Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pelican Pointe Health And Rehabilitation Center during CMS and state inspections, most recent first.
Delayed response to urinary retention after catheter removal. A resident with severe cognitive impairment and multiple neurologic diagnoses had an indwelling catheter removed and then did not void for hours. The nurse documented that the resident felt unwell and that the bladder scanner was not working, but the MD was not notified at that time. The resident’s representative reported green discharge, penile swelling, and discomfort and requested hospital transfer, but the resident remained in the facility for several more hours before EMS transport. At the hospital, the resident was found to have a distended bladder, suprapubic cramping, green urethral discharge, and 1300 ml drained after catheter placement.
A resident with severe cognitive impairment and multiple neurologic diagnoses was prescribed cephalexin for a UTI, but the MAR and dispensing records showed multiple missed and inconsistently documented doses. The resident received some doses, but several were omitted, one dose was only half the ordered amount, and the physician was not documented as being notified about the missed antibiotic doses.
Catheter Bag Left on Floor: A resident with an indwelling catheter was observed multiple times with the catheter bag touching or lying on the floor, including while seated in a wheelchair and while in bed. The bag was also seen without a privacy cover at times, and an LPN and the DON stated catheter bags should be kept below the bladder and off the floor for infection control and dignity purposes.
A resident with dementia, COPD, pneumonia, and mild depression was prescribed an antidepressant, an antianxiety medication, and an antipsychotic, but the record did not show documented behaviors to justify the antipsychotic use. The care plan lacked specific target behaviors, the MARs did not include mood or behavior tracking or side effect monitoring for the antipsychotic and antianxiety meds, and the chart did not contain consent documentation for the psychotropic medications.
Care Plan Not Timely Revised for Catheter Care and Recurrent UTI Prevention: A resident with dementia, Parkinson’s disease, urinary obstruction, and an indwelling suprapubic catheter had recurrent UTIs and frequently manipulated the catheter tubing. Staff documented repeated reminders, hand hygiene assistance, distraction techniques, fluid encouragement, and timely emptying of the drainage bag, and the IDT noted the resident’s cognition and catheter touching were barriers to treatment. However, the resident’s care plans were not updated to include these catheter care interventions, even though staff knew they were being used.
Failure to Offload Heels and Provide Timely Wound Care: Two residents with pressure injuries did not receive care consistent with MD orders and care plans. One resident with dementia and severe cognitive impairment was observed in bed without heel offloading devices, with the heels resting directly on the mattress and no dressing on the necrotic right heel. Another resident with severe cognitive impairment had a right heel dressing that had not been changed for several days despite an order for daily wound care. Staff interviews confirmed the ordered wound care and heel offloading were not consistently completed.
A resident with ESRD, DM2, and cognitive impairment had repeated gaps in dialysis communication documentation. The facility’s dialysis forms were often incomplete, missing pre-dialysis weights, meds given before treatment, or nurse signatures, and the dialysis RN reported the forms were frequently not filled out completely. Staff also described communication and transportation problems that delayed dialysis-related care and pickup.
Staff failed to follow infection control practices during resident care involving EBP. During wound care for one resident with a complicated wound, an ADON touched furniture with gloved hands and continued care without changing gloves or performing hand hygiene, and another staff member rubbed his face on his gown and kept using the same gown. For another resident with open foot wounds on EBP, a CNA assisted with a transfer while wearing gloves but no gown, despite signage requiring gown and glove use for high-contact care. Interviews showed inconsistent staff understanding of EBP and facility training.
Failure to monitor and document antibiotic side effects for a resident receiving cefuroxime for a UTI. The resident had dementia, an indwelling urinary catheter, and a G-tube, and the chart showed monitoring for UTI signs such as cloudy urine and hematuria, but no consistent documentation of antibiotic adverse reaction monitoring. Staff said nurses were responsible for watching for side effects and documenting them, yet the EMR lacked that evidence and the care plan did not include specific antibiotic side effect interventions.
A resident with severe cognitive impairment and psychiatric conditions repeatedly exhibited physically aggressive behaviors toward several other cognitively impaired residents, including attempts to harm a roommate and other residents using objects and direct aggression. The facility did not conduct timely interdisciplinary reviews, update care plans, or implement effective interventions after these incidents, and staff communication and training on resident-specific behaviors were lacking, resulting in repeated exposure of vulnerable residents to harm.
The facility failed to ensure the acting NHA was properly licensed, resulting in a lapse when the DON's temporary NHA permit expired and was not renewed in time. The facility also did not notify the State Survey Agency of the change in NHA position, as confirmed by staff interviews and record review.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident with severe cognitive impairment reported missing personal items, including a cell phone and eye glasses, but the facility failed to document and follow up on these grievances. Despite the facility's policy requiring prompt resolution of grievances, the social services director and nursing home administrator did not ensure the process was followed, leading to a deficiency identified during the survey.
The facility failed to provide necessary ADL assistance to three residents, including bathing and shaving. A resident with a surgical incision did not receive ordered daily showers, while another did not consistently receive bed baths due to staff being too busy or understaffed. A third resident was not shaved as needed, and documentation was lacking. The DON was unaware of these issues, indicating a lack of monitoring.
A facility failed to prevent the elopement of a resident with dementia, who left the premises without the wanderguard alarm activating. The facility did not investigate the incident or ensure routine checks of the wander prevention devices. Additionally, care plans for other residents at risk of elopement were not updated, and there was a lack of communication and documentation among staff regarding these incidents.
The facility failed to maintain proper infection control practices, as staff did not adhere to hand hygiene protocols and did not allow sufficient contact time for disinfecting glucometers. Observations showed that staff members did not perform hand hygiene before and after glove use, and glucometers were not disinfected according to the manufacturer's instructions. Interviews revealed a lack of awareness about the correct disinfection procedures, contributing to the deficiencies.
Delayed response to urinary retention after catheter removal
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who had an indwelling catheter removed and then did not void in a timely manner. The resident had diagnoses including cerebral infarction, Parkinson’s disease, and Alzheimer’s disease, and was severely cognitively impaired, dependent on staff for toileting-related care and transfers. The physician’s order after catheter removal required post-void residual checks every six hours for 24 hours and notification of the provider if there was greater than 400 ml remaining after voiding or no voiding in 12 hours. After the catheter was removed, the resident told the nurse later that day that he was not feeling well. The nurse documented that the resident had not voided and attempted to use a bladder scanner, but the scanner was not functioning. There was no documentation that the physician was notified at that time regarding the inability to void and the non-functional bladder scanner. Later that evening, the resident’s representative voiced concerns about green exudate at the meatus, swelling of the penis, and the resident’s lack of voiding. The nurse documented reassurance that efforts were ongoing and that the physician would be notified, but the resident remained in the facility for several more hours. The resident’s representative requested transfer to the hospital because the resident was uncomfortable, had not voided, and she did not want the facility to perform a catheter procedure there. The resident was not sent out until over nine hours after catheter removal. At the hospital, the resident was found to have a distended bladder, suprapubic cramping, a strong urge to void, and green discharge from the urethral meatus. An indwelling catheter was placed immediately and returned 1300 ml of urine. The resident was diagnosed with urethritis, urethral discharge, and retention of urine.
Missed Antibiotic Doses and MAR Documentation Errors
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when Resident #5 did not receive the physician-ordered cephalexin for a urinary tract infection as prescribed. Resident #5 had diagnoses including cerebral infarction, Parkinson's disease, Alzheimer's disease, and neuromuscular dysfunction of the bladder, and was severely cognitively impaired, dependent on staff for multiple activities of daily living, and incontinent of urine. After returning from the emergency room with a new order for cephalexin 500 mg by mouth three times daily for seven days, the resident's medication administration record did not consistently reflect the ordered doses. The first dose given on 4/30/26 was documented in a nursing progress note and in the automated dispensing system, but not on the MAR. On 5/1/26, the resident received doses at 8:00 a.m. and 2:00 p.m., but the 8:00 p.m. dose was not administered and was coded to see the progress note. On 5/2/26, the resident received doses at 8:00 a.m., 2:00 p.m., and 8:00 p.m., although the dispensing record showed no more 500 mg capsules were available after the morning transaction that day. On 5/3/26, the resident received a 250 mg cephalexin capsule instead of the ordered 500 mg dose, and the 2:00 p.m. dose was left blank on the MAR. The MAR also showed additional 500 mg doses as given later that day, even though the dispensing record did not show more cephalexin available after the 250 mg dose. On 5/4/26 and 5/5/26, multiple doses were not administered and were documented in progress notes as ordered or waiting for delivery from the pharmacy. The resident then received doses again on 5/5/26, 5/6/26, and 5/7/26, and the medication was discontinued after the 7-day course. In total, the record showed 10 missed doses out of 21 ordered doses, and there was no documentation that the physician was notified about the missed antibiotic doses on 5/1/26, 5/3/26, 5/4/26, and 5/5/26.
Catheter Bag Left on Floor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when Resident #5’s indwelling catheter bag was observed touching the floor on multiple occasions. The resident was seen in the dining room with the catheter bag clipped to the underside of the wheelchair, but the bottom of the bag was sitting on the floor and about one to two inches of catheter tubing was dragging on the floor. There was no privacy bag covering the catheter bag at that time. Later the same day, the resident was observed in the room with the catheter bag lying flat on the floor next to the bed, again without a privacy bag covering it. At another observation, the catheter bag had a privacy covering, but the bag was still lying flat on the floor next to the bed, with the top half of the bag out of the privacy bag and approximately three to four inches of catheter tubing lying on the floor. During a later observation, the resident was in bed with the catheter bag propped against the bed, but the bottom half of the bag was out of the privacy bag and sitting on the floor mat next to the bed. Staff interviews confirmed that catheter bags should be kept below the bladder and not touching or lying on the floor, and that they should be covered for infection control and dignity purposes.
Psychotropic Medication Monitoring and Consent Deficiency
Penalty
Summary
The facility failed to ensure one resident was as free from unnecessary psychotropic medications as possible. The resident, who was admitted with diagnoses including pneumonia, COPD, and dementia, had orders for citalopram for depression, clonazepam for anxiety, and quetiapine for dementia. The resident’s MDS showed cognitive intactness with a BIMS score of 13 out of 15, mild depression, and no documented behaviors of psychosis, aggression, pacing, exit seeking, rejection of care, or sexually inappropriate behavior. Record review showed the psychoactive medication evaluation for quetiapine listed dementia as the diagnosis, but it did not document any behaviors for the resident. The resident’s care plan addressed psychosocial well-being and included general interventions such as allowing time to answer questions, verbalizing feelings, involving family, and removing the resident to a calm safe environment during conflict, but it did not document specific target behaviors to monitor to justify the psychotropic and antipsychotic medications. The December 2025 and January 2026 MARs also did not contain mood or behavior tracking, and while sleep and side effect tracking was documented for the antidepressant, there was no side effect tracking for the antipsychotic or antianxiety medications. The pharmacy consultation report recommended adding behavior and side effect tracking to the MAR for clonazepam, citalopram, and quetiapine. In addition, the record did not contain documentation that consent had been obtained for the psychotropic medications. During interview, the RN stated the resident was on quetiapine for dementia and clonazepam for anxiety and that the facility was monitoring sleep for the antidepressant, while the DON stated the facility should have triggered antipsychotic behavior monitoring and acknowledged that psychotropic medication consents should have been documented, but the consents were not provided during the survey.
Care Plan Not Timely Revised for Catheter Care and Recurrent UTI Prevention
Penalty
Summary
The facility failed to ensure Resident #9’s comprehensive care plan was reviewed and revised in a timely manner to include the instructions needed for effective and personalized catheter care to help prevent recurrent UTIs. The resident had diagnoses including unspecified dementia, Parkinson’s disease, benign prostatic hyperplasia with lower urinary tract symptoms, urethral stricture, and bladder neck obstruction, and the 12/5/25 MDS showed severe cognitive impairment with a BIMS score of 0 out of 15. The assessment also showed the resident had an indwelling catheter and required varying levels of assistance with activities of daily living. Record review showed existing care plans for methenamine hippurate and for a suprapubic catheter, but the documented interventions did not reflect the newer measures staff were using to address the resident’s repeated catheter manipulation and recurrent UTIs. Notes documented that the resident required cues to stop pulling on the catheter, was encouraged not to tamper with the tubing, and was being seen by speech therapy to educate him on catheter hygiene. IDT notes documented that the resident often unhooked and touched the catheter throughout the day because of impaired cognition, did not recall staff education, and had barriers to UTI treatment related to frequent touching of the catheter tubing and skin without proper hand hygiene and catheter care. Additional documentation showed the resident was being seen for recurrent UTI and catheter pain, and staff continued to assist with catheter care, remind him not to touch the tubing and bag, encourage handwashing, engage him in activities, offer snacks to distract him, encourage fluids, and empty the drainage bag timely. Interviews with CNA, RN, IP, and DON staff confirmed that catheter care was being provided and that staff were aware the resident’s dementia and frequent touching of the catheter contributed to chronic UTIs. However, the care plans were not updated to include these interventions, despite staff knowledge that the resident should have had a catheter care plan with interventions for nursing staff to use to prevent infection.
Failure to Offload Heels and Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that two residents with pressure injuries received care consistent with physician orders and professional standards of practice. One resident, who had dementia, anxiety, hypothyroidism, pain, insomnia, and severe cognitive impairment, had an unstageable right heel pressure injury and was supposed to have her heels offloaded while in bed and a hydrocolloid dressing applied to the right heel. During observation, she was lying on her side on an air mattress with no heel protection devices on either foot, and her heels were positioned directly on the mattress. When wound care was observed, her right heel had black necrotic tissue and no dressing was in place. The resident’s record showed that her skin assessment documented no heel pressure injuries on admission, but later identified a right heel wound onset date. Her physician’s orders directed staff to cleanse the right heel, apply a hydrocolloid dressing weekly and as needed, and encourage heel offloading and side-to-side positioning in bed. Her care plan also included floating the heels as necessary and administering treatments as ordered, but the care plan was not updated to reflect the air mattress and staff did not consistently implement the heel offloading interventions observed. A second resident, who had hypertension, chronic kidney disease, anxiety, depression, transient ischemic attack, and severe cognitive impairment, had an unstageable right heel pressure injury. During wound care observation, the dressing on the right heel was dated four days earlier, showing that the ordered daily dressing change had not been completed. The physician’s order required cleansing the area, applying xeroform, and covering it with bordered gauze daily and as needed. The resident’s care plan identified an actual skin integrity impairment and included wound treatments as ordered, but the dressing remained unchanged beyond the ordered timeframe.
Incomplete Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure dialysis communication forms were consistently and completely completed for a resident who required dialysis services. The resident had end stage renal disease, type 2 diabetes, and moderate cognitive impairment, and was dependent on staff for multiple activities of daily living. Facility policy required ongoing communication and collaboration with the dialysis facility, including documenting resident assessments, interventions, medications given before dialysis, pre-dialysis weight, and access-site assessment information. Record review showed multiple dialysis communication forms were incomplete. One form did not document medications administered before dialysis, another did not document a pre-dialysis weight, and additional forms later provided after survey exit also lacked pre-dialysis weights, medication documentation, or nurse signatures. None of the forms provided after survey exit included information from the dialysis center on them. Staff interviews confirmed that the facility used the communication sheet to send information with the resident to dialysis and that the primary nurse was responsible for completing it, while the dialysis RN stated the forms were often not filled out completely and that communication with the facility was difficult. The record also reflected communication and transportation problems related to dialysis care. The dialysis RN reported that on one occasion the resident was left at the dialysis center for an extra hour and a half to two hours because no one from the facility was there to pick her up, and on another occasion treatment was delayed because the facility forgot to send the resident’s sling for transfers. The DON acknowledged that the facility used the communication form and that missing forms were sometimes requested from the dialysis center, but the reviewed record still showed repeated gaps in the documentation and communication process.
Infection Control Lapses During Wound Care and EBP
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program during resident care on two units. During wound care for a resident with enhanced barrier precautions (EBP), the assistant director of nursing touched the resident’s dresser drawer with gloved hands to retrieve barrier pads and then continued wound care without changing gloves or performing hand hygiene. During the same wound care, an unidentified staff member wore a gown and gloves but rubbed his face on his left arm twice and then continued assisting without changing the gown until the observation was brought to his attention. A second resident with open wounds on the left foot was also on EBP, with signage on the door indicating that gloves and a gown were required for resident care activities including transfers, hygiene, linen changes, toileting, and wound care. While assisting this resident with a toilet-to-chair transfer, a CNA wore gloves but did not don a gown. The CNA stated she did not know the resident was on precautions and did not recall receiving specific education regarding EBP from the facility. The report also included staff interviews showing inconsistent understanding of EBP and infection control practices. One agency CNA said she did not receive specific facility training and relied on prior training from other facilities. An LPN stated that residents with indwelling Foley catheters or open wounds required gowns and gloves for care. The infection preventionist and DON stated that all nursing staff received EBP education during orientation and quarterly infection control education, and the DON said she would provide education to staff regarding hand hygiene and gown changes.
Failure to Monitor Antibiotic Side Effects and Document Antibiotic Stewardship
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included monitoring of antibiotic use and resident response for one resident receiving antibiotics. The cited deficiency involved a resident with obstructive uropathy, dementia, TIA, epilepsy, spinal stenosis, an indwelling urinary catheter, and a gastrostomy tube, who had moderate cognitive impairment and required extensive assistance with care. The resident was prescribed cefuroxime axetil 500 mg by G-tube twice daily for a UTI for three days. Record review showed the facility had alert charting for the UTI that tracked abnormal urine color, cloudy urine, hematuria, and bladder spasms, but there was no documentation that antibiotic side effects were consistently reviewed or monitored. The resident’s infection care plan addressed infection risk related to indwelling devices, enhanced barrier precautions, monitoring for signs and symptoms of infection, vital signs, and education on hand hygiene, but it did not include specific interventions for caregivers to monitor for antibiotic side effects. The resident also stated he did not know what side effects of the medication to watch for. Staff interviews indicated nurses were expected to monitor antibiotic effectiveness and adverse reactions and document this in the EMR, but the resident’s record did not contain such documentation. The CNA stated antibiotic monitoring was not part of her role, and the LPN said side effects such as nausea, vomiting, or upset stomach would be monitored and documented in progress notes. The IP and DON acknowledged that residents on antibiotics should have monitoring documented in the EMR and that there was no monitoring documentation for this resident.
Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect cognitively impaired residents from repeated incidents of physical abuse and attempted abuse by another resident with a history of severe cognitive loss and psychiatric diagnoses. Multiple altercations occurred involving this resident, who exhibited escalating physically aggressive behaviors toward several other residents, all of whom also had significant cognitive impairments. These incidents included attempts to harm a roommate by threatening with oxygen tubing and placing a bedside table on the roommate's chest, as well as attempts to harm other residents by using objects such as a walker and by direct physical aggression, resulting in at least one resident falling to the floor. Despite these events, the facility did not conduct timely or comprehensive interdisciplinary team (IDT) reviews or clinical assessments to address the changes in the resident's behavior. There was no evidence that the facility updated care plans or implemented effective interventions to prevent recurrence after the initial incidents. The facility also failed to separate residents known to have conflicts, and did not update behavior monitoring orders or care plans to reflect new aggressive behaviors. Staff interviews revealed a lack of communication and training regarding resident-specific behaviors and interventions, particularly among contract and agency staff, leading to further risk of harm. Additional incidents of resident-to-resident altercations occurred on other units, with no timely evidence of interventions to prevent repeat abuse. The facility's documentation and monitoring practices were inconsistent, and staff were not always aware of or following care plan interventions. The lack of prompt and effective action to address and prevent aggressive behaviors resulted in repeated exposure of vulnerable residents to potential and actual harm.
Removal Plan
- Initiate one-to-one staff supervision for Resident #4 and maintain until survey exit.
- Provide all staff education on prevention and de-escalation of behaviors with Resident #4.
- Initiate resident abuse education for staff by the DON; complete at the beginning of each shift until 100% of staff are educated; provide ongoing education prior to the start of shift for all contracted staff.
- Create an additional binder at the nurses’ station to provide education to agency staff on abuse expectations and procedures.
- Initiate education with staff on all residents’ plan of care updates.
- Initiate a binder for resident-specific behaviors, identified triggers, and interventions and place it at every nurses’ station.
- Review and update Resident #4’s comprehensive care plan and abbreviated care plan with up-to-date triggers and non-pharmacological interventions.
- Complete a facility-wide audit for all residents with a history of verbal and/or physical aggression; update care plans with person-centered interventions including triggers and non-pharmacological interventions.
- Have the DON or designee complete audits on three random residents three times per week for twelve consecutive weeks, including observation of resident interactions/roommate situations and staff interviews to confirm staff awareness of resident behaviors, triggers, and interventions.
Lapse in NHA Licensing Due to Expired Temporary Permit
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable state laws. During the survey, it was found that the DON was acting as the nursing home administrator (NHA) while the facility had a NHA in training preparing to become the permanent licensed NHA. A review of the state licensing website revealed that the DON had applied for a temporary NHA license for emergency situations, but this permit had expired. There was a lapse in the NHA licensing, as the temporary permit was not renewed in time, resulting in a period where the acting NHA was not properly licensed. Interviews with the DON and the corporate operations director confirmed that the DON's temporary NHA license had expired and that there was no evidence the State Survey Agency was notified of the change in the NHA position. The corporate operations director believed that the licensing and regulatory agency would notify the State Survey Agency, but could not provide documentation to support this. Documentation later provided by the DON confirmed the lapse in licensing for the acting NHA.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for a resident who reported missing personal items, including a cell phone and eye glasses. The facility's grievance policy requires that grievances be documented, investigated, and resolved promptly, with the grievance official responsible for overseeing this process. However, the facility did not document or follow up on the grievances reported by the resident and their representative regarding the missing items. The resident, who has severe cognitive impairment and requires assistance with daily activities, reported missing eye glasses and a cell phone. The resident's representative confirmed the loss of multiple cell phones and eye glasses over time and reported these issues to the facility staff. Despite these reports, the facility did not document a grievance for the most recent missing eye glasses and failed to follow up on previous grievances adequately. Interviews with the social services director (SSD) and the nursing home administrator (NHA) revealed a lack of documentation and follow-up on the grievances. The SSD acknowledged the oversight in not completing a grievance form for the missing items and admitted to not having any follow-up documentation. The NHA was aware of the missing items but did not ensure that the grievance process was followed. The facility's failure to document and address the grievances promptly led to the deficiency identified during the survey.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for three residents who were unable to perform these tasks independently. Resident #1, who had a surgical incision and required daily showers as part of her wound care, did not receive showers on multiple occasions as ordered by her physician. The documentation in the electronic medical record (EMR) indicated that showers were not provided on several specific dates, and the Director of Nursing (DON) was unaware of these lapses. Resident #3, who required bed baths due to her size and preference, did not receive them consistently as scheduled. The resident reported that staff often cited being too busy or understaffed as reasons for not providing the baths. The EMR and paper records showed discrepancies in the documentation of her baths, with no record of baths during a specific week and an instance where a bath was not given due to short staffing. Resident #5, who needed assistance with personal hygiene including shaving, was observed with long facial hair and expressed a desire to be shaved. The EMR and paper records indicated that the resident did not receive baths consistently, and there was no documentation of shaving on certain dates. The DON acknowledged the lack of documentation and was unaware of the reasons for these deficiencies, indicating a lack of monitoring and oversight in ensuring that ADL care was provided and documented as required.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide an environment free of accident hazards and ensure adequate supervision and assistance devices to prevent accidents for several residents. Specifically, the facility did not provide supervision to prevent the elopement of a resident who had a wander prevention device. The resident, who had dementia and was at risk for wandering, managed to leave the facility without the wanderguard alarm going off. The facility did not investigate how the resident eloped, and there were no physician's orders for the wanderguard or documentation that its function was routinely checked. Additionally, the facility did not complete accurate elopement risk assessments for two other residents and failed to update care plans to include their wander risk and wanderguards. The care plans for these residents did not reflect their current needs, and there was no documentation of routine checks of the wander prevention devices. The nursing staff and administration were not aware of the lack of physician's orders and routine checks for the devices, and there was no increased supervision or monitoring of the residents at risk of elopement. Interviews with facility staff revealed a lack of communication and documentation regarding the elopement incidents. The nursing home administrator and director of nursing were not aware of the specifics of the elopement incidents, and there was no investigation conducted to determine the cause. The maintenance director did not document door checks on weekends, and there were reports of door alarms not functioning properly. The facility's failure to ensure the proper functioning of wander prevention devices and lack of adequate supervision contributed to the residents' risk of elopement.
Inadequate Infection Control Practices in Glucometer Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and inadequate disinfection of glucometers. The facility's policy required the use of an alcohol-based hand rub or soap and water in specific situations, including before and after direct contact with residents and after removing gloves. However, staff members were observed not adhering to these guidelines. For instance, an LPN did not perform hand hygiene before donning gloves and after removing them, and another LPN failed to perform hand hygiene before applying gloves and after removing them. Additionally, the facility did not ensure that glucometers were properly disinfected between uses. The manufacturer's instructions for the Sani-Cloth Germicidal Disposable Wipes specified a contact time of two minutes for effective disinfection. However, observations revealed that staff members did not allow the glucometer surfaces to remain wet for the required time. One LPN wiped the glucometer, leaving it wet for only nine seconds, while another LPN allowed it to remain wet for approximately ten seconds. Furthermore, a registered nurse did not disinfect a resident's glucometer after use. Interviews with staff revealed a lack of awareness regarding the proper dwell time for the disinfectant wipes. The Director of Nursing acknowledged that nurses should perform hand hygiene before and after donning gloves and that glucometers should be disinfected after each use. However, the DON admitted that she had not provided education on the contact time for the Sani-Cloth Germicidal Disposable Wipes, contributing to the observed deficiencies in infection control practices.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbine Commons Health And Rehab Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| Center At Rock Creek, Llc | 7.2 mi | — | 0 | 0 |
| Grace Pointe Cont Care Sr Campus, Skilled Nursing | 7.3 mi | ★★★★★ | 4 | 0 |
| Center At Centerplace, Llc, The | 8.6 mi | ★★★★★ | 11 | 1 |
| Lemay Avenue Health And Rehab Llc | 9 mi | ★★★★★ | 12 | 0 |
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