she had not yet received her medications and was feeling anxious without her anxiety medication, yet the MAR showed the morning medications as successfully administered. An RN stated she documented the medications as given even though she had not administered them yet, and the regional director of clinical services stated medications should not be marked as administered until after they are successfully given because doing otherwise is false documentation.
Failure to Provide Pressure Injury Prevention for Left Ankle
Penalty
Summary
The facility failed to ensure appropriate interventions were in place to prevent a resident from developing a non-blanchable wound to the left outer ankle. The resident was admitted with diagnoses including type 2 diabetes, polyneuropathy, impaired mobility, and contractures of both hands. He used a wheelchair for mobility and required assistance with dressing, hygiene, footwear, bathing, repositioning, and transfers. The resident reported that he had a sore spot on his left ankle bone and stated he got the wound from lying on his side too long. He also said staff told him they were going to find a boot to reduce pressure to his ankle, but he never received one. During observation, he was found lying in a regular bed without a pressure-reducing mattress, and his left ankle was resting directly on the bed without pillows or a pressure-reducing boot to offload the ankle. An oval-shaped deep purple discoloration was observed over the bony prominence of the left outer ankle. A later continuous observation showed the resident remained in a regular bed without an air mattress, with the left ankle bony prominence lying directly on the mattress for an extended period without staff entering the room to provide care. When the resident used the call light, an LPN observed that the dark purple area on the left ankle was intact but non-blanchable. The resident denied pain. The LPN then provided a pressure-reducing ankle boot. Record review showed the resident had previously had a suspected deep tissue injury to the left outer ankle that was documented as healed, with interventions including a pressure-reducing mattress and a wheelchair cushion. The care plan later documented a pressure ulcer to the left outer ankle and included an air mattress, but observations showed the resident did not have an air mattress in place. A subsequent skin assessment documented discoloration to the left outer ankle, and a progress note described the area as intact, discolored, and blanchable, but the care plan did not show a pressure-relieving device such as protective boots had been added before the non-blanchable area was observed.
Unsafe Hoyer Lift Transfers
Penalty
Summary
The facility failed to ensure residents were free from accidents or hazards during Hoyer lift transfers for two residents. Facility policy required staff to perform mechanical lifts and transfers according to the manufacturer’s instructions, and the FDA safety guide stated the lift base legs should be in the full open position for stability and that the lift should have space to pivot and move freely. The Hoyer lift manufacturer’s instructions also stated that the caster brakes should not be applied when lifting a patient and that the lift should be allowed to find its center of gravity. One resident, who had quadriplegia, neurogenic bowel, neuromuscular bladder dysfunction, and was dependent on staff for transfers, reported sustaining multiple abrasions and a bruise during Hoyer lift transfers. The resident stated a leg was scratched during a transfer before a doctor’s appointment and that a bruise to the left buttock occurred when staff transferred the resident to a shower chair and the lift began to tip, causing the resident to land roughly on the chair. The record showed orders for treatment and monitoring of a superficial scratch to the left lower leg, but the documentation did not identify how the scratch occurred, and there was no documentation related to the reported buttock bruise. For the other resident, who had aphasia after cerebral infarction, arthrogryposis multiplex congenita, altered mental status, and muscle weakness, staff were observed performing a Hoyer lift transfer with the lift brakes applied while the resident was in the sling. During the transfer, the lift legs became caught on a cable under the bed, and staff then closed the lift legs to a narrower position because the lift did not appear to fit under the bed. The resident was lifted and moved while the lift remained in the closed position, and staff kept their hands on the sling to prevent swaying. Staff interviews confirmed the lift was closed during the transfer because it did not fit well under the bed, and a regional clinical leader stated the closed position during motion could increase the risk of tipping for certain residents.
Failure to Set Up and Care Plan BiPAP Use
Penalty
Summary
The facility failed to provide respiratory services for Resident #42 by not ensuring his BiPAP machine was set up so he could use it at night, and by not including the BiPAP in his care plan. Resident #42 was admitted with diagnoses including quadriplegia, neurogenic bowel, neuromuscular dysfunction of the bladder, and narcissistic personality disorder. His MDS showed he was cognitively intact with a BIMS score of 15 out of 15, but he required substantial assistance with eating, hygiene, bathing, toileting, and dressing, and was dependent on staff for transfers. He told the surveyor he had brought his BiPAP machine to the facility but had not used it since admission because he had not seen a respiratory therapist or received help setting it up. He also said he slept poorly and felt tired during the day because he did not have his BiPAP machine. Record review showed a physician note documenting that the resident requested setup for his CPAP machine and had a history of obstructive sleep apnea, but the note referred to CPAP even though the resident had a BiPAP machine. The August 2025 physician orders included a respiratory therapist order for BiPAP settings and to call the sleep clinic one time for BiPAP settings, but the EMR had no documentation that the sleep clinic was called. The comprehensive care plan, initiated and revised during the stay, did not include a specific focus for the resident's BiPAP. Staff interviews showed a CNA had seen a device in the room but was unsure whether it was CPAP or BiPAP, an LPN had not seen the resident wear either device and did not know why there were no orders, and the regional director of clinical services was not aware the resident had a BiPAP machine in his room.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that Resident #7, who had a diagnosis of PTSD and a documented history of childhood abuse, received trauma-informed and culturally competent care that accounted for his experiences and preferences. The deficiency involved the facility not completing an assessment to identify potential trauma behaviors, not identifying triggers related to the resident’s past childhood trauma, and not documenting resident-specific care approaches to reduce re-traumatization. The resident was cognitively intact on the MDS, used a wheelchair, and required varying levels of assistance with eating, hygiene, toileting, and showering. Record review showed that behavioral health documented the resident’s report of childhood emotional and physical abuse, including being denied food, isolated from siblings, and physically abused by his mother. The resident’s trauma care plan identified only general mood-related concerns tied to significant trauma in the past and included broad interventions such as medication administration, behavioral health consultation, and monitoring for mood changes. The care plan did not identify the resident’s specific trauma behaviors, did not identify what triggered those behaviors, did not include resident-specific interventions related to his childhood abuse, and did not identify the PTSD diagnosis. The resident told surveyors that food was very important to him and that the facility environment reminded him of his childhood home, including the dining area and his room. He described childhood trauma involving food being used as a weapon by his parents and said the facility should know about that history. Staff interviews showed CNA #6 and RN #1 did not know the resident had trauma, did not know his triggers, and did not know what approaches helped him. The SSD said a trauma assessment was completed within 48 to 72 hours of admission and that trauma was documented in the care plan, while the regional director of clinical services stated the resident’s care plan should have been specific to his childhood emotional and physical abuse surrounding food and should have included triggers related to that trauma.
Incomplete psychotropic monitoring and refusal documentation
Penalty
Summary
The facility failed to ensure that two residents with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. For one resident with vascular dementia, anxiety disorder, and depression, the record showed orders for Risperdal, Zoloft, and lorazepam, but the resident refused multiple doses of each medication. The electronic medical record did not show that the physician was notified of the refusals, and it did not show what interventions were attempted when the medications were refused. The resident’s record also did not show that hours of sleep were monitored while the resident was receiving antidepressant medication. In addition, the psychotropic meeting review form did not identify the target behaviors the resident had exhibited since admission, the non-pharmacological interventions used, or the resident’s response to those interventions. For another resident with schizoaffective disorder, major depressive disorder, anxiety disorder, and severe cognitive impairment, the record showed orders for sertraline, trazodone, and buspirone. The resident refused sertraline and buspirone on multiple occasions, but the record did not show that the physician was notified of those refusals. The record also did not show what interventions were attempted when the medications were refused. The psychotropic meeting review form documented that the resident took buspirone for anxiety and sertraline for major depressive disorder, and the committee recommended a referral to behavioral health services, but the form did not identify what non-pharmacological interventions were used or the resident’s response to them. Staff interviews showed that non-pharmacological interventions such as redirection, snacks, drinks, music, talking, and other person-centered approaches were described as typical interventions for behavioral symptoms, and staff stated that refusals of psychotropic medications should be reattempted and then reported to the physician if the resident still refused. However, staff also stated they did not know what behaviors were being monitored for the two residents, and the regional director of clinical services said she did not know the residents had refused their psychotropic medications or that the psychotropic meeting forms lacked documentation of non-pharmacological interventions and responses. The record also noted that Resident #3 had no documentation showing behavioral health services had been provided, despite the committee recommendation.
Improper Storage and Labeling of Medications and Wound Supplies
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards. During observation, topical medications were found left on one resident’s bathroom counter, including a jar of triamcinolone acetonide 0.1% cream labeled with another resident’s name, along with two tubes of zinc oxide ointment and one tube of hydrocortisone acetate 1% cream in a blue basket on the counter. The resident said nursing staff used the creams and ointments on her skin, and the record did not show that she was able to self-administer medications or treatments. The record also did not show an order for hydrocortisone acetate 1% cream, although there was an order for hydrocortisone acetate 2.5% cream. A second resident’s bedside table contained an unlocked drawer labeled wound supplies. Inside were a skin integrity wound cleanser spray, 0.9% sodium chloride irrigation, skin prep protective barrier spray, triad hydrophilic wound dressing paste, and medihoney gel. The resident said he did not know what the supplies were used for and stated he did not have any pressure ulcers. His record did not show that he was able to self-administer his own medications and treatments. Staff interviews confirmed the medications and wound treatment supplies should not have been left in the residents’ rooms. A CNA said she did not know why the creams and ointments were in the resident’s bathroom. An RN said medications should never be left at a resident’s bedside unless the resident had an assessment showing the ability to self-administer, and she stated neither resident had such an assessment. The DON also stated there were no residents in the facility with an assessment allowing self-administration and said the wound supplies and creams should not have been left in the residents’ rooms.
Missing Catheter Care and Output Documentation
Penalty
Summary
Accurate medical records were not maintained for one resident with a suprapubic catheter, including documentation of urine output and catheter care in the EMR. The resident was admitted with diagnoses including quadriplegia, neurogenic bowel, neuromuscular dysfunction of the bladder, and narcissistic personality disorder. The resident’s MDS assessment showed he was cognitively intact with a BIMS score of 15 out of 15, required substantial assistance with multiple ADLs, was dependent on staff for transfers, used a motorized wheelchair, and had an indwelling catheter. The resident stated that nursing staff did not empty the suprapubic catheter at a consistent time during the day and that it was often emptied only when staff noticed the drainage bag was almost full. He reported that at times the bag became so full that urine backed up into the tubing and caused discomfort. Review of the August 2025 TAR showed missing documentation for catheter care on multiple dates, and missing catheter output documentation on multiple dates, including both day and night shifts on some days. Review of the September 2025 TAR for 9/1/25 through 9/11/25 also showed missing documentation for catheter care on several dates and missing catheter output documentation on several dates. Staff interviews showed differing understandings of who was responsible for catheter care and when catheter output should be recorded. A CNA stated the floor nurse was responsible for cleaning the catheter and the assigned CNA was responsible for emptying it and recording output, and said catheter output was usually not reported during handoff. An LPN said the floor nurse provided catheter care and the assigned CNA emptied and recorded output, and that catheters were usually emptied toward the end of the shift. The regional director of clinical services stated staff were expected to empty the catheter and document output every shift, and said the missing documentation was more likely a recording issue than a failure to provide care.
Failure to Perform Hand Hygiene While Serving Meals
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when staff did not perform appropriate hand hygiene while assisting residents in the dining room. During a continuous observation of the lunch meal in the dining room, ambulatory and wheelchair-bound residents were seated and waiting for their meals while CNA #4 brought lunch plates on trays from the kitchen to residents and returned to the food-service window counter for additional plates. Hand sanitizing dispensers were observed on the wall next to the food-service window counter, but CNA #4 did not sanitize her hands after serving each tray. At 12:00 p.m., CNA #4 was observed touching her hair and running her fingers through her hair on several occasions while continuing to serve all residents in the dining room without performing hand hygiene. During interview, CNA #4 stated she touched her hair frequently when nervous and acknowledged that not performing hand hygiene could contaminate residents' food with her hair. The regional director of clinical services stated staff should perform hand hygiene when serving food to residents in the dining area and that CNA #4 should have washed her hands after touching her hair before touching residents' meals.
Survey Results Binder Not Available or Known to Residents
Penalty
Summary
The facility failed to ensure residents, family members, and legal representatives had full access to review the results of the most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction for the preceding three years. The facility policy stated that a readable copy of the most recent federal and/or state survey report and plan of correction was to be maintained in a 3-ring binder titled Results of Most Recent Survey and located in the main lobby for review by interested persons. On observation, the survey results binder could not be located in the main lobby at the time of surveyor review. Later that day, the binder was printed and placed on a desk in the lobby. During a resident group interview, four interviewable residents stated they did not know what the survey binder was or where it was located. In interview, the regional vice president of operations stated the binder should have been available during the survey but had not been printed until it was placed in the lobby.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the secure and confidential storage of residents' personal and medical records, as required by its own policies and HIPAA regulations. Surveyors observed three brown paper bags and one large black trash bag containing confidential resident information left open and unattended at the nurse's station. Staff interviews confirmed that these bags, filled with resident documents, had been at the nurse's station for several weeks due to the absence of designated shred box containers. Staff were instructed to place confidential documents in these bags, and the director of nursing acknowledged that the facility did not have shred boxes at the time of the survey. Additionally, a locked medication cart was found unattended in the hallway with its computer screen visible to passersby, displaying a portion of a resident's medication administration record. Both the regional nurse consultant and a registered nurse confirmed that the screen should not have been visible to the public and that there was a lock button available to secure the screen. These actions and inactions resulted in the failure to maintain the privacy and confidentiality of residents' medical records.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide timely and necessary treatment and services to prevent and manage pressure injuries for two residents, leading to severe health complications. Resident #85, who had diabetes and kidney disease, was admitted with a stage 2 pressure injury on her coccyx/sacrum and was at moderate risk for further pressure injuries. Despite an assessment on 11/16/23 revealing discoloration on her heels, the primary care physician was not informed until 11/20/23. By then, the resident had developed deep tissue injuries on both heels, cellulitis, and sepsis, requiring hospitalization. The facility did not implement the care plan interventions for turning, repositioning, and off-loading heels, nor did they update the care plan with new interventions after the heel discoloration was noted. Resident #140, with a history of sacral fracture and peripheral vascular disease, was admitted with intact skin but developed a blister on his right foot two days later. The wound care physician later documented deep tissue injuries on his right toe and heel. The facility failed to off-load the resident's heels as per the care plan and did not accurately document the resident's skin condition in daily notes. The resident's condition worsened, leading to cellulitis and sepsis, necessitating ICU care. The facility did not ensure timely physician notification of the resident's condition changes, and the care plan was not updated with appropriate interventions. The systemic failure to provide timely interventions and necessary treatment for pressure injuries created an immediate jeopardy situation, posing a likelihood of serious harm to other residents with similar conditions. The facility's medical director confirmed that the pressure injuries were avoidable if proper care had been provided, indicating that the facility's protocols and care plans were not followed by staff.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection control preventionist (ICP) who had completed specialized training in infection prevention and control, which had the potential to affect all residents residing in the facility at the time of the survey. The Centers for Disease Control and Prevention (CDC) guidelines recommend that nursing homes assign individuals with training in infection prevention and control (IPC) to manage the IPC program on-site. However, the facility was unable to provide documentation that the acting infection preventionist, who was also the wound care nurse, had completed the necessary specialized training. During interviews, the wound care nurse confirmed that she was the acting infection preventionist but had not yet completed her certification, although she was enrolled in a training program. Additionally, the regional nurse consultant, who was providing assistance due to the recent departure of the director of nursing, was unaware that the wound care nurse had not completed her IP training. This lack of a qualified infection preventionist involved in the facility's infection prevention and control program was identified as a deficiency during the survey.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis after the previous DON resigned. A review of the facility's staffing list and assessment revealed the absence of a full-time DON. Interviews with staff, including a licensed practical nurse (LPN) and the minimum data set (MDS) coordinator, confirmed that there was no designated DON or charge nurse on duty. Instead, nursing staff deferred questions to the wound care nurse and the MDS nurse, both of whom were LPNs and not in management positions. The nursing home administrator (NHA) acknowledged the vacancy in the DON position and stated that the facility had been actively searching for a replacement. In the interim, two nurse managers, who were LPNs, were managing the DON duties. The NHA also mentioned that corporate leadership provided support, with a regional clinical support RN present in the building to assist until the position could be filled.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 16.67%. During medication administration, an LPN did not apply a prescribed lidocaine patch to the correct location on a resident's body and documented the administration despite not applying it. Another resident was administered a lidocaine patch to an incorrect area, contrary to the physician's order, and the LPN failed to verify the resident's heart rate or blood pressure before administering metoprolol tartrate. Additionally, the LPN documented the administration of a medication that the resident had refused. A third resident received their Parkinson's medication, carbidopa-levodopa, outside the prescribed administration window, which was confirmed as a medication error by a physician assistant. The facility's policy required medications to be administered within a two-hour window, but the medication was given 50 minutes late. Interviews with staff, including a physician assistant and the regional nurse consultant, confirmed the importance of adhering to prescribed medication administration times and locations, particularly for medications with specific timing requirements like Parkinson's medications.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during medication administration and patient care. Observations revealed that an LPN did not perform hand hygiene before entering a resident's room, after administering eye drops, or before administering oral medications. The LPN also failed to clean a pulse oximeter before and after use on a resident. Another LPN was observed preparing medications without performing hand hygiene and entered a resident's room without doing so. Additionally, a staff member picked up a pill from the floor and handed it to an LPN, who disposed of it without performing hand hygiene before continuing to prepare medications. Interviews with the wound care nurse, who oversees the facility's infection control program, confirmed that hand hygiene should be performed before administering resident care and medications, especially eye drops, to prevent infection spread. The nurse also stated that vital signs monitoring equipment should be cleaned after each resident use. These observations and interviews highlight the facility's failure to implement appropriate infection prevention measures, as outlined by the CDC and other professional references.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with professional standards. Observations revealed that multi-dose medications, such as Anoro Ellipta inhalers, Latanoprost eye drops, and SoloStar insulin pens, were not labeled with the date they were opened. Additionally, a resident's used inhaler was improperly stored in a tissue within a medication cart. These lapses in labeling and storage practices were observed in two medication carts, indicating a systemic issue in medication management. The facility also failed to maintain secure access to medications, as evidenced by an LPN leaving a medication cart unattended with the keys in the lock, making the medications accessible to unauthorized individuals. Furthermore, the disposal of unused, wasted, or damaged medications was not conducted in a manner that prevented diversion or accidental exposure. Instances were noted where medications were improperly disposed of in trash cans instead of using the available drugbuster bottles designed for safe disposal. The medication storage room was found to be cluttered, with expired medications and those belonging to discharged residents left on the counter. The refrigerator in the storage room was observed to have a dried brown liquid on the bottom shelf, indicating a lack of cleanliness and organization. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and medication disposal, contributing to the deficiencies observed in medication management and storage practices.
Failure in QAPI Program and Resident Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and address compliance concerns related to quality of life and quality of care. The QAPI committee did not address issues such as medication administration errors and infection control, which were identified during a recertification survey. The facility's regulatory record showed repeat deficiencies, including a medication administration error rate above five percent and infection control issues, both cited at an E level scope and severity. Additionally, the facility failed to ensure pressure injuries were assessed and treated timely, leading to a resident developing a wound infection with sepsis, creating an immediate jeopardy situation with actual serious harm. Interviews revealed that the medical director was unaware of a resident's hospitalization due to infected wounds, indicating a lack of communication and oversight. The new nursing home administrator (NHA) had only participated in one QAPI meeting and was not aware of the identified concerns, such as pressure injuries and medication issues. The NHA was unable to locate any investigations or notes from the previous administrator, highlighting a gap in continuity and documentation. Despite submitting a QAPI plan of correction for medication errors, the NHA did not provide evidence of staff education or audits being conducted, further demonstrating the facility's failure to address and rectify the identified deficiencies.
Removal Plan
- Education to all nurses
- Audits for expired, discontinued or missing medications to be completed
Facility Fails to Prevent Theft of Resident's Electric Tricycle
Penalty
Summary
The facility failed to prevent the misappropriation of property for a resident whose electric tricycle was stolen from behind a locked gate. The resident, who was cognitively intact and dependent on supplemental oxygen, had been admitted to the facility and later discharged to another long-term care facility. The resident's inventory sheets did not list the electric tricycle, and a grievance was filed when the tricycle was not replaced or reimbursed by the facility. The facility's administrator stated that they were not liable for the loss, and corporate management did not authorize reimbursement for the tricycle, which was valued at approximately $4,000. Interviews with staff revealed that the previous nursing home administrator had agreed to store the tricycle in a nearby building due to its size. A police report was filed after the tricycle was stolen, but it was not recovered. The current administrator was unaware of the incident, and the facility lacked a policy for personal property responsibility. The resident was offered a few hundred dollars, which was not accepted, and requested an unused electric wheelchair from the facility as a replacement, which was not provided.
Premature PICC Line Removal and Missed Antibiotic Doses
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident who required intravenous (IV) therapy. The resident, who was over 65 years old and had been diagnosed with acute osteomyelitis of the mandible and an inflammatory condition of the jaw, was prescribed a course of IV antibiotics through a peripherally inserted central catheter (PICC) line. However, the nursing staff removed the PICC line prematurely, before the completion of the prescribed antibiotic course, without a physician's order. The removal of the PICC line led to the resident missing three doses of the antibiotic, as documented in the medication administration record. The error was not reported to a physician until several days later, delaying the replacement of the PICC line and the continuation of the antibiotic therapy. The facility's policy did not include specific guidelines for PICC line care, contributing to the oversight. Interviews with staff revealed a lack of clarity regarding the necessity of a physician's order for PICC line removal and the importance of timely notification and replacement in case of an error. Additionally, the facility failed to adhere to the physician's orders for PICC line dressing changes, as the dressing was not changed every seven days as required. This oversight was noted in the medication administration record, with missed dressing changes on specific dates. Staff interviews highlighted the importance of regular dressing changes to prevent infection at the insertion site and the need for adherence to the antibiotic stewardship program to track and manage infections effectively.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct a performance review for two certified nurse aides (CNAs) within the required 12-month period, as mandated by regulations. CNA #1, hired on February 28, 2023, and CNA #2, hired on November 29, 2022, did not have documented performance reviews completed within the past year. This deficiency was identified through record reviews and staff interviews. The human resources director confirmed that each department lead was responsible for conducting annual performance reviews, but acknowledged that reviews for CNA #1 and CNA #2 were not completed. The regional nurse consultant also confirmed the absence of performance reviews for these CNAs.
Failure to Honor Resident Preferences in Care and Scheduling
Penalty
Summary
The facility failed to honor the residents' rights to make choices about aspects of their lives, specifically for two residents. Resident #7, who was cognitively intact and had multiple medical conditions including a sacral pressure ulcer, was not provided assistance in scheduling a wound care appointment at his preferred in-network clinic. Instead, the facility arranged for him to attend an out-of-network clinic, resulting in a significant financial burden. The resident and his representative were not informed about the network status or financial implications of the clinic chosen by the facility. Despite the resident's request to attend an in-network clinic closer to the facility, the facility scheduled an appointment at a distant location, causing additional discomfort due to the long travel. Resident #2, who was also cognitively intact and diagnosed with Parkinson's disease, expressed a preference for three showers per week. However, the facility assigned shower days based on room numbers without consulting the resident's preferences. There was no documentation in the resident's electronic medical record or the shower binder to indicate the resident's shower preferences, and the staff followed a predetermined schedule without accommodating individual requests. Interviews with staff, including the wound care nurse and the regional nurse consultant, revealed a lack of communication and documentation regarding the residents' preferences and the financial aspects of care. The facility's policy on residents' rights was not adhered to, as staff failed to facilitate and support the residents' choices, leading to dissatisfaction and potential financial strain for the residents involved.
Failure to Revise Care Plan for Resident's Medication Refusals
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised in a timely manner to include necessary instructions for effective and personalized care. The resident, who had severe cognitive impairments and multiple diagnoses including Huntington's disease, dementia, and depression, frequently refused physician-ordered medications and treatments. Despite these refusals, the care plans did not document or address the resident's pattern of refusals, nor did they include person-centered interventions to manage these refusals. The resident's medication administration record revealed multiple instances where medications such as Aspercreme and Haloperidol were not administered due to the resident's refusal. Additionally, the treatment administration record showed that the resident often refused to be moved to her chair for meals, as requested by her family. There was no documentation in the resident's electronic medical record indicating that the facility attempted to address these repeated refusals or update the care plan accordingly. Interviews with facility staff, including an LPN, a primary care provider, and a regional nurse consultant, confirmed that the resident's refusals were known but not adequately addressed. The LPN and RNC acknowledged the resident's right to refuse care but emphasized the need for re-approaching the resident and seeking assistance from other nurses. However, the care plan did not reflect these strategies or any person-centered interventions to reduce the number of refusals, leading to a deficiency in the resident's care management.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene. The resident, who was under 65 years old and had multiple diagnoses including multiple sclerosis and severe cognitive impairments, was dependent on staff for showering and dressing. Despite the resident's preference for morning baths, as documented in her care plan, she reported not receiving a shower since her admission to the facility. Observations and interviews revealed that the resident's hair was greasy and her fingernails were unkempt, indicating a lack of personal hygiene care. The facility's records showed no documentation of the resident being offered a shower since her admission. A grievance was filed by the resident, but there was no documentation of any follow-up action to offer her a shower after the grievance was filed. Interviews with staff, including an LPN and a CNA, indicated that showers were scheduled based on room numbers rather than resident preferences. The staff were unaware if the resident had received a shower since her admission. The regional nurse consultant acknowledged the grievance and stated that the resident should have been offered a shower within 24 to 48 hours of admission, highlighting a failure in the facility's process to ensure timely and appropriate personal hygiene care for the resident.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, specifically for two certified nurse aides (CNAs). The deficiency was identified through record reviews and staff interviews, revealing that the facility did not ensure that these CNAs received necessary training in areas such as abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights. Additionally, the facility did not provide documentation to confirm that these CNAs completed at least 12 hours of annual in-service training as required. Interviews with the human resources director (HRD) and the regional nurse consultant (RNC) further highlighted the issue. The HRD admitted that while training was supposed to be completed through an electronic learning management program, there was no documentation to prove that the CNAs had completed the required training in the past 12 months. The HRD also mentioned an annual skills clinic training and monthly staff meetings that included training, but again, there was no documentation to confirm attendance by the CNAs. The RNC acknowledged the difficulty in ensuring staff completed the required annual training, confirming that the CNAs did not complete the necessary training in the past year.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 210 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katherine And Charles Hover Green Houses | 3.4 mi | ★★★★★ | 9 | 0 |
| Mcintosh Care And Rehabilitation Center | 3.4 mi | ★★★★★ | 10 | 0 |
| Peaks Care Center, The | 4 mi | ★★★★★ | 13 | 0 |
| Life Care Center Of Longmont | 4.9 mi | ★★★★★ | 16 | 0 |
| Winding Trails Post Acute | 8.9 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.