Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Suites At Someren Glen Care Center, The during CMS and state inspections, most recent first.
A facility failed to ensure informed consent was obtained and documented for proposed treatment changes. One resident received psychotropic medications without a consent form showing the risks and benefits were explained, another resident’s Seroquel dose was increased without updated consent from the resident or representative, and a third resident received ceftriaxone for a suspected UTI even though the representative had requested comfort-focused care and no antibiotic treatment.
Failure to Timely Report Abuse Allegations: The facility did not report three abuse allegations to the State Agency within the required two-hour timeframe. The incidents involved alleged verbal abuse between two residents and alleged sexual abuse involving a resident and a CNA. Record review and interviews showed the reports were delayed by about 20 hours, 20 hours, and 90 hours, despite facility policy and staff statements that abuse allegations should be reported immediately.
The facility failed to thoroughly investigate multiple abuse and neglect allegations involving a CNA and two residents. One resident with COPD, depression, muscle weakness, and moderate cognitive impairment reported inappropriate touching of her breasts, but the investigation lacked an interview with the CNA, resident representative follow-up, and staff interviews. Another resident with Parkinson’s disease, GERD, anxiety, and depression reported sexualized touching during a transfer, but the file lacked the CNA interview, related education, and observation of transfer technique. A separate neglect allegation involved a CNA sleeping on shift while residents were on the unit, but the investigation did not include the reporter’s statement or complete documentation of work restriction during the investigation.
Failure to resolve resident council grievances about call light delays. Residents reported long waits for call lights, especially overnight, with some waits lasting up to two hours and staff not consistently responding even to repeated bathroom call light pulls. Meeting minutes showed the same concerns were raised over several months, but the facility did not document a resolved response or outcome for the ongoing staffing and call light complaints.
A facility failed to ensure two residents were treated with dignity and respect during transfers. One resident with COPD, muscle weakness, and moderate cognitive impairment said a male CNA moved her breasts during a toilet-to-wheelchair transfer without properly explaining what was happening, while another resident with Parkinson’s disease, anxiety, and depression reported that the same CNA patted the area just below her bottom during a bed transfer and felt the contact was sexual in nature. Both residents had care plan preferences for female caregivers when possible.
The facility failed to document self-administration assessments for two residents with medications or supplements kept at the bedside. One resident with multiple chronic conditions had prescribed creams left on the bedside table, including products the resident and representative could not identify, and staff said the medications should not have been left unattended. Another resident with Parkinson’s disease had supplements at the bedside despite an order allowing self-administration, but the EMR did not show an assessment confirming the resident could safely manage them.
Failure to Knock Before Entering a Resident's Room: A resident with Alzheimer’s disease, dementia, and type 2 diabetes reported that staff sometimes entered his room without knocking across all shifts. During an interview, two staff members entered his room without knocking while checking on his roommate. Staff confirmed the expectation to knock and wait before entering, and noted the resident preferred privacy and his door to remain closed.
Psychotropic Medication Monitoring and Care Planning Deficiencies: Surveyors found that two residents had psychotropic medication use that was not monitored or reviewed in a resident-specific way. One resident with dementia, anxiety, depression, and a recent femur fracture had antipsychotic and sleep medications ordered without documentation of resident-specific behaviors, effective interventions, or person-centered non-pharmacological approaches in the care plan. Another resident with Parkinson’s disease, anxiety, and depression had antidepressant and anti-anxiety medication orders with generic behavior and intervention templates that were not individualized, and the record did not show what interventions were used or whether they worked.
Incomplete hospital transfer documentation: A resident with CVA history, AFib, hyperlipidemia, and severe cognitive impairment was sent to the hospital after new right-sided weakness was noted. Although staff documented the ambulance transfer and family involvement, the EMR did not show that transfer information was provided to the hospital and the discharge summary was not completed at the time of transfer. The DON and an RN stated that a transfer form and related documentation should be completed and sent whenever a resident leaves the facility.
Incomplete care planning and missed interventions for two residents. One resident with stroke-related hemiplegia and a right hand contracture was repeatedly observed without the ordered wheelchair pillow support or WHFO brace, and the care plan was not updated to reflect refusal of the brace or current needs. Another resident with multiple chronic conditions and heel wounds had incomplete admission care planning, no care plan focus for knee contracture, and no inclusion of heel booties in the skin integrity plan despite discharge instructions to keep the boots in place; the booties were observed off the resident while he was in bed.
A resident with multiple diagnoses, including an open wound and mobility impairment, had an air mattress attached to the bed, but the chart did not show a physician order for the mattress or documentation of routine monitoring, maintenance, or the correct setting. Staff said the mattress was arranged through admissions and the DME company, but RN staff did not know who set the parameters, and leadership stated no assessment was completed before the mattress was used.
Unsafe transfers and wheelchair transport resulted in resident injuries. One resident who depended on a sit-to-stand lift fell when staff transferred her with the device, and the record did not show an RN assessment, physician/representative notification, incident report, or PT/OT re-evaluation after the fall. Another resident with cognitive impairment sustained a left forearm skin tear when a CNA moved her wheelchair too quickly and her arm struck a dining room table.
Missing Physician Order for Resident Oxygen Use: A resident was observed with a nasal cannula in place and an oxygen concentrator turned on at the bedside, but the chart contained no physician order for oxygen. The resident's MDS did not indicate oxygen therapy, while the care plan did, and staff stated oxygen requires a physician order and that nurses manage oxygen settings and placement.
Improper storage and labeling of medications and biologicals were found in a medication cart and two medication rooms. An expired bisacodyl bottle remained in stock, an opened Spiriva inhaler for a resident was not dated, an RSV vaccine kit for a discharged resident was still stored in the refrigerator, and two opened Tubersol PPD vials remained in use beyond the allowed time after opening.
Incomplete Documentation of End-of-Life Event: A resident with CHF, CKD, metabolic encephalopathy, and dementia had a DNR/no CPR status, but the EMR did not accurately document that CPR was not performed when he was found unresponsive and died in the facility. The nursing note recorded that the nurse called a code and 911, and staff interviews confirmed that CPR was not done, yet the record did not clearly reflect the actual events.
Hospice care records and care coordination were not properly maintained. Two residents receiving hospice services had hospice notes that were not readily available in the EMR, and their care plans did not clearly divide responsibilities between facility staff and the hospice team. Staff described inconsistent communication methods, could not locate hospice binders, and reported there was no specific hospice coordinator.
Infection control failures occurred when housekeeping staff did not follow proper room-cleaning procedures, including cleaning high-touch areas, changing gloves, and performing hand hygiene between tasks. A housekeeper cleaned a resident room without cleaning the sink first or sanitizing the call light, and another housekeeper moved through multiple cleaning tasks without changing gloves or cleaning hands. An LPN also failed to keep an Oxivir wipe wet for the required dwell time on a blood pressure cuff and reused the cuff on another resident without disinfecting it between residents.
A resident with orthostatic hypotension, dementia, chronic kidney disease, and other comorbidities had a physician order for midodrine with a hold parameter to stop the dose when systolic BP exceeded 100 mmHg. Review of the MAR showed that nursing staff administered midodrine 49 times despite documented systolic BP readings above the ordered threshold. Facility policy required medications to be given exactly as prescribed and vital signs to be obtained and reviewed before administration, but interviews with the regional nurse, medical director, NHA, and nursing staff confirmed a systemic pattern of not following BP parameters for this medication, resulting in a significant medication error.
A resident with severe dementia and Parkinson's disease was physically redirected by a CNA after spilling a drink, without any verbal explanation or reassurance, contrary to the individualized care plan that required verbal and person-centered interventions. Staff interviews confirmed that the care plan was not followed, resulting in a failure to provide a dignified and appropriate response.
Two residents with cognitive and physical impairments did not receive timely assistance with toileting and incontinence care, resulting in prolonged periods without being checked or changed. Staff did not follow care plans or facility policy, and one resident was found soiled with urine and skin redness, while another remained wet for over five hours due to delayed care and inability to use the call light.
The facility failed to provide timely interventions and proper documentation for two residents at risk of pressure injuries, leading to the development and worsening of stage 3 and unstageable pressure injuries. Staff did not offer frequent repositioning or toileting, and there was a lack of documentation for refusals of care.
The facility failed to complete annual performance reviews and provide regular in-service education for five CNAs. The NHA and DON confirmed that the evaluations were not conducted as required, and a previously scheduled evaluation fair was poorly attended due to an illness outbreak.
The facility failed to post accurate staffing information, including the actual working hours of licensed and unlicensed staff, on multiple days. Observations and staff interviews confirmed that the posted information was either outdated or incomplete.
The facility failed to properly store and label medications, including expired medications in a medication cart, unlabeled insulin pens, and medications stored in a dormitory-style refrigerator with significant ice build-up. The LPN and DON were unaware of proper storage requirements.
The facility failed to maintain an infection control program, as a resident's foley catheter bag was repeatedly found on the floor, and mechanical lifts were not disinfected between uses. Staff interviews confirmed these practices, which could lead to infections.
The facility failed to ensure that a CNA received the required 12 hours of annual in-service training, with one CNA completing only 0.75 hours. Staff interviews confirmed awareness of the deficiency, and a new staff development coordinator was hired to address training compliance.
Failure to Obtain and Document Informed Consent for Psychotropic Medications and Antibiotic Therapy
Penalty
Summary
The facility failed to ensure residents were fully informed of the treatment, including the risks and benefits, of proposed care and that they could choose an alternative option if they preferred. The deficiency involved three residents: one resident who was cognitively intact and receiving psychotropic medications, one resident with severe cognitive impairment whose psychotropic dose was increased, and one resident with severe cognitive impairment whose representative did not want antibiotic treatment for a suspected urinary tract infection. For the cognitively intact resident, the record showed orders for risperidone for dementia with behaviors and sertraline for depression, and the first doses were administered. The consent form for these psychotropic medications did not reveal whether the facility explained the risks versus benefits of the medications to the resident or representative. Staff interviews indicated nursing staff were responsible for obtaining consent for medications with black box warnings and were expected to explain side effects, monitoring, and risks versus benefits, but the resident’s consent form did not document that information. For the resident whose psychotropic medication was increased, the record showed an initial consent for Seroquel 12.5 mg twice daily, followed by recommendations and administration changes that increased the dose to 25 mg twice daily and later to 50 mg twice daily. The chart did not contain documentation that the resident’s representative was informed of and agreed to the dose increase, and there were no updated psychotropic informed consent forms for the higher dose. Staff interviews confirmed that a new consent should have been obtained when the dose increased, but none could be found. For the resident whose representative opposed antibiotic treatment, the resident had severe cognitive impairment, a MOST form for comfort-focused treatment only, and a durable power of attorney naming the wife as representative. After the resident developed signs of a possible UTI, ceftriaxone was ordered and two doses were administered. Documentation showed the representative requested that treatment be held until hospice re-evaluated the resident and later stated she did not want antibiotic therapy, but the facility still administered antibiotics before the order was cancelled. The record also showed the breakdown in communication between the on-call physician and nursing staff could not be verified.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey and Certification Agency within the required two-hour timeframe for three of six abuse allegations. The incidents included an alleged verbal abuse between two residents on 2/18/26, an alleged sexual abuse between a resident and CNA #6 on 12/19/25, and another alleged sexual abuse between a resident and CNA #6 on 1/3/26. The facility’s abuse policy stated that suspected or actual abuse must be reported and that the executive director would ensure applicable regulatory agencies were notified within 24 hours of becoming aware of the allegation; staff interviews also reflected that abuse should be reported immediately and that the State Agency should be notified within two hours. Record review showed the alleged sexual abuse involving Resident #82 and CNA #6 occurred at 3:45 p.m. on 12/19/25, but the report to the State Agency was not made until 11:51 a.m. on 12/20/25, about 20 hours later. The alleged sexual abuse involving Resident #79 and CNA #6 occurred at 7:00 p.m. on 1/3/26, but was not reported until 1/7/26 at 1:49 p.m., about 90 hours later. The alleged verbal abuse between Resident #46 and Resident #56 occurred at 4:00 p.m. on 2/18/26, but was not reported until 12:15 p.m. on 2/19/26, about 20 hours later. Interviews with the NHA, social services assistant #2, and the DON confirmed the facility’s expectation that abuse allegations be reported promptly, including within two hours.
Failure to Thoroughly Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate three allegations involving abuse and neglect. The report states that the facility did not fully investigate a sexual abuse allegation involving CNA #6 and Resident #82, a sexual abuse allegation involving CNA #6 and Resident #79, and a neglect allegation involving CNA #5. The facility policy required a detailed investigation, immediate initiation by the senior staff member on duty, documentation of all relevant evidence, and determination of whether the allegation was verified, not verified, or inconclusive. For Resident #82, who had COPD, depression, muscle weakness, difficulty walking, overactive bladder, and moderate cognitive impairment with a BIMS score of 10, the investigation documented that she reported CNA #6 had his hands where they should not be and clarified that she meant her breasts. The interview with Resident #82 occurred three days after the allegation. The investigation did not document an interview with CNA #6, did not document that the resident’s representative was informed or interviewed, did not include staff interviews about the incident, and the resident-specific interview questions used for other residents did not address the sexual abuse allegation. The resident later told surveyors that an employee had touched her inappropriately and that she had reported it with her pastor. For Resident #79, who had Parkinson’s disease, GERD, anxiety, depression, and a BIMS score of 12, the investigation documented that she said CNA #6 patted the area below her bottom during a transfer and that she felt the contact was sexual in nature. The facility suspended CNA #6, but the investigation did not include documentation of his interview, education provided to him, any training related to abuse and transfers, or attempts to observe and assess his transfer technique. For the neglect allegation involving CNA #5, the facility documented that he was observed sleeping on the overnight shift while residents were on the unit. The investigation included interviews and a review of personnel and call light records, but it did not include CNA #4’s statement or interview, and the facility could not provide documentation showing CNA #5 was not allowed to work during the investigation. Staff interviews also indicated CNA #5 had a pattern of sleeping on shift, and the executive director and DON stated they were unaware of some of the reporter’s statements when reviewing the case.
Failure to Resolve Resident Council Grievances About Call Light Delays
Penalty
Summary
The facility failed to ensure a response, action, and rationale for resident group grievances related to long call light wait times. The grievance management policy stated that grievances brought by residents or resident representatives were to be investigated, with a written explanation of findings and proposed remedies provided within three calendar days and a final written outcome within 30 days. However, the resident council meeting minutes from January 2026 through April 2026 showed repeated concerns about delayed call light response times and staffing, and the minutes did not show that the facility resolved those ongoing concerns. During a group interview, four residents reported that call light wait times were long, especially on the night shift, and that there were not enough CNAs to help residents in a timely manner. The residents said needs were not always met because of low staffing, that waits could be up to two hours, and that some residents activated neighboring residents' call lights to get staff attention. One resident said she waited one hour for her bathroom call light to be answered on the morning of the interview and sometimes got up without assistance because staff did not respond timely, despite being at risk for falls and not supposed to get up alone. Another resident reported waiting one hour for staff to respond to a call light the previous day and said staff rarely responded even when she pulled the bathroom call light cord multiple times. Staff interviews confirmed that the facility had received complaints about call lights, that call light concerns were discussed in resident council meetings and through a performance improvement plan, and that the executive director expected call lights to be answered within 10 minutes. A CNA stated that one CNA was responsible for approximately 11 to 12 residents on one unit and that residents sometimes waited 30 minutes to one hour for assistance during busy shifts, with some toileting themselves because they could not wait for staff.
Residents Report Inappropriate Touching During Transfers
Penalty
Summary
The facility failed to ensure two residents were treated with dignity and respect during transfers. Survey findings showed that a male CNA was involved in transfer-related interactions with both residents that they perceived as inappropriate, and the facility’s own investigation documented that one resident said she felt the CNA’s hands were where they should not have been and that she was referring to her breasts. The resident stated she felt safe but did not like being touched by male caregivers when possible. The facility determined the event was more of a dignity issue related to not informing the resident what was going to happen during the transfer. One resident, who had COPD, depression, muscle weakness, difficulty walking, overactive bladder, moderate cognitive impairment, and required substantial to maximal assistance with most ADLs, was transferred from the toilet back to her wheelchair when the CNA attempted to move her breasts out of the way because they hung down to her waistline. Her care plan included stand-pivot transfers with one-person assist and use of a Hoyer lift on days she was weak, and later added paired care and a preference for female caregivers. The resident told the SSD she felt safe and did not like being touched by male caregivers when possible. The second resident, who had Parkinson’s disease, GERD, anxiety, depression, and moderate cognitive status, required assistance with toileting, dressing, and moving from sitting to lying. During a bed transfer, she reported that the CNA patted the area of her leg right below her bottom and said the interaction felt sexual in nature. Her care plan and Kardex indicated a preference for female caregivers when possible and for a female caregiver to be present when male caregivers were involved. The resident later stated she thought the CNA intentionally touched her inappropriately when he laid her in bed.
Missing self-administration assessments for bedside medications
Penalty
Summary
The facility failed to ensure self-administration of medications was clinically appropriate for two residents because assessments were not documented to determine whether they could safely self-administer medications. The facility policy stated that residents who desire to self-administer medications must have a prescriber’s order and an interdisciplinary team assessment of cognitive, physical, and visual ability, with the results recorded in the medical record. For one resident, who had diagnoses including chronic atrial fibrillation, COPD, peripheral vascular disease, prediabetes, chronic kidney disease stage three, obesity, and a left artificial knee joint, the record showed physician’s orders for Nystop powder and nystatin, zinc, and lidocaine cream. During observation, three medication containers were found on the bedside table, including the prescribed creams and a silicone cream, and the resident and representative did not know what the medications were for or when they were last used. The EMR did not show documentation of an assessment for safe self-administration, and staff stated the creams should not have been left unattended with the resident. For the second resident, who had Parkinson’s disease, GERD, anxiety disorder, and depression and was cognitively intact with a BIMS score of 12, bottles of circulation and vein support supplements and glucosamine chondroitin were observed on the bedside table on multiple occasions. Although the CPO included an order allowing the resident to self-administer lion’s mane, circulation and vein support, and glucosamine chondroitin, the EMR did not contain documentation of an assessment to determine whether the resident could safely self-administer the supplements. The DON stated an evaluation should have been completed to confirm the resident could identify the medications, read the label, and remember what was taken and when.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to ensure personal privacy for one resident by not consistently requiring staff to knock before entering his room. The resident, who had Alzheimer's disease, dementia without behavioral disturbance, and type 2 diabetes, had moderate cognitive impairment with a BIMS score of 11 out of 15 and required set-up assistance with oral hygiene, toileting hygiene, and dressing. He reported that staff sometimes entered his room without knocking across all shifts, that it happened a few times, and that he preferred staff to knock because he frequently used the phone or watched television and wanted privacy. During the interview, two unidentified staff members entered the resident's room without knocking and stated they were checking on his roommate. The resident said this was annoying and that he had not reported it to anyone. Staff interviews confirmed the expectation to knock and wait for a response before entering a resident's room, including when checking on a roommate or when the call light was activated. Staff also stated the resident preferred his door to remain closed and did not want anyone entering without knocking, yet the resident continued to experience staff entering without knocking across different shifts.
Psychotropic Medication Monitoring and Care Planning Deficiencies
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Surveyors found that Resident #4’s antipsychotic medication use was not appropriately monitored or reviewed by the interdisciplinary team for continued medical necessity, and that both Resident #4 and Resident #79 had behaviors related to psychotropic medication use that were not identified and monitored in a resident-specific way. The facility also did not include resident-specific non-pharmacological care approaches in either resident’s care plan for the behaviors described in the record. Resident #4 was admitted with diagnoses including dementia, anxiety, depression, osteoarthritis, hypertension, aortic stenosis, a history of falling, and a displaced left femur fracture. The resident’s assessment showed he was cognitively intact with a BIMS score of 14, had minimal depression, and did not have hallucinations, delusions, or behavioral symptoms toward others during the assessment look-back period. His record included orders for melatonin for insomnia, sertraline for depression, and antipsychotic medications including quetiapine and risperidone for anxiety with behavioral disturbances and dementia with behaviors. However, the record did not include physician orders identifying resident-specific behaviors to monitor for each psychotropic medication, and there was no documentation showing what behaviors were being monitored, what interventions were offered, or whether those interventions were effective. His care plans for depression, dementia with behavior, elopement risk, and sleep disturbance also did not identify person-centered non-pharmacological interventions. Resident #79 was admitted with diagnoses including Parkinson’s disease, anxiety disorder, and depression. Her assessment showed moderate cognitive intactness with a BIMS score of 12 and mild depression. Her physician orders included venlafaxine for depression and clonazepam for generalized anxiety, along with template monitoring orders listing behaviors and non-pharmacological interventions. Surveyors found those orders were not resident-specific and did not identify which behaviors or interventions applied to this resident. Although the care plan described anxiety-related call light use and repeated requests, the record did not document what specific interventions were offered when behaviors occurred or whether they were effective. Staff interviews confirmed the resident had frequent call light use and high anxiety, but the EMR did not show individualized behavior monitoring or effective non-pharmacological interventions.
Incomplete Hospital Transfer Documentation
Penalty
Summary
The facility failed to provide and document sufficient discharge preparation and documentation for one resident who was transferred to the hospital. The resident was greater than 65 years old, had diagnoses including cerebral infarction, atrial fibrillation, hyperlipidemia, and long-term anticoagulant use, and was severely cognitively impaired with a BIMS score of 4 out of 15. The resident required partial to moderate assistance with dressing and showering, set-up assistance with toileting and oral hygiene, and was independent with eating. The resident was discharged to the hospital after staff and the family noted new increased right-sided weakness and clumsiness. Record review showed that on the day of transfer, a physician documented concern that the resident had developed more right-sided weakness than had been present before arrival at the facility, and that PT, OT, and the bedside nurse agreed the right side appeared to be the problematic side. Nursing documentation later stated the resident was transported by ambulance to the local hospital with the son following in his own car, and that the family requested the ED visit because of the new weakness. The resident was in stable condition upon leaving the facility. However, the electronic medical record did not show that transfer information was provided to the hospital at the time of transfer, and the discharge summary was not completed at the time of the hospital transfer. During interviews, the DON stated that when a resident was transferred to the hospital, the nurse should obtain a physician order, notify the family, print the transfer move-out record, and send the resident’s facesheet and MOST form. She acknowledged that the hospital transfer form for this resident was not completed, although she believed it may have been printed and sent with the resident. RN #6 stated that a transfer document in the computer needed to be completed by the nurse and that the resident’s representative, physician, and other pertinent staff should be notified and documented on the hospital transfer documentation. She also stated that the hospital transfer form and required documentation should always be completed when a resident left the facility.
Incomplete Care Planning and Missed Interventions for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents. For one resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, and a right hand contracture, the care plan included placing a small pillow on the right side of the wheelchair to keep the arm elevated and applying a WHFO brace to the right hand and arm. During the survey, the resident was repeatedly observed sitting in the wheelchair with the contracted right hand resting on the lap or held against the chest without the pillow support, and the WHFO brace was not in place. Record review showed the resident’s care plan interventions had been in place for years and included the pillow and brace, but the resident had documented worsening stiffness and pain with brace application. The DON stated the care plan interventions for the right hand contracture were from 2020 and should have been updated to reflect the resident’s refusals and current needs. Staff interviews indicated CNAs were expected to notify nurses of refusals, but the DON stated she did not have documentation showing the resident refused the right arm support pillow intervention. For another resident with multiple medical diagnoses including peripheral vascular disease, obesity, chronic kidney disease, COPD, and a left artificial knee joint, the facility did not complete the care planning section on the admission assessment and did not develop a care plan focus for knee contracture. The resident had physician-discharge instructions to keep heel boots in place at all times for left heel and toe wounds, but the EMR did not identify heel boots as a physician order or as a care plan intervention. The skin integrity care plan addressed wounds and skin tears, but it did not include the booties, and it did not identify the resident’s risk for knee contractures. During observations, the resident’s blue booties were found under the desk rather than on the resident while he was in bed, and both feet were touching the footboard of the bed.
Missing Order and Maintenance Documentation for Air Mattress
Penalty
Summary
The facility failed to ensure services met professional standards of quality for one resident who had an air mattress in use. Resident #40, who was cognitively intact, had diagnoses including osteoporosis, hypertension, prediabetes, an open wound on the left knee, osteoarthritis, and anxiety. The resident required assistance with several activities of daily living and was observed sitting in a recliner while an air mattress was attached to the bed in the room. Review of the May 2026 computerized physician orders did not show a physician's order for the air mattress, and the electronic medical record did not contain documentation showing the mattress was monitored and maintained on a routine basis or documenting what the air mattress setting should be or whether an assessment had been completed. Staff interviews showed the mattress had been obtained through admissions staff and the durable medical equipment company, but RN #1 stated there should have been a physician's order to monitor the mattress function every shift. RN #1 also said nursing staff were responsible for routine maintenance checks, but she did not know who was responsible for setting the mattress function parameters and did not know whether the settings were correct for the resident. The DON and vice president of clinical services stated the resident had a special mattress because she complained about the original mattress, that the regular mattress setting was stage 2, and that an assessment was not completed prior to a mattress being utilized. The vice president of clinical services also said a wound care physician may recommend a special mattress and that would be reflected in a physician's order.
Unsafe Transfers and Wheelchair Transport Resulted in Resident Injuries
Penalty
Summary
The facility failed to keep the environment as free of accident hazards as possible for two residents. One resident with Parkinson's disease, acute kidney failure, obstructive sleep apnea, cognitive intactness, and dependence on staff for transfers was documented as requiring a sit-to-stand mechanical lift with one to two staff assistance. The resident had a history of falls and was identified in care plans as needing extensive assistance with transfers using the sit-to-stand lift. During a transfer with the sit-to-stand lift, the resident released her hands from the device and was lowered to the floor. The record showed that the resident later reported a new CNA with limited experience operated the lift without supervision and that another CNA told her not to hang on, which resulted in her falling a short distance. The record did not show documentation of an RN assessment or notification to the physician or resident's representative after the fall, and it did not show that PT/OT re-evaluated the resident's mechanical lift use after the incident. Interviews confirmed that staff believed the event should have been reported and assessed, and the executive director stated there was no incident report or investigation for the fall. A second resident with COPD, depression, muscle weakness, difficulty walking, overactive bladder, and moderate cognitive impairment sustained a skin tear to the left forearm when being transported in a wheelchair to the dining room. The resident stated her arm hit the dining room table while a CNA was moving her too quickly. The nursing note documented that the CNA brought the resident to the nurse, who assessed and treated the 6.5 cm by 3.5 cm skin tear and notified the unit manager and the resident's son. Staff interviews indicated the injury occurred when the wheelchair struck the table, and the RN stated there were no interventions put in place to prevent the injury from happening again.
Missing Physician Order for Resident Oxygen Use
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident who had oxygen in use without a physician's order. Resident #4, who had diagnoses including displaced fracture of the left femur, hypertension, aortic stenosis, dementia, osteoarthritis, anxiety, and depression, was observed lying in bed with a nasal cannula in place and an oxygen concentrator turned on next to the bed. The resident stated his oxygen was great but did not know how long he had used it or what it was for. The resident's MDS assessment indicated he was not receiving oxygen therapy, yet the oxygen therapy care plan stated he had oxygen therapy. Record review of the resident's May 2026 computerized physician orders revealed no order for oxygen. Facility staff stated nurses were responsible for oxygen therapy and that a physician's order was required for any resident receiving oxygen. RN #1 and RN #3 said they knew which residents needed oxygen based on hospital reports and discharge orders, and RN #1 later observed the resident with oxygen on while resting but did not know why he had it in place. The DON also stated there needed to be a physician's order for any resident using oxygen and said the resident should either have an order for oxygen as needed or the concentrator should be removed from the room.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Drugs and biologicals were not properly stored, secured, and labeled in one medication cart and two medication rooms. During observation of the transitional care unit medication storage room, an expired bottle of bisacodyl 5 mg tablets was found with an expiration date of April 2026. In the Aspen medication cart, an opened Spiriva Respimat inhaler for Resident #63 was stored in a labeled medication box, but the inhalation device itself was not labeled with the date it was opened. In the Aspen medication storage room refrigerator, an Arexvy RSV vaccine vial kit was found in a labeled medication box for Resident #107 even though that resident had been discharged from the facility on 4/3/26. Also in the refrigerator were two multi-use vials of Tubersol PPD, one opened on 2/1/26 and one opened on 2/19/26. Both vials had been open for more than 30 days and were still present in the medication supply. Staff interviews confirmed the findings. RN #3 stated the expired bisacodyl should have been removed. LPN #2 stated the Spiriva inhaler should have been labeled with the opening date, the RSV vaccine should have been removed after the resident’s discharge, and the Tubersol vials should have been discarded 30 days after opening. The DON stated she would not have expected the expired bisacodyl or the discharged resident’s medication to remain in storage and said the Tubersol vials should have been moved to expired stock after 30 days.
Incomplete Documentation of End-of-Life Event
Penalty
Summary
The facility failed to maintain an accurately documented medical record for a resident who died in the facility. Resident #106 had diagnoses including acute systolic congestive heart failure, chronic kidney disease, metabolic encephalopathy, and dementia, and his care plan indicated a no CPR/DNR code status. A nursing note documented that the nurse found the resident taking his last breath, unable to be roused, with no vital signs, purple lips, cold fingers, and unresponsiveness. The note also documented that the nurse called a code and called 911, and that emergency staff arrived and later confirmed the resident's death. However, the resident's EMR did not document that CPR was not actually performed because of the resident's code status, despite staff interviews confirming that CPR was not conducted. The LPN stated the resident was DNR, that he called a code blue and 911, and that CPR was not done. The ADON also stated CPR was not performed, even though a code and 911 were called because the resident was unresponsive and the event was unexpected. The DON and MDS coordinator stated that if a resident was DNR, they would not call 911 and would instead call the physician and family, and they noted that the terminology used in the record suggested CPR had been performed when it had not.
Hospice care records and care coordination were not properly maintained
Penalty
Summary
The facility failed to meet hospice care requirements for two residents receiving hospice services by not keeping hospice notes readily available in the EMR, not developing comprehensive care plans that clearly divided responsibilities between facility staff and the hospice team, and not having a designated hospice care services coordinator. The facility policy stated that the DON/health wellness director/assisted living director or designee was responsible for coordinating ordered care and documenting it in the resident service plan or care plan, and that hospice or palliative care providers were to provide documentation for the resident record as soon as practicable. Resident #75, who had diagnoses including anxiety disorder, chronic kidney disorder, and cerebral arteriosclerosis, had moderate cognitive impairment and required substantial to maximal assistance with most ADLs. Her representative reported that the hospice nurse had not been around for three weeks, facility nurses said she was running low on supplies, and the unit nurse did not know who to contact. Record review showed she was admitted to hospice on 4/1/26, but her comprehensive care plan, initiated 4/2/26, identified her as receiving hospice services without including interventions or a delineation of care services between the facility and hospice team. Her routine hospice care service notes were not uploaded into the EMR until 5/5/26 during the survey process. Resident #38, who had diagnoses including acute kidney failure, COPD, and hemiplegia/hemiparesis following cerebral infarction, was cognitively intact but needed substantial to maximal assistance with most ADLs. Record review showed he was admitted to hospice on 12/8/25, but his hospice care plan was not initiated until 4/1/26, four months later, and it also failed to include a delineation of care responsibilities between the facility and hospice team. His routine hospice care service notes were also not uploaded into the EMR until 5/5/26 during the survey process. Staff interviews showed inconsistent communication methods, including binders that could not be found, verbal updates, whiteboards, and uncertainty about who was coordinating hospice care, while the DON and regional director stated there was no specific hospice coordinator.
Infection Control Failures in Housekeeping and Vital Signs Equipment Disinfection
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 infection. During observation, housekeeping staff did not consistently follow proper cleaning procedures in resident rooms, including cleaning high-touch areas and changing gloves or performing hand hygiene between tasks. One housekeeper entered a resident room with a bottle labeled bleach, cleaned the toilet, wiped the counter and sink area, and removed trash, but did not clean the sink before the toilet and did not clean the resident’s call light. Another housekeeper cleaned the bathroom, then moved to mopping the floor, cleaning the bedside table, window, and window sills, vacuuming, and adjusting the trash bag without changing gloves or performing hand hygiene between tasks. Interviews showed that the housekeepers identified cleaning products by bottle color, and one housekeeper stated he should have changed gloves, performed hand hygiene, and donned new gloves after completing one task and before moving to another task. The housekeeping supervisor stated that staff should clean the toilet area first, then remove gloves, perform hand hygiene, and don new gloves before moving to the sink area, and that gloves should be removed before cleaning high-touch areas. The supervisor also stated housekeeping staff were responsible for cleaning and sanitizing residents’ remotes and call lights, although CNAs also sanitized those items. The infection preventionist stated housekeeping staff received infection prevention education and confirmed that the housekeeper should have changed gloves and performed hand hygiene between cleaning tasks to avoid bringing bacteria from one area to another. The facility also failed to follow chemical dwell times and to disinfect a blood pressure cuff between residents. An LPN used an Oxivir Tb wipe on the blood pressure cuff for about 15 seconds, even though the product label required the surface to remain visibly wet for one minute. The cuff did not appear shiny or wet after wiping. After obtaining a blood pressure on one resident, the LPN returned the cuff to the equipment basket without disinfecting it again, then used the same cuff on another resident without disinfecting it between residents. The LPN stated she did not disinfect the cuff before using it on the second resident and was unsure whether the one-minute dwell time meant the product should dry for one minute or remain wet for one minute. The infection preventionist and DON both stated the blood pressure cuff should be cleaned between residents and that the facility used Oxivir wipes with a one-minute dwell time.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was kept free from significant medication errors when nursing staff did not administer a prescribed blood pressure medication according to physician-ordered parameters. Record review showed that the resident, an individual over 70 years old with orthostatic hypotension, unspecified dementia with behavioral disturbances, chronic kidney disease, hypomagnesemia, and osteoarthritis, had an order for midodrine 10 mg by mouth twice daily, later increased to three times daily, with instructions to hold the dose if the systolic blood pressure (SBP) was greater than 100 mmHg. Despite this clear order, the medication administration record documented that midodrine was administered 49 times when the resident’s SBP was outside the ordered parameters. The resident’s medical record indicated that the midodrine order with SBP parameters was in place from August through at least early September, and the medication administration record from 8/12/25 to 9/10/25 showed repeated administrations that did not comply with the hold parameter. These administrations occurred even when the documented SBP exceeded the threshold at which the medication was to be withheld. The facility’s own Medication Administration Guidelines policy required that medications be administered as prescribed, that nurses review and confirm orders on the MAR, obtain and record vital signs as necessary prior to administration, and clarify any questionable orders with the prescriber or pharmacy before giving the medication. Nonetheless, the documented practice for this resident did not align with those requirements. Interviews with facility staff further confirmed that the problem was systemic and involved multiple nurses not following physician orders for medication parameters. The regional corporate nurse stated that an audit of the resident’s electronic medical record revealed that nursing staff had failed to hold midodrine 49 times when the SBP was over 100 mmHg. The medical director reported that there was a systemic problem in the facility with following physician orders for medication parameters and stated that he expected nursing staff to follow those orders. The NHA also acknowledged a systemic problem with nurses following physician orders related to medication administration and adherence to blood pressure parameters. Nursing staff interviews referenced subsequent training on medication parameters, indicating that prior to that training, nurses had not consistently followed the ordered blood pressure parameters for midodrine, which led to the cited deficiency.
Failure to Provide Dignified, Person-Centered Redirection for Resident with Dementia
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to honor a resident's right to a dignified existence and person-centered care. The resident, a 70-year-old individual with severe dementia, mood disturbances, and Parkinson's disease, was observed during a lunch meal service to have spilled a glass of clear liquid on the food preparation counter. The CNA approached the resident from behind and physically redirected her by placing both hands under her armpits and moving her away from the area, without providing any verbal explanation, reassurance, or calming interaction. This action was not in accordance with the resident's care plan, which specified the use of verbal redirection, allowing time for response, and other person-centered interventions tailored to her cognitive and communication impairments. The resident's care plans, which addressed her impaired communication and cognitive functioning, outlined interventions such as providing verbal and visual cues, explaining procedures, and using calm, simple language. Physical redirection was not included as an intervention. Staff interviews confirmed that the CNA did not follow the care plan and that the expected approach was to use verbal redirection or comforting objects. The incident demonstrated a failure to implement the individualized care plan interventions, resulting in the resident not experiencing a dignified and person-centered response during the incident.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment and total dependence on staff for ADLs, observations revealed that she was not offered or provided with incontinence care or toileting assistance for a period of four hours. Staff interviews confirmed that the resident was last changed at 7:45 a.m., and no further care was provided until a hospice aide arrived for a scheduled shower, at which point the resident was found soiled with urine and had a reddened area near her tailbone. The care plan for this resident required assistance with toileting throughout the day and always upon rising, but this was not followed during the observed period. Another resident, who had moderate cognitive impairment and required staff assistance for all ADLs, was also not provided with timely incontinence care. Observations showed that the resident was not checked or changed from 5:03 a.m. until 10:40 a.m., a period of over five hours. During this time, staff did not offer toileting or incontinence care before or after breakfast, and the resident was found to be wet and soiled when finally changed. Interviews with staff indicated that care was delayed due to workload and assumptions that the resident would use the call light if assistance was needed. However, the resident was unable to effectively use the call light due to physical limitations, and there was no documentation of her refusing care. Both residents had care plans and facility policies in place that required regular assessment and assistance with toileting and incontinence care, but these were not consistently implemented. Staff interviews revealed inconsistent practices and reliance on subjective judgment rather than adherence to scheduled care routines. The lack of timely incontinence care resulted in residents remaining soiled for extended periods, contrary to their care plans and facility policy.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two residents. Resident #27, who was at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium. The care plan for Resident #27 did not include interventions to encourage repositioning while sitting in his recliner or frequent toileting/incontinence care. Continuous observations revealed that Resident #27 was not offered frequent repositioning or toileting by the staff, leading to the development of the pressure injuries. Resident #1, who was frequently incontinent of urine and bowel and at risk for developing pressure injuries due to decreased mobility, was identified to have an open area on her coccyx during a routine skin assessment. However, there was no documentation indicating that the wound care physician was notified, and no new physician's orders were obtained to treat the wound. It took 13 days for the facility to initiate treatment for the unstageable pressure wounds on Resident #1's coccyx and left buttock. The care plan for Resident #1 also failed to include interventions for frequent repositioning and incontinent care. Staff interviews revealed that CNAs and LPNs were aware of the need for frequent repositioning and toileting for residents at risk of pressure injuries but failed to document refusals of care or provide the necessary interventions. The Director of Nursing acknowledged that residents should be repositioned every two hours and that refusals should be documented, but there was no evidence of such documentation in the residents' electronic medical records. The facility's failure to provide timely interventions and proper documentation led to the development and worsening of pressure injuries in both residents.
Failure to Complete Annual Performance Reviews 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 those reviews for five certified nurse aides. Specifically, the facility had not completed annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8, which would have determined their potential training needs. The facility did not have a performance evaluation policy, as confirmed by the nursing home administrator (NHA). During record review and interviews, it was revealed that the annual performance reviews for the mentioned CNAs were requested but not available. The NHA admitted that the evaluations had not been completed and acknowledged that they should have been done annually. The director of nursing (DON) also confirmed that performance evaluations should be conducted annually and mentioned that a previously scheduled performance evaluation fair was poorly attended due to an illness outbreak. The facility plans to schedule another performance evaluation fair in the near future to comply with the regulations.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a prominent place and readily accessible to residents and visitors. Specifically, the facility did not include the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Observations on multiple days revealed that the staffing information was either not current or did not include the actual working hours for the staff. For instance, on 4/22/24, the staffing information was posted but did not include the actual working hours. Similar issues were observed on 4/23/24, 4/24/24, and 4/25/24, where the posted staffing information was either outdated or incomplete. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the deficiencies. The DON mentioned that a receptionist who only worked occasionally was responsible for the incorrect posting on 4/23/24 and was unsure why the actual working hours were not included. The NHA acknowledged awareness of the regulatory requirement to include actual working hours in the daily staffing post but could not explain why it was not done. Both the DON and NHA indicated that they would take immediate steps to correct the issue.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly in one of three medication carts and one of two medication storage rooms. Specifically, expired medications were found stored with current medications in the medication carts, and insulin pens were not labeled with resident names and open dates. Additionally, medications were stored in a dormitory-style refrigerator/freezer combination, which is not recommended for medication storage due to the risk of freezing medications. An open bottle of Melatonin that expired in January 2024 and a Lantus insulin pen without a resident name or open date were found in the Juniper medication cart. The LPN acknowledged that the expired Melatonin should have been removed and that the insulin pen should have been labeled to ensure proper usage and effectiveness. The Juniper medication room contained a dormitory-style refrigerator with significant ice build-up, which was in contact with a box of Trulicity, potentially compromising the medication's integrity. The LPN and DON were unaware that medications should not be stored in such refrigerators, although temperature logs did not indicate any out-of-range temperatures.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, specifically in the handling of a foley catheter and the cleaning of mechanical lifts. Observations revealed that Resident #69's foley catheter collection bag was repeatedly found on the floor, contrary to the facility's policy that required the catheter to be stored in a dignity bag or placed in a basin to avoid contact with the floor. Interviews with the resident and staff confirmed that the catheter bag was consistently placed on the floor, which could lead to infections due to the unsanitary conditions of the floor. Both the registered nurse and the director of nursing acknowledged that the catheter bag should not be on the floor as it could result in a urinary tract infection for the resident. Additionally, the facility failed to ensure that mechanical lifts were cleaned between residents. A certified nurse aide was observed transferring two residents using the same sit-to-stand mechanical lift without disinfecting it between uses. The aide stated that it was the night shift's responsibility to clean the lifts, while a licensed practical nurse and the director of nursing indicated that the lifts should be cleaned between each use with sanitization wipes. The lack of proper disinfection between uses, especially after the lift was in the bathroom, posed a risk of spreading bacteria among residents.
Failure to Ensure Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, one CNA out of five reviewed had only completed 0.75 hours of the required 12 hours of continued education units (CEU). This deficiency was identified through a review of the CNA's training records and confirmed through staff interviews. The facility's policy, revised in July 2018, mandates comprehensive orientation and training programs to prepare associates for their roles, including legal and regulatory compliance. However, the facility did not adhere to this policy in the case of CNA #9. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility was aware of the deficiency. The DON acknowledged that all CNAs should complete 12 hours of CEU annually and mentioned that CNA #9 had been written up for not meeting this requirement. The NHA indicated that a new staff development coordinator had been hired to track and ensure compliance with training requirements. Despite these measures, the deficiency remained unaddressed at the time of the survey, highlighting a lapse in the facility's training program implementation and oversight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Centennial
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Suites At Holly Creek Care Center, The | 0.6 mi | ★★★★★ | 0 | 0 |
| Orchard Park Health Care Center | 1 mi | ★★★★★ | 10 | 0 |
| Brookdale Greenwood Village | 2.7 mi | ★★★★★ | 25 | 0 |
| Vi At Highlands Ranch Skilled Nursing | 3.5 mi | ★★★★★ | 0 | 0 |
| Cherrelyn Healthcare Center | 3.5 mi | ★★★★★ | 1 | 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.