Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lowry Hills Care And Rehabilitation during CMS and state inspections, most recent first.
Care plans were not timely revised for several residents to reflect current catheter care, wound and feeding precautions, and psychotropic medication behaviors. Two residents with Foley catheters lacked catheter hygiene interventions, a resident with wounds and dysphagia lacked updated skin, diet, and swallow precautions, and three residents on psychotropic meds lacked specific target behaviors and non-pharmacological interventions in their care plans.
A facility failed to keep seven of 10 resident rooms in good repair, with observations of spackle not painted, broken or missing blinds, damaged walls exposing a steel frame, chipped and peeling tile, a missing transition piece, and paint worn off walls. A resident said the bathroom floor around the toilet had been cracked for months and that he had told the DON and maintenance director, but nothing had been done; the maintenance director said repairs were prioritized and scheduled around resident availability.
Medication storage carts contained multiple expired drugs and biologicals, unlabeled opened medications, improperly stored insulin and eye drops, and unidentified pills with no resident or medication labels. Surveyors found these issues across several carts, while an LPN and the DON confirmed staff were responsible for checking expiration dates, labeling opened products, and discarding expired medications.
Missing Privacy Curtains in Resident Rooms: Surveyors found that 6 of 10 resident rooms lacked full visual privacy, with some beds having no privacy curtain, one curtain too small to fully enclose a bed, and one room lacking a ceiling track or portable privacy screens. A resident said she had to go into the bathroom to dress or undress, while a CNA and an LPN described providing care in the bathroom or asking roommates to step aside when curtains were unavailable; the NHA was unaware of the missing curtain.
A resident with dementia and multiple orthopedic injuries was admitted wearing a CAM boot on the right leg after a right ankle ORIF and left hip hemiarthroplasty. The facility documented the boot in the care plan and wound note, but the EMR did not contain physician orders for wearing the boot during transfers or when out of bed, or for skin checks under the boot. Staff interviews confirmed the hospital discharge direction for the boot was not entered into the record, leaving the order unclear to staff.
A resident with dementia, severe malnutrition, a stage 4 pressure ulcer, and generalized weakness was dependent on staff for most ADLs and had care plan directions for one-to-one meal assistance and finger foods as needed. A CNA delivered the lunch tray, did not offer help, briefly uncovered the plate after the resident asked for assistance, then left without feeding the resident; meal help was not provided for over 30 minutes until the PT assisted with eating. Staff interviews showed conflicting understanding of the resident’s feeding needs, while the DON stated CNAs should encourage eating and offer help frequently during meals.
A resident with dementia, generalized weakness, and a left hand contracture was observed with the hand curled closed and no splint in place. Records showed OT had not addressed the contracture, the care plan did not include PROM for the hand, and the Kardex/CNA task list had no ROM documentation. The DON stated the resident was not receiving ROM services, although PT later completed an evaluation for ROM exercises.
Delayed and inconsistent wander guard assessment for an elopement-risk resident. A resident with cognitive impairment, hallucinations, and poor safety awareness had documented wandering and exit-seeking behavior, yet the EMR showed consent, the physician order, and the wander guard evaluation were not completed or entered in a timely and consistent manner. The care plan said the resident was to continue using a wander guard and staff were to ensure proper placement and functionality, but the chart also contained conflicting elopement and fall documentation. Staff reported the resident wandered throughout the building and had been using the bracelet for some time.
A resident with COPD, CHF, and chronic respiratory failure did not receive oxygen at the ordered flow rate. The care plan and physician’s order specified oxygen via nasal cannula at 4 LPM every shift, but staff observed the concentrator set at 2.5 LPM. RN confirmed the setting did not match the order, and the resident stated her oxygen was sometimes not set correctly and that she thought she was supposed to be on 3 LPM.
Incomplete dialysis documentation and communication: A resident with acute kidney failure, renal dialysis dependence, and DM2 had missing and incomplete dialysis communication forms, delayed EMR entry of weight orders, and inconsistent documentation of pre- and post-dialysis weights. Staff and leadership confirmed that dialysis forms were not thoroughly completed and that required weight documentation was absent for multiple dialysis sessions.
A resident with anxiety disorder, major depressive disorder, ADHD, and moderate cognitive impairment missed multiple scheduled doses of Wellbutrin because the medication was not on hand, on order, or pending delivery. Nursing notes showed repeated gaps in administration, and staff described expected steps for reordering and notifying the physician when meds were unavailable, but the resident still missed five doses.
Failure to Follow EBP and Keep Catheter Equipment Off the Floor: An LPN and a respiratory therapist did not wear gowns during high-contact care for residents with an indwelling urinary catheter and a tracheostomy, despite EBP requirements for residents with indwelling medical devices. In addition, urinary catheter drainage bags and tubing for two residents were observed on or dragging along the floor, including under a wheelchair and beneath a bedside table wheel.
Incomplete State Agency Complaint Posting: A facility posting meant to inform residents how to file complaints with the State Agency had the wrong phone number and did not include the required list of other pertinent State agencies and advocacy groups with their mailing and email addresses and phone numbers. In a resident group interview, several residents said they did not know how to file a complaint, and most only knew how to contact the ombudsman.
Survey Results Not Available to Residents and Families: The facility did not ensure residents, family members, and legal representatives had full access to the most recent survey findings, including survey results, complaint investigations, and plans of correction. During a resident group interview, several residents said they were unaware they could view the survey results. Record review showed the survey results binder only contained an older survey and did not include 2025 recertification or complaint survey results, and the NHA said the 2025 documents were kept in a different folder in her office and were not available to residents or family members.
Two residents with significant care needs were discharged home without comprehensive discharge plans, confirmed home health services, or adequate instructions regarding medications and care. In both cases, documentation was lacking, and necessary arrangements for services and follow-up were not completed, resulting in one resident being hospitalized after a seizure due to missed medications.
A resident with dementia and incontinence did not receive timely incontinence care, remaining in a soiled and saturated brief for over four hours despite multiple staff interactions. Staff failed to follow the care plan requiring checks every two hours, and documentation did not match observed care provided.
Two residents did not receive personalized activity programming as outlined in their care plans, resulting in missed opportunities for engagement in preferred activities such as music, reading, outdoor time, and social interaction. Staff did not consistently invite or assist these residents to participate in group or individual activities, and meaningful engagement was not provided, despite clear documentation of their interests and needs.
A resident with multiple diagnoses, including dementia and MS, was not provided with a prescribed vegetarian diet and was served chocolate cake despite needing to avoid chocolate. The care plan did not reflect the resident's dietary preferences or restrictions, and staff did not consistently use the vegetarian menu extension, resulting in the resident receiving inappropriate meals.
Staff failed to maintain infection control during wound care by not providing a clean area for supplies, not using gowns for high-contact care, and not performing proper hand hygiene or glove changes between tasks. Supplies were placed among personal items, and staff assisted multiple residents without changing gloves or using hand sanitizer, despite being aware of required protocols.
A resident with severe cognitive impairments and a history of aggression physically abused another resident on two occasions. The facility's investigations were inconclusive due to a lack of witnesses and injuries. Staff interviews revealed inadequate training and communication about the assailant's behaviors, contributing to the deficiency.
The facility failed to obtain informed consent for psychotropic medications for three residents. One resident with a court-ordered guardianship was administered Zyprexa without the guardian's consent. Another resident was given olanzapine without being informed of possible drug interactions. A third resident was administered Seroquel and Zoloft without prior informed consent. Staff interviews confirmed that informed consents should be obtained before medication administration.
The facility failed to complete annual performance reviews and provide regular in-service education for five CNAs. The DON confirmed that the reviews and subsequent training had not been conducted, and a full audit would be necessary to identify which employees required evaluations.
The facility failed to maintain sanitary food handling and storage practices. A dietary aide repeatedly handled soiled and clean dishes without proper hand hygiene, and multiple food items in the nourishment refrigerator were not labeled, dated, or disposed of timely. Despite previous education on hand hygiene and food safety policies, these standards were not consistently followed, leading to unsanitary conditions.
The facility failed to maintain a sanitary and safe environment in one of its shower rooms. Observations revealed damp and stained chairs, a dirty shower curtain, holes in the walls, debris in the grout, missing floor tiles, and personal hygiene items and trash on the floor. Staff interviews indicated a lack of awareness and adherence to cleaning procedures.
The facility failed to ensure that five CNAs received the required 12 hours of annual in-service training. The SDC admitted that there was no process to track the training hours and was working on developing a tracking form and new employee training packets.
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice by not obtaining weekly weights per physician's orders for two residents. One resident with severe protein-calorie malnutrition and another with severe cognitive impairment did not have their weights monitored as required, leading to a deficiency in care.
A resident was administered acetaminophen in excess of the recommended dose and was not given hydralazine as needed for high blood pressure. Staff failed to notify the physician of these issues, leading to potential health risks for the resident.
The facility failed to properly store and label medications, including not disposing of expired medications and not labeling insulin pens and Tubersol vials with open dates. Expired medications were found in the main nurses' medication room and the 400 hall medication cart, posing risks to residents.
The facility failed to provide mechanically altered diets as prescribed, serving residents inappropriate food textures such as non-pureed stuffed peppers, non-slurried wheat rolls, and non-pureed corn. The dietary manager and staff were not adequately trained, leading to these deficiencies.
The facility failed to maintain an infection control program, as housekeeping staff did not follow proper cleaning techniques, were not appropriately trained, used incorrect surface disinfectant products, and did not adhere to disinfectant times. Observations revealed improper cleaning practices, and interviews confirmed a lack of training and awareness among staff.
The facility failed to complete a Level II PASRR for a resident with mild neurocognitive disorder and major depressive disorder, despite a recommendation for the assessment. The resident was cognitively intact and required minimal assistance with daily activities. Interviews with staff confirmed the oversight.
The facility failed to provide scheduled showers to two residents who were dependent on staff for bathing. Resident #69 and Resident #35 missed multiple scheduled showers and bed baths over several months, despite their care plans indicating the need for assistance with bathing. Staff interviews confirmed the importance of scheduled showers for hygiene and skin integrity, but the reason for the missed showers was not determined.
Care plans not updated for catheter care, wounds, swallowing precautions, and psychotropic behaviors
Penalty
Summary
The facility failed to timely review and revise comprehensive care plans for multiple residents so the plans included resident-specific instructions needed to provide care based on current assessments, physician orders, and observed changes in condition. Record review and staff interviews showed that care plans were not updated for catheter care, skin integrity and swallowing precautions, dementia and behavioral interventions, and psychotropic medication target behaviors and interventions. For two residents with indwelling urinary catheters, the care plans addressed catheter-related trauma, discomfort, and UTI monitoring, but did not include catheter hygiene. One resident had a physician order for indwelling urinary catheter care to cleanse the site with soap and water, rinse, and pat dry every shift after returning from the hospital with a UTI and Foley catheter. The other resident also had a physician order for catheter care every shift, but the care plan still did not reflect hygiene-related interventions. Staff interviews indicated catheter cleaning and related care should have been included in the care plans. For another resident with multiple wounds and nutritional concerns, the care plan did not identify the right heel condition as a scab present on admission and was not updated after the resident developed a right heel stage 4 pressure ulcer. The nutrition care plan also was not updated after diet orders changed from regular texture to minced and moist and then to puree, and after speech therapy documented suspected moderate/severe oropharyngeal dysphagia with elevated aspiration risk and recommended safe swallow strategies during one-to-one feeding. The care plan did not include the new diet textures or the swallowing precautions recommended by speech therapy. The remaining residents had care plans that did not reflect the specific behaviors and interventions tied to psychotropic medication use. One resident with severe vascular dementia and behavioral disturbance had a behavioral care plan that listed crying, wanting to leave, and pacing, but it did not include additional non-pharmacological interventions documented on the MAR for episodes of confusion, emotional distress, self-isolation, crying, hallucinations, and delusional thinking. Two other residents receiving antidepressant, anti-anxiety, and antipsychotic medications had care plans that did not include the specific target behaviors such as anxiety, tearfulness, scratching, depression, isolation, loss of appetite, hallucinations, paranoia, and distrust of staff, even though those behaviors and interventions were documented in physician orders, MARs, and staff interviews.
Resident Rooms Not Kept in Good Repair
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable homelike environment for seven of 10 resident rooms by not keeping multiple rooms in good repair. Observations identified spackle on walls that had not been painted, broken or intertwined blinds, damaged wall areas exposing a steel frame by a bathroom door frame, missing base vinyl with chipped paint, bent or missing blind slats, and walls with multiple white spots where brown paint had been removed. One room also had decorative butterflies and birds on the wall that the resident said were already there when he moved in and that no one had asked him about. Additional observations found cracked paint and peeling around a toilet, chipped and peeling tile around the toilet, a scratched door frame, a missing transition piece exposing bare floor, tape pieces on the inside of a door, and another room with paint worn off all the walls. A resident stated the bathroom floor around the toilet had been cracked for three months and said he had told the DON and maintenance director, but nothing had been done. The maintenance director said some issues were identified through the IDT room inspections and resident reports, that plumbing and electricity were top priorities, and that repairs depended on scheduling, parts, and resident availability.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored, secured, and labeled in accordance with accepted professional standards in three of six medication storage carts. Surveyors found multiple expired medications left in the carts, including blood pressure medication, antihistamines, simvastatin, eye drops, calcium products, diphenhydramine, bisacodyl, insulin, sertraline, aspirin, loratadine, folic acid, thiamin, biotin, iron, potassium, methimazole, ondansetron, phenazopyridine, and other medications with expiration dates that had passed or were missing. Surveyors also found several medications that were not labeled with the date they were opened, including fluticasone propionate and salmeterol inhalers, latanoprost eye drops, Humalog insulin, Incruse Ellipta inhaler, budesonide-formoterol inhalers, and ipratropium bromide and albuterol inhaler. In addition, unopened Humalog insulin was not stored properly in the refrigerator, unopened latanoprost eye drops were not refrigerated, and multiple bottles of medications had no expiration date listed. Surveyors observed multiple unidentified pills in the bottoms of cart drawers in two medication carts with no resident identifying information or medication label. During interview, the DON stated the night shift supervisor was supposed to audit medication storage weekly, and nurses working on the medication carts were responsible for checking expiration dates and discarding expired medications. She also stated that medications with shortened expiration dates needed an opened date label so staff would know when to discard them, and that expired medications should be discarded so they would not be administered to residents.
Missing Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to be designed or equipped to assure full visual privacy for residents in 6 of 10 rooms. Surveyors observed multiple resident rooms without adequate privacy curtains, including rooms with no curtain at all for certain beds, a curtain that was too small to fully enclose a bed, and a room with only one curtain between two beds and no ceiling track or portable privacy screens available. Facility policy stated that resident bedrooms must be equipped to assure full visual privacy for each resident, including ceiling-suspended curtains around each bed in non-private bedrooms. During interviews, a resident stated there should be a curtain for privacy and said she had to go into the bathroom to get dressed or undressed. A CNA said that if a privacy curtain was not available, she would take the resident to the bathroom for care, and that one room had not had a privacy curtain between residents for over a year. An LPN said she knew there was no privacy curtain between beds in one room but had not reported it to management or maintenance. The maintenance director initially said a curtain had been damaged and ordered, then stated he had just learned there was no ceiling track in that room and was in the process of ordering one. The NHA said she was not aware of the missing privacy curtain.
Failure to Enter and Follow CAM Boot Orders
Penalty
Summary
The facility failed to ensure Resident #104 received treatment and care in accordance with professional standards of practice for the resident’s controlled ankle motion (CAM) boot on the right leg. Resident #104 was admitted with diagnoses including traumatic subdural hemorrhage, dementia, displaced trimalleolar fracture of the right lower leg, and dependence for all ADLs. The resident’s care plan included a CAM boot to the lower right leg, and the admission note documented the resident arrived with a CAM boot on the right leg after significant orthopedic interventions, including a left hip hemiarthroplasty and a right ankle ORIF with hindfoot nail. Record review showed a skin and wound note documented the CAM boot on the resident’s right lower extremity and stated the boot was to be used when out of bed, but the electronic medical record did not contain physician’s orders for the resident to wear the CAM boot for transfers and when out of bed, or orders for monitoring the skin underneath the boot. The physician orders included a weight-bearing order for stand-and-pivot transfers in the CAM boot that was later discontinued, followed by another weight-bearing order that did not include the CAM boot. Staff interviews confirmed the resident had the CAM boot on admission, that the boot covered the heel and extended below the knee, and that the hospital discharge order was for the boot to be worn for transfers when out of bed, but the order was not entered into the facility record.
Delayed Meal Assistance for a Dependent Resident
Penalty
Summary
The facility failed to ensure Resident #8 received timely meal assistance. Resident #8 had diagnoses including severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, CHF, dementia, and generalized muscle weakness. The 4/30/26 MDS showed the resident was unable to complete the BIMS, had short- and long-term memory problems, moderately impaired cognitive skills for daily decision making, and was dependent on staff for most ADLs, including setup or clean-up assistance for eating. The care plan directed staff to provide finger foods when the resident had difficulty using utensils and to assist the resident one-to-one with meals, and the RD noted the resident required feeding assistance/encouragement at meals as needed. On 6/2/26 at 11:40 a.m., a CNA delivered the resident’s lunch tray to the room, said hello, but did not ask whether the resident needed help eating or offer to assist with the meal. After the resident said she could not get the cover off the food plate and asked for assistance, the CNA uncovered the plate, said she would help the resident eat in a moment, then replaced the cover and left without offering any bites of food. The resident did not receive meal assistance for over 30 minutes after the tray was delivered, until the PT entered the room and assisted with eating. During interviews, the CNA stated she assisted the resident with eating and that the resident generally needed help, while another CNA said the resident did not need staff assistance and could feed herself. The DON stated CNAs should encourage the resident to eat and offer help frequently during meals.
Failure to Provide ROM Services for Resident with Left Hand Contracture
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to maintain or improve ROM. Resident #8 had diagnoses including severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, CHF, dementia, and generalized muscle weakness. The resident’s MDS showed impairment on one side of the upper extremities and no ROM services. On observation, the resident’s left hand was contracted, with the hand unable to fully open and fingers curled closed; no hand splint was present. Record review showed the resident’s OT and plan of treatment from 12/26/24 did not document that the left hand contracture was being addressed by therapy. The care plan identified limited physical mobility related to dementia, encephalopathy, decreased mobility, and left-sided weakness, but did not include passive ROM assistance for the left hand contracture. The resident’s hospice transition note recommended considering restorative care for PROM and palliative movement, and a later note repeated that recommendation. However, the Kardex and CNA task section contained no documentation for left hand ROM, and the DON stated the resident was not receiving ROM services, although PT completed an evaluation on 6/2/26 for ROM exercises.
Delayed and Inconsistent Wander Guard Assessment for an Elopement-Risk Resident
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident who was at risk for elopement. Resident #29 had diagnoses including cognitive communication deficit, psychotic disorder with hallucinations due to known physiological conditions, and major depressive disorder, and the MDS showed memory impairment and moderately impaired decision-making. Although the resident’s care plan documented wandering and exit-seeking behavior, the record also showed inconsistencies in the assessment and documentation of the resident’s wander guard use and elopement risk status. The resident’s wandering care plan, revised in February and April 2026, documented that the resident made statements about leaving, attempted to leave the building, and was to continue using a wander guard for safety. The care plan also directed staff to ensure proper placement of the wander guard and that it was working properly. However, the EMR showed consent for the wander guard was not obtained until March 14, 2026, the physician order to ensure the wander guard was working properly was not entered until May 27, 2026, and the resident was not evaluated for use of a wander guard until May 30, 2026. The resident was observed on June 1, 2026 with a wander guard on the wrist. Record review also showed the elopement evaluation documented on March 15, 2026 stated the resident had not expressed a desire to go home, packed belongings, or stayed near an exit, even though the care plan documented wandering and attempts to leave the building. The same evaluation also documented no falls in the prior three months, although progress notes showed a fall on February 22, 2026. Staff interviews indicated the resident wandered throughout the building, had been on a wander guard for some time, and the facility had identified during the survey that the order had not been entered when the bracelet had been applied. The NHA and DON stated the resident’s representative had given consent on March 14, 2026, but the documentation of the wander guard order, monitoring, and evaluation did not align with the resident’s documented wandering behavior.
Oxygen Flow Rate Not Set Per Physician Order
Penalty
Summary
Respiratory care was not provided in accordance with the physician’s order for one resident with COPD, congestive heart failure, and chronic respiratory failure. The resident’s care plan and June 2026 physician’s orders directed oxygen via nasal cannula at 4 LPM every shift, and the resident’s MDS indicated she was receiving oxygen therapy and required substantial to maximal assistance for transfers. During observation on 6/2/26, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was set at 2.5 LPM rather than the ordered 4 LPM. The resident stated she had continuous oxygen and reported that at times her oxygen was not set at the correct LPM; she also said she believed it had been set too high earlier that day and that she normally received 3 LPM. RN #2 later observed the concentrator still set at 2.5 LPM and confirmed that this did not match the physician’s order for 4 LPM. When asked about the ordered flow rate, the resident said she thought she was supposed to be on 3 LPM. RN #2 stated she would contact the physician to clarify the oxygen flow rate. The DON stated she would generally expect oxygen flow rates to match the physician’s order and that any 0.5 LPM variation should be documented in the resident’s progress notes if it occurred.
Incomplete dialysis documentation and communication
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident who required hemodialysis. The resident had diagnoses including acute kidney failure, dependence on renal dialysis, and type 2 diabetes mellitus without complications. The 4/25/26 MDS showed moderate cognitive impairment with a BIMS score of 10 out of 15, dependence on staff for toileting and eating, and substantial to maximum assistance needed for oral hygiene. The resident’s dialysis care plan, initiated 4/19/26, addressed dialysis related to anasarca and included interventions such as encouraging attendance at scheduled dialysis appointments, monitoring vital signs, notifying the medical director of significant abnormalities, and checking and changing the access-site dressing daily, but it did not include monitoring weights before and after dialysis. Record review showed the physician’s orders for pre- and post-dialysis weights were not entered into the EMR until 5/6/26, even though dialysis treatment began on 5/1/26. The resident’s dialysis communication binder also lacked forms for multiple dialysis sessions, including 5/4/26, 5/6/26, 5/8/26, 5/13/26, 5/15/26, 5/18/26, and 5/20/26. Several completed forms were incomplete because the pre-dialysis section was not filled out by facility staff for 5/1/26, 5/11/26, 5/13/26, 5/22/26, and 5/25/26. The facility’s May 2026 TAR documented pre- and post-dialysis weights on some dates, but there was no documentation of those weights for 5/1/26, 5/4/26, and 5/6/26. Interviews confirmed staff expected to obtain and document vital signs and weights before residents left for dialysis and again when they returned, and to send the dialysis communication form with the resident. The ADON acknowledged that some of the resident’s dialysis communication forms were not completed properly and said she was not aware of additional missing forms in the binder. The DON stated nurses were expected to document weights pre- and post-dialysis in the EMR and on the communication forms, and also noted that the resident missed one dialysis session and refused another. The facility was unable to provide some requested missing dialysis communication forms by the time of survey exit.
Medication Not Available for Resident’s Scheduled Wellbutrin
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident by not ensuring the resident’s anti-anxiety medication was ordered and delivered in a timely manner. Resident #64 had diagnoses including Wernicke’s encephalopathy, muscle weakness, anxiety disorder, major depressive disorder, and ADHD, and the MDS showed moderate cognitive impairment with a BIMS score of 9. The resident reported missing scheduled Wellbutrin doses and said she began to feel withdrawal side effects and increased anxiety, describing it as feeling like her insides were going to jump out. Record review showed the resident’s Wellbutrin XL 300 mg daily was not administered on five separate dates because the medication was not on hand, unavailable, or on order. Nursing notes documented that the medication was not on hand on two dates, was pending delivery after the pharmacy was contacted on another date, and was still on order on later dates. Staff interviews indicated nurses were expected to reorder medications when supply was low, contact the pharmacy if delivery was delayed, and notify the physician if a medication was unavailable, but the resident’s medication remained unavailable and the resident missed five doses.
Failure to Follow EBP and Keep Urinary Catheter Equipment Off the Floor
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The deficiency involved failure to follow enhanced barrier precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter and a resident with a tracheostomy, as well as failure to keep urinary catheter drainage bags and tubing off the ground for two residents. For one resident with an indwelling urinary catheter, an LPN entered the room to administer medication, then put on clean gloves and drained urine from the catheter bag into a container and measured it, but did not don a gown before performing catheter care. For another resident with a tracheostomy, an LPN administered medication and a respiratory therapist assisted with care; the respiratory therapist suctioned the tracheostomy before a nebulizer treatment, and both staff members failed to don a gown before administering treatments and suctioning the tracheostomy. Facility policy stated that EBP required gown and glove use during high-contact care activities for residents with wounds or indwelling medical devices. The facility also failed to keep catheter equipment from contacting the floor. One resident’s urinary catheter drainage bag was observed lying on the floor with a bedside table wheel on top of it. Another resident was observed in a wheelchair with urinary catheter tubing dragging under the wheelchair on the ground, and later the drainage bag was also observed dragging on the ground while the resident was moving around the hallways. Staff interviews confirmed that gown and glove use was expected for residents on EBP during high-contact care and that catheter tubing and drainage bags should not be dragging on the ground.
Incomplete State Agency Complaint Posting
Penalty
Summary
The facility failed to post, in a form and manner accessible and understandable to residents, a complete list of names, mailing and email addresses, and telephone numbers for all pertinent State agencies and advocacy groups, along with a statement that residents may file a complaint with the State Survey Agency. A facility policy dated April 2025 stated that required postings were to include contact information for agencies and advocacy groups such as the State Survey Agency, State Licensure office, Adult Protective Services, the State Long-Term Care Ombudsman, Protection and Advocacy Network, Home and Community Based Service Programs, Family and Medical Leave Act, Medicaid Fraud Control Unit, and information on applying for Medicare and Medicaid. During a resident group interview, five residents who routinely attended resident council meetings said they did not know how to file a complaint with the State Agency, and four said they only knew how to contact the ombudsman. An observation of the posted complaint information found a bulletin board posting with an address, phone number, and email address for the State Agency, but the phone number was not the correct number for filing a complaint. The posting also did not include the required list of other pertinent State agencies and advocacy groups or their mailing addresses, email addresses, and telephone numbers. The social services director and social services assistant later confirmed that the posting did not contain the required information.
Survey Results Not Available to Residents and Families
Penalty
Summary
The facility failed to ensure residents, family members, and legal representatives had full access to review the most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction for the preceding three years. During a resident group interview, three of five interviewable residents said they were not aware they could view the federal and state survey results and were unaware the results were supposed to be posted for resident access. Record review of the survey results binder showed the last survey on file was from 9/3/24, and the binder did not contain any 2025 survey results or plans of correction. The folder also did not include the 2025 complaint survey results from 1/22/25, 3/13/25, 6/26/25, 8/18/25, and 12/22/25. The NHA stated the 2025 survey results were on file in a different folder in her office and were unavailable to residents and family members.
Failure to Ensure Safe and Person-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure that two residents were provided with the necessary care and services to support a safe and person-centered discharge to the community. One resident, who was cognitively intact but required substantial assistance with all activities of daily living (ADLs) due to multiple sclerosis and muscle weakness, was discharged home without a documented care plan addressing discharge goals and needs. The resident's representative reported that there was no discharge planning until a few days prior to discharge, and that the facility did not arrange for home health services or complete the necessary Medicaid waiver in time. As a result, the resident was discharged without confirmed services in place, despite assurances that home health care would begin the same day. Documentation in the electronic medical record (EMR) did not show a completed plan for follow-up monitoring or contingency actions if services could not be started immediately. Another resident, also cognitively intact and dependent on staff for all ADLs due to quadriplegia and other complex medical needs, was discharged home without a thorough discharge plan. The resident's representative stated that the facility did not complete the waiver services application, did not provide a medication list or instructions, and did not arrange for a primary physician. After discharge, the resident experienced a seizure and was hospitalized, with the representative reporting that they were unaware the resident was supposed to take anti-seizure medications. Review of the EMR did not reveal documentation of a comprehensive discharge plan, updated care plan, or evidence that the resident or representative received necessary information regarding medications or care needs at discharge. Staff interviews confirmed that discharge planning was not always documented, and that in both cases, there was no formal discharge care plan or documentation of interdisciplinary team (IDT) involvement at discharge. The facility's own policy required that discharge planning begin on admission, be regularly updated, and be fully documented, including referrals and updates to the care plan. However, the records for both residents lacked evidence of these required actions, and the facility failed to ensure that the residents' needs and preferences were met or that they were prepared for a safe transition to the community.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care and assistance with activities of daily living (ADLs) for a resident with cognitive impairment and incontinence. According to the care plan, the resident required assistance with toileting and was to be checked every two hours. However, direct observation revealed that the resident was not offered or provided incontinence care for over four and a half hours while he remained in his wheelchair, despite multiple interactions with CNAs. The resident's brief was found to be soiled and saturated only after survey staff intervened and notified a registered nurse, prompting care to be provided. Documentation inconsistencies were also noted, as CNA task records indicated incontinence care was provided at a time when the resident was observed napping in the dining room. Staff interviews confirmed that the expectation was to provide incontinence care every two hours and to address refusals by re-approaching the resident within 15 to 20 minutes. Despite these policies, the resident did not receive timely care, and staff did not follow the established protocol for managing incontinence and refusals.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program that met the individualized needs and preferences of two residents, as required by their care plans. For one resident with multiple sclerosis and autism, who was cognitively intact, the care plan specified interests such as reading, writing, music, pet visits, outdoor time, and spiritual activities. However, records and interviews revealed that this resident was not invited to activities, did not receive assistance to go outside, and did not participate in pet visits or spiritual activities, despite these being documented as important to him. Another resident with dementia, blindness, and chronic kidney disease, who required moderate ADL assistance, was also not provided with activities aligned with his preferences. Observations showed that staff did not offer or facilitate engagement in music, news, coffee time, or other preferred activities, even though these were outlined in his care plan. The resident was often left in his room or in common areas without meaningful interaction or stimulation, and staff did not provide reminders or assistance to participate in group or individual activities. Staff interviews confirmed that while activity preferences were assessed and calendars provided, there was inconsistency in inviting and encouraging residents to participate in activities. The activities director acknowledged that CNAs may need reminders and re-education to ensure residents are consistently engaged according to their care plans. The lack of personalized activity programming and failure to offer or encourage participation resulted in unmet physical, mental, and psychosocial needs for the affected residents.
Failure to Accommodate Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to provide food and drinks that accommodated a resident's allergies, intolerances, and preferences, specifically not ensuring a vegetarian diet as prescribed and preferred by the resident. Despite a physician's order and meal ticket indicating a vegetarian diet, the resident was served non-vegetarian food, including a pork chop at lunch and marble cake containing chocolate at dinner, which the resident was supposed to avoid due to a prior medical procedure. The resident reported that her food choices were repetitive and that she was not offered a vegetarian diet during her stay. Review of the care plan revealed it did not identify the resident's preference for a vegetarian diet or her inability to eat chocolate cake. Staff interviews confirmed that although a vegetarian menu extension existed, it was not utilized for this resident. The dietary manager stated that the resident would communicate her food preferences directly to the kitchen, but a specific vegetarian menu was not consistently provided. The registered dietitian acknowledged learning only recently about the resident's need to avoid chocolate, confirming that the cake served contained chocolate.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during wound care for several residents. Staff did not consistently provide a clean location for wound care supplies, with one instance where dressing change supplies were placed on a resident's bedside table among personal food items without cleaning the table or creating a clean field. This was contrary to facility policy, which requires setting up a clean field for wound care supplies. Staff also failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during high-contact care activities. Certified nurse aides (CNAs) assisted with repositioning residents for wound care without donning gowns, as required for high-contact activities involving residents with wounds. In several cases, CNAs and licensed practical nurses (LPNs) did not change gloves or perform hand hygiene between dirty and clean tasks, such as after removing soiled dressings or cleaning wounds and before applying new dressings. One CNA left a resident's bedside during wound care to assist another resident and returned without changing gloves or performing hand hygiene. Interviews with staff confirmed awareness of the required procedures, including the need for gowns during wound care and the importance of hand hygiene after glove removal and between tasks. However, staff acknowledged that these practices were not consistently followed, citing issues such as lack of hand sanitizer or paper towels, but also recognizing that these were not valid reasons to omit hand hygiene. The director of nursing and other clinical leaders confirmed that the observed practices did not meet facility policy or CDC guidelines.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. The incidents involved two altercations between the residents, where one resident was the victim of hair-pulling and coffee-splashing by the other resident. Despite the incidents, the facility's investigations were unable to substantiate the abuse due to a lack of witnesses and the absence of injuries or intent to harm. The victim, who had moderate cognitive impairments, did not recall the incidents and denied feeling unsafe. The assailant, who had severe cognitive impairments and a history of delusional thinking and aggression, was involved in multiple incidents of aggression. The facility's interventions included one-on-one supervision and psychological support, but the interventions were not consistently documented or effectively communicated to the staff. The assailant's behaviors were not adequately monitored, and there was no behavior monitoring order in place until after the survey began. Staff interviews revealed a lack of training and communication regarding the assailant's behaviors and triggers. The DON acknowledged the challenges in creating effective interventions due to the assailant's cognitive fluctuations and delusions. The facility's failure to implement and document appropriate interventions and staff training contributed to the deficiency, as the staff was not adequately prepared to manage the assailant's aggressive behaviors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of psychotropic medications for three residents. Resident #46, who was moderately cognitively impaired and had a court-ordered guardianship, was administered Zyprexa without the guardian's consent. The resident's electronic medical record did not contain an informed consent signed by the guardian, and the consent form provided was signed by the resident without a date, despite the resident being unable to make decisions due to confusion from medical diagnoses. Staff interviews confirmed that the informed consent should have been obtained from the guardian before administering the medication. Resident #25, who was cognitively intact, was administered olanzapine without being informed of the possible interactions with his other medications, including mirtazapine. The resident's electronic medical record lacked documentation indicating that he was informed of the risks associated with the medication. Although a medication review was conducted during the survey, it did not specifically document that the resident was informed of the risks of taking olanzapine. Staff interviews revealed that informed consents should be obtained upon the resident's arrival and for any new medication orders. Resident #47, who was cognitively intact and diagnosed with generalized anxiety disorder and bipolar depression, was administered Seroquel and Zoloft without informed consent. The resident's electronic medical record showed that the informed consents for these medications were signed during the survey, not prior to the administration. Staff interviews confirmed that informed consents should be signed before administering psychotropic medications to ensure residents and their representatives are aware of the risks and side effects.
Failure to Complete Annual Performance Reviews and In-Service Education for CNAs
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five certified nurse aides. Specifically, the facility had not completed annual performance reviews for CNAs #1, #4, #5, #6, and #7 to determine potential training needs. The Evaluation Process policy, revised on 4/12/24, mandates a formal written evaluation of employees' work performance, including job performance, achieving goals, attendance record, and adherence to workplace policies. However, the facility was unable to provide annual performance evaluations for 2023 for the five CNAs mentioned above. The Director of Nursing (DON) confirmed that the annual performance reviews for CNAs #1, #4, #5, #6, and #7 had not been completed, and consequently, these CNAs had not received the required annual in-service education based on the outcome of their reviews. The DON, who had only been employed at the facility during the week of the survey, stated that she was unaware of which employees had their performance reviews completed by the previous DON and would need to conduct a full audit to determine which employees required their performance evaluations to be completed.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, specifically in the areas of hand hygiene and food labeling. During lunch meal service, a dietary aide (DA) repeatedly handled soiled dishes and then clean dishes without performing proper hand hygiene. The DA was observed lifting the dish machine door, handling soiled dishes, and then immediately touching clean and sanitized dishes without washing her hands. This occurred multiple times, including instances where the DA used gloves to handle dirty dishes and then touched clean items without changing gloves or washing hands. Despite the facility's policy and previous education on hand hygiene, the DA did not adhere to these standards, leading to potential cross-contamination of clean dishes used for food production. In addition to hand hygiene issues, the facility also failed to ensure that food in the nourishment refrigerator was properly labeled, dated, and disposed of in a timely manner. Observations revealed multiple items in the refrigerator that were either not labeled, not dated, or had expired dates. These included plastic food containers, a fast food sandwich bag, a sandwich in a clear bag, a container of carrot juice, an open yogurt container, and individual portion cups. Some items had resident names but no dates, while others had neither. The facility's policy required that all food be labeled, dated, and monitored for expiration, but this was not consistently followed. Interviews with staff, including the director of housekeeping, dietary manager (DM), and nursing home administrator (NHA), confirmed that hand hygiene education had been provided but was not effectively implemented. The dietary aide admitted to not receiving recent handwashing education until the survey. The DM and NHA acknowledged that the dietary staff were responsible for monitoring the refrigerator and removing expired items, but this was not done consistently. The failure to follow proper hand hygiene and food labeling procedures led to unsanitary conditions in the facility's food handling and storage areas.
Facility Fails to Maintain Sanitary and Safe Shower Room
Penalty
Summary
The facility failed to maintain a sanitary and safe environment in one of its shower rooms, as observed on 5/7/24. The shower room between unit 100 and 200 had two wooden fabric woven chairs that were damp and stained, a shower curtain divider with brown and black stains that touched the ground, and multiple holes in the walls with jagged tile edges. The grout in the shower room had hardened debris, and there were missing floor tiles by the shower entrance. Additionally, personal hygiene items, trash, and a razor were found on the floor, and the sharps container was full. No disinfectant products were visible for CNAs to use between residents, except for a bottle of glass cleaner on the floor. Interviews with staff revealed a lack of awareness and adherence to cleaning procedures. Housekeeper #1 was unaware of the need to clean the shower room, and the Director of Housekeeping acknowledged that the shower room was not being cleaned according to the facility's procedures. The Director of Nursing and the Infection Preventionist confirmed that the chairs used in the shower room were inappropriate due to their porous surfaces and potential to harbor bacteria. They also noted that all items should be picked up off the floor, sharps should be disposed of properly, and broken tiles and holes in the wall should be repaired to prevent pathogen development.
Failure to Provide Required Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that five certified nurse aides (CNAs) received the required 12 hours of annual in-service training for continued competence. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. However, a review of the training records revealed that documentation of the annual training was not maintained for the five CNAs. The Staff Development Coordinator (SDC) admitted that the facility did not have a process to track the required training hours and was in the process of developing a tracking form and new employee training packets. The SDC also mentioned that a skills fair was planned for June 2024 to address the training needs.
Failure to Monitor Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two residents reviewed for nutrition status. Specifically, the facility did not obtain weekly weights per the physician's orders for Resident #60 and Resident #58. Resident #60, who was under 65 years old and had severe protein-calorie malnutrition among other diagnoses, had a physician's order for weekly weights starting from 2/26/24. However, the facility did not record any weights between 2/3/24 and 4/1/24, during which the resident lost 4.3 pounds, or 4.4% of his body weight. This weight loss was not significant but indicated a failure to follow the physician's orders for weekly monitoring. Resident #60 expressed concern about his recent weight during an interview on 5/1/24, highlighting the facility's oversight in monitoring his nutritional status as required by the physician's order and facility policy. The facility's policy stated that newly admitted residents and those with weight loss should have their weight monitored weekly for four weeks, but this was not adhered to in Resident #60's case. Resident #58, who was over 65 years old and had severe cognitive impairment along with other diagnoses, also had a physician's order for weekly weights starting from 4/17/24. However, her weight was not obtained after her initial admission weight on 4/3/24. The electronic medical record (EMR) noted that weights were not applicable or the resident was not available on the scheduled dates, and there was no documentation of refusal except for one instance on 4/25/24. The facility updated the physician's order on 5/6/24 to weigh Resident #58 every Tuesday for four weeks, but this was during the survey and did not address the initial failure to follow the physician's orders. Interviews with staff, including a CNA and an LPN, revealed that residents were supposed to be weighed upon admission and then every two weeks, with more frequent weighing if requested. Staff were also expected to document refusals and notify a nurse if a resident refused to be weighed. The DON confirmed that staff should obtain residents' weights per the facility policy and document any refusals. Despite these procedures, the facility did not adhere to the physician's orders for weekly weights for both residents, leading to a deficiency in providing appropriate treatment and care according to professional standards of practice.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #46's drug regimen was free from unnecessary drugs. Specifically, the resident was administered acetaminophen in excess of the recommended maximum dose of 3 grams in a 24-hour period. On two occasions, the resident received an additional 650 mg of acetaminophen over the maximum recommended dose, and there was no documentation that the physician was notified of this excessive dosage. Additionally, the resident had an as-needed order for hydralazine to be administered for systolic blood pressure over 160 mmHg, but the medication was not administered on two occasions when the resident's blood pressure exceeded this threshold. There was also no documentation that the physician was notified of the missed doses of hydralazine. Resident #46, who is over 65 years old, has multiple diagnoses including atrophy of the kidney, cerebral infarction, osteomyelitis of the lumbar vertebra, dementia with psychotic disturbances, and hypertension. The resident is dependent on staff for various activities of daily living and has moderate cognitive impairment. The resident's medication regimen included scheduled acetaminophen and as-needed acetaminophen for pain, as well as as-needed hydralazine for high blood pressure. Interviews with staff revealed a lack of awareness and adherence to the physician's orders. An LPN stated she was unaware of the as-needed order for hydralazine and acknowledged the risks of not administering antihypertensive medication. The DON confirmed that nurses should check blood pressure before administering antihypertensive medications and that not administering these medications could place the resident at risk. The DON also stated that exceeding the recommended dose of acetaminophen could strain the resident's liver and that the physician should be notified in such cases, which was not done.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards. Specifically, the facility did not dispose of expired medications and vaccines in a timely manner, and failed to label insulin pens and Tubersol vials with open dates. Observations revealed that expired medications, including Lantus insulin pens, Tubersol vials, and a Spivax Covid-19 vaccine, were found in the main nurses' medication room. Additionally, an opened Novolog insulin vial was found to be six months past the recommended use-by date. Registered Nurse #2 acknowledged that expired medications should have been removed to prevent administration to residents. Further observations in the 400 hall medication cart revealed that Latanoprost eye drops were stored well past their recommended use-by dates, and a vial of Lantus insulin with no open date was found stored improperly. Registered Nurse #1 confirmed that it was the nurses' responsibility to remove expired medications and acknowledged the risks associated with using expired medications, including reduced effectiveness and potential bacterial growth in eye drops. The Director of Nursing (DON) confirmed that insulin medications were only good for 30 days once opened and emphasized the importance of labeling medications with open dates. However, the DON's understanding of the expiration periods for Novolog, Lantus, and Latanoprost did not align with the manufacturer's guidelines. The DON reiterated that it was the nurses' responsibility to ensure expired and discontinued medications were removed from the medication carts and refrigerators to maintain medication efficacy for residents.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure residents who were prescribed mechanical soft diets received food prepared according to their diet orders. During a lunch meal service, it was observed that the mechanically altered items were not prepared correctly. Specifically, the stuffed pepper was not pureed, the corn was not served in a pureed form, and the wheat roll was not slurried. These discrepancies were noted despite the facility's dietary manual and mechanically altered diet menu specifying the required modifications for these items. The cook identified the incorrect items as mechanical soft foods, and the dietary manager admitted to not following the mechanically altered menus, instead using the dietary manual as a guideline. Further interviews revealed that the dietary manager was new to the facility and unfamiliar with the menu program, which contributed to the failure in providing the correct mechanically altered foods. Additionally, a certified nurse aide (CNA) reported not receiving training on mechanically altered diets or how to recognize if a modified texture diet was prepared incorrectly. This lack of training and awareness among staff members further exacerbated the issue, leading to residents receiving food that did not meet their prescribed dietary needs. The nursing home administrator (NHA) acknowledged the deficiencies and mentioned that the facility planned to transition to the International Dysphagia Diet Standardization Initiative (IDDSI) with the help of speech therapists for staff training. However, at the time of the incident, the facility's failure to adhere to the prescribed mechanical soft diet modifications resulted in residents being served inappropriate food textures, posing a potential risk to their health and safety.
Inadequate Infection Control Practices in Housekeeping
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infections on two of six units. Specifically, the facility did not ensure that housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touch areas such as call lights, door handles, and handrails. Additionally, housekeeping staff were not appropriately trained on housekeeping procedures, did not use the correct surface disinfectant products, and did not adhere to surface disinfectant times as required by the facility's policy and procedure. During observations, it was noted that housekeeping staff used a surface cleaner instead of a disinfectant to clean the surfaces in resident rooms. Housekeeping staff used the same cleaning agent-soaked cloth to clean multiple surfaces and did not sanitize or clean high-frequency touch areas. For example, in one instance, a housekeeper used a toilet brush to clean both the inside and outside of the toilet bowl, which is against proper cleaning protocols. Interviews with housekeeping staff revealed that they were not trained properly and were unaware of the high-frequency touch areas that needed to be disinfected. The Director of Housekeeping (DOH) acknowledged the deficiencies and stated that there were areas of opportunity to improve housekeeping and routine room cleaning procedures. The DOH admitted that the facility disinfectant needed to be used when cleaning resident rooms and that high-frequency touch areas needed to be disinfected. The Director of Nursing (DON) and the Infection Preventionist (IP) also confirmed that surface disinfectant times should be adhered to and that only approved facility disinfectant products should be used. They emphasized that housekeeping staff should change cleaning cloths and gloves and complete hand hygiene appropriately between different areas of cleaning the resident rooms.
Failure to Complete Level II PASRR for Resident
Penalty
Summary
The facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one of the residents reviewed. Specifically, Resident #33, who was younger than 65 and had diagnoses including mild neurocognitive disorder, nonpsychotic mental disorder, and major depressive disorder, was recommended for a Level II PASRR evaluation. However, the facility did not complete this assessment. The resident was cognitively intact with a BIMS score of 14 out of 15 and required minimal assistance with activities of daily living. Despite the recommendation for a Level II PASRR, there was no evidence that it had been completed, and the resident's behavior care plan indicated resistance to care related to major depression. Interviews with the social services director (SSD) and the director of nursing (DON) confirmed the oversight. The SSD acknowledged that a Level II PASRR was recommended but not completed and stated that she would immediately submit a request for the assessment. The DON emphasized the importance of completing a Level II assessment to document triggers for behaviors and determine the level of care needed. The SSD conducted an audit of all Level I PASRRs to ensure compliance moving forward, but this action was taken after the deficiency was identified.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide scheduled showers to Resident #69 and Resident #35, who were dependent on staff for bathing. This deficiency was identified through observations, record reviews, and interviews with the residents and staff members. Resident #69, who had diagnoses including chronic kidney disease, congestive heart failure, and traumatic brain injury, reported that he had not received his scheduled showers for three weeks. The review of shower logs confirmed that Resident #69 missed multiple scheduled showers from February to May 2024. The ADL care plan for Resident #69 indicated that he required supervision and assistance with showering due to his self-care performance deficit. Similarly, Resident #35, who had diagnoses including Guillain-Barre syndrome, muscle weakness, and morbid obesity, also reported not receiving his scheduled bed baths. The review of shower logs revealed that Resident #35 missed several scheduled bed baths from February to April 2024. The ADL care plan for Resident #35 indicated that he required assistance with bathing and preferred sponge baths when a full bath or shower could not be tolerated. Interviews with staff members, including CNAs and the DON, confirmed the importance of scheduled showers for hygiene and skin integrity, but they were unable to explain why the showers were missed.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 538 citations issued within 25 miles in the last 12 months — including the 7 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Rehabilitation & Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Center At Lowry, Llc | 1.1 mi | ★★★★★ | 11 | 0 |
| Hilltop Park Post Acute | 2.2 mi | ★★★★★ | 17 | 0 |
| Veterans Community Living Center At Fitzsimons | 2.4 mi | ★★★★★ | 0 | 0 |
| Berkley Care Center | 2.4 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.