Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Rehab Coccomo during CMS and state inspections, most recent first.
Excessively Low Weekend Staffing: PBJ submissions showed the facility triggered for excessively low weekend staffing across multiple quarters. The DON, Administrator, and scheduler each stated they were not in place for most of the period reviewed, but all acknowledged weekend call outs and general low staffing contributed to the shortage, with the scheduler noting fewer staff were available on weekends and the facility had since hired more staff and stopped using agency staff.
A resident with DM2, ESRD, and dialysis dependence was allowed to keep and self-administer U-500 insulin without a documented nursing assessment of competence. Surveyors observed the insulin pen unsecured at bedside, the resident reported independently managing insulin and BG checks, and the MAR showed repeated refusals with notes that the resident self-managed. The DON was unaware of the bedside insulin and the record contained a blank self-administration assessment form.
The facility failed to obtain pre-employment references for an RN, an LPN, and two NAs whose personnel files contained no such documentation. Staff interviews confirmed the references were not obtained before hire, and the facility's Abuse policy did not state that these references were required during pre-hire screening.
A resident with Parkinson’s disease, orthostatic hypotension, and a history of falls was found on the floor after an unwitnessed fall, and facility records stated the call light was not in reach even though the care plan required it to be kept within reach. The facility also failed to develop a comprehensive care plan for another resident with quadriplegia and OSA, omitting key person-centered interventions for total ADL dependence, specialized call bell use, positioning needs, and oxygen use when out of bed.
Failure to Hold Quarterly IDT Care Plan Meetings The facility did not hold required quarterly IDT care plan meetings for four residents with ongoing care needs, including catheter care, dementia, mobility dependence, communication impairment, and anxiety. Records showed missed or overdue care plan conferences, and staff interviews confirmed the meetings were expected but could not explain why they were not completed as required by policy.
Incomplete fluid intake monitoring for two residents with urinary issues led to deficient care. One resident with a suprapubic tube and catheter complications had repeated gaps in I&O documentation despite a fluid goal and ongoing hematuria/sediment concerns, while another resident with recurrent UTIs and dysuria also had missing I&O records despite a fluid goal and orders to encourage fluids. Staff interviews showed confusion about where I&O requirements were documented and how totals were tracked.
Failure to ensure CPAP management orders were in place. A resident with OSA, quadriplegia, and morbid obesity was observed wearing CPAP while lying supine with the HOB flat on multiple occasions. The record lacked orders for CPAP cleaning, filling the water reservoir, and changing tubing, and the care plan and MDS did not identify CPAP use. The DON stated the admitting nurse was responsible for ensuring CPAP management orders were entered.
A resident with ESRD and DM receiving HD via a right subclavian double-lumen CVC had orders and TAR instructions that incorrectly referred to a fistula on the right upper chest and directed staff to remove the dressing 8 hours post-dialysis. The chart, care plan, and dialysis facility confirmation all identified a catheter access, and the DNS acknowledged the orders were inaccurate.
Medication administration errors exceeded the acceptable rate, with an observed error rate of 17.86%. An LPN incorrectly prepared and administered an injectable medication for one resident, another LPN failed to notify the supervisor and provider when ordered meds were unavailable, and an LPN gave two oral meds after a meal even though one was ordered before meals and the other on an empty stomach.
Surveyors found the facility’s only ice machine had black spots inside and had not been cleaned per manufacturer guidance. Staff were unclear who was responsible for cleaning it after the maintenance contract was cancelled, and the DON, Administrator, and Maintenance Director each described different understandings of who serviced the machine. The manufacturer manual required descaling and sanitizing at least every 6 months, but no facility policy for ice machine cleaning was provided.
A resident with Parkinson’s disease and severe cognitive impairment had multiple unwitnessed falls, including falls with head injury and ER transfers. Nursing notes stated neuro checks were initiated or should be monitored, but record review showed many neurological assessments were not completed, including after return from the hospital. The DON stated the repeated missed neuro checks had not been identified or reviewed in QAPI meetings.
Improper Storage and Labeling of Resident Personal Care Items: Surveyors found multiple bedpans, basins, and a urinal in resident private and shared bathrooms that were unlabeled, uncovered, and stored on the floor, on toilets, or at the back of toilets. An IP RN stated facility policy required these items to be labeled and covered, while an NA could not explain why the policy was not followed and the DON could not identify the policy for resident bedpans, basins, and urinals.
Advance directive documentation was incomplete for two residents. For one resident, the chart contained a Medical Interventions Form with DNR/DNI and other treatment choices, but no matching MD order was found. For another resident, the record showed full code status, but the DNR paperwork was missing, a consent form was incomplete, and multiple RN/APRN/MD notes did not document any advance directive discussion despite cognitive impairment and fluctuating orientation.
Failure to notify the provider of medication omissions. A resident with dementia, alcohol abuse with withdrawal, and GERD missed scheduled B12 and pantoprazole doses when the meds were unavailable in the med cart. An LPN documented the meds as unavailable and ordered them from the pharmacy, but the record did not show provider notification or documentation of the omission. Interviews confirmed the LPN did not notify the RN supervisor or provider, and facility policy required immediate physician notification, resident/family notification, pharmacy contact, and documentation.
Incomplete and Late BCP Documentation: A resident admitted with quadriplegia, OSA, and morbid obesity had a handwritten BCP that omitted several individualized care needs, including dietary needs, special call bell use, extensive assistance needs, and medication-related considerations. The 72-hour meeting documentation was completed late, left many questions blank, did not identify interdisciplinary participation, and the BCP lacked resident or responsible party signature showing review and receipt of the BCP summary.
A resident with severe cognitive impairment and repeated unwitnessed falls had multiple required neuro checks left incomplete after falls, including after a head injury and after return from the hospital, despite facility protocol requiring ongoing neurological assessments. In a separate event, a resident with dementia had a cup of scheduled AM meds left on the bedside table; the resident, an LPN, and an RN all confirmed the meds should not have been left in the room and that the nurse should have remained with the resident until the meds were taken.
Failure to follow a physician order for compression stockings occurred for a resident with Parkinson disease, PVD, HTN, and bilateral pitting edema. The resident was observed out of bed on multiple occasions without compression stockings and wearing only nonskid socks. Staff interviews showed the order was not reflected on the resident care card, and nursing staff and NAs relied on that card for direction; one LPN also reported no stockings were found in the room and the resident refused them that morning.
A resident with dementia and impaired decision-making had a cup of scheduled AM meds found on the bedside table during a tour. The resident said the meds appeared to be from the prior day, and an LPN confirmed they were not the meds she had given and had not noticed them left in the room. The RN supervisor stated the meds should not have been left at the bedside and that the nurse should have stayed until the resident swallowed them; the record also did not identify the resident as able to self-administer oral meds.
A resident with severe cognitive impairment, hemiplegia, anoxic brain damage, and epilepsy did not have quarterly personal funds statements sent to the resident representative. The resident’s representative reported never receiving the statements, and the BOM confirmed the statements had been sent to the resident instead of the responsible party, despite the resident’s impaired memory, decision-making, and communication abilities.
A facility failed to provide or document a Notice Regarding Reservation of a Resident's Bed for two residents transferred to the hospital. One resident with dementia, schizoaffective disorder, and HTN was sent out after suicidal ideations and severe behavioral distress, and another resident with COPD, dementia, and epilepsy was transferred for respiratory distress and pneumonia findings. Nursing notes documented the transfers and family notification, but not the required bed-hold notice, and staff interviews showed inconsistent understanding of who handled the form and where it was kept.
A resident with Parkinson disease, PVD, and HTN was admitted to hospice, but the facility did not complete a Significant Change MDS assessment after the change in status. The quarterly MDS showed severe cognitive impairment and dependence for several ADLs, and staff later documented hospice approval, hospice start, and hospice admission. An RN stated she did not think hospice was a significant change, while another RN stated the assessment should have been completed within the RAI timeframe.
A resident who sustained a femur fracture from a fall and was readmitted after surgery did not have their care plan or care card promptly updated to reflect new physician and therapy orders for non-weight bearing status and mechanical lift transfers with two staff. Staff interviews revealed confusion about the resident's current transfer status, and the facility's policy requiring timely updates to care plans was not followed.
Multiple observations revealed persistent issues with cleanliness and maintenance, including soiled floors, peeling paint, leaking sinks, broken tiles, and non-functioning lights across several units. Residents expressed dissatisfaction with the facility's condition and lack of completed repairs. Staff interviews highlighted inadequate training, missing maintenance records, and housekeeping staffing shortages, with supervisors unable to confirm recent cleaning. The facility could not provide a maintenance policy when requested.
A resident receiving IV antibiotics for osteomyelitis did not receive the full prescribed dose on three occasions because nursing staff failed to flush the IV line after medication administration, resulting in a significant portion of the medication remaining in the tubing and being discarded. This occurred despite facility policy requiring safe and accurate medication administration.
A resident reported a grievance about a broken television remote, but the facility did not act to replace it. Observations found that three residents had remotes with missing pieces or taped parts, and interviews confirmed they had reported the issue to staff without resolution. The Regional Director of Maintenance was unaware of the problem and could not verify if it had been addressed.
A resident with dementia and impaired decision-making left the facility alone despite an order requiring accompaniment, and staff were unaware of the resident's absence for over six hours. Multiple staff failed to follow the missing resident policy, including not conducting an overhead alert, not searching outside, and not notifying police. The resident was later found by law enforcement after a vehicle accident and exposure to cold, resulting in an Immediate Jeopardy finding.
A resident with cognitive impairment was subjected to verbal abuse by an LPN, who made derogatory remarks about the resident's alleged drug use and criminal behavior during a loud argument at the nurse's station. Several nursing assistants witnessed the incident but did not immediately report it, resulting in a delay in facility response. The facility's policies prohibit such mistreatment, but the resident was not protected from verbal abuse.
A resident with cognitive impairment was subjected to inappropriate and derogatory comments by an LPN during a loud argument, which was witnessed by multiple nursing assistants. The staff did not immediately report the incident to supervisors, and there was a significant delay in notifying the DON and submitting the required report to the state agency, contrary to facility policy.
A resident with chronic wounds and diabetes repeatedly refused wound care treatments, a therapeutic beverage, and prescribed offloading boots. Despite these refusals being documented in clinical records, the care plan was not updated to address or manage the resident's refusals, contrary to facility policy and expectations confirmed by the DON.
A resident with chronic wounds and diabetes did not receive a low air-loss mattress as ordered by a wound consultant, due to the facility's failure to obtain the necessary physician order and to maintain the specialized mattress in place. Staff replaced the low air-loss mattress with a standard one after it broke, despite having additional mattresses available, and did not promptly restore the required pressure relief device.
A resident with dementia and a history of alcohol abuse left the facility unaccompanied, contrary to LOA orders, and was later involved in a motor vehicle accident. The facility did not perform an elopement risk assessment upon the resident's return, and when an assessment was eventually completed, it inaccurately indicated no history of elopement, despite the recent unauthorized absence.
Excessively Low Weekend Staffing
Penalty
Summary
The facility failed to provide the appropriate number of weekend staff for Quarter 3 and Quarter 4 of Fiscal Year 2024 and Quarter 1 and Quarter 2 of Fiscal Year 2025 after Payroll Based Journal (PBJ) submissions triggered for excessively low weekend staffing. Review of the PBJ submissions for the period from April 1, 2024 through March 31, 2025 showed the facility had triggered for excessively low weekend staffing across those quarters. During interviews, the DON stated she was not working at the facility for most of the time the PBJ submissions triggered, but she was aware the facility had a low staffing problem on weekends. She reported the facility had staff call outs and general low staffing during that time. The Administrator stated she was not aware of the triggering because she had not been employed until a few weeks before the interview, and she identified that HR had been recruiting and hiring extensively and the facility had stopped using agency staff in the last month or so. The facility scheduler stated she was aware of some, but not all, of the quarters and attributed the lower weekend staffing to more call outs on weekends and fewer staff available to work.
Failure to Assess Resident’s Ability to Self-Administer Insulin
Penalty
Summary
The facility failed to assess a resident’s ability to safely self-administer insulin before allowing self-administration. The resident was admitted with diagnoses including type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Orders in effect directed blood sugar checks before meals and Humulin R U-500 KwikPen injections after breakfast, lunch, and dinner, with one order stating the resident was approved to keep insulin at bedside to self-administer. However, there was no documentation of a nursing assessment of competence to self-administer insulin, and the APRN progress note did not include documentation related to the resident’s ability to self-administer insulin. The resident told surveyors that he/she self-administered insulin, kept the insulin in the room, and monitored blood glucose independently. Surveyors observed the insulin pen unsecured on the bedside table, and the resident stated that a family member provided the insulin directly from the pharmacy without additional verification by facility staff. The MAR showed multiple instances of refusal of blood glucose monitoring and insulin administration with notes that the resident self-managed or self-administered insulin. The DON stated she was not aware the resident was keeping insulin at bedside or self-administering, and the record contained a blank Self-Administration of Medications Assessment form. The DON also stated the resident had not been assessed for self-performing and monitoring blood glucose.
Missing Pre-Employment References for New Hires
Penalty
Summary
The facility failed to ensure pre-employment references were obtained for four employees: an RN, an LPN, and two NAs. Review of personnel records showed no pre-employment references in the files for these employees, and the facility was unable to provide them when requested. Staffing schedules and time records confirmed that all four employees were currently working at the facility. During interview, the DNS stated that pre-employment references had not been obtained before hire for the RN, LPN, and NAs and should have been. The regional nurse also could not locate the references and stated she thought they were no longer required. Review of the facility's Abuse policy showed it did not indicate that required pre-employment references would be obtained during the screening of new employees.
Call Bell Not in Reach After Fall; Care Plan Missing Key Needs for Quadriplegia and OSA
Penalty
Summary
The facility failed to ensure a call bell was within reach for a resident with Parkinson’s disease, orthostatic hypotension, a history of falls, and moderate cognitive impairment. The resident’s care plan identified the resident as a fall risk and directed staff to keep the call bell within reach when the resident was in bed or in the bedside chair, encourage the resident to ask for and wait for staff assistance, and provide set-up and assistance as needed. The resident’s MDS also documented extensive assistance needs for bed mobility, toileting, and transfers. On 7/1/25, the resident was found on the floor next to the bed after an unwitnessed fall. Facility documentation stated the resident reported trying to find the red button and that the call bell was not in reach. The fall assessment and fall scene investigation both identified that the call light was not in reach, and one form noted the resident had 7 falls in the prior 30 days. A nursing note documented the resident was observed on the floor in the room and stated the resident slipped while trying to get up from the recliner chair. Staff interviews indicated the resident’s call light should have been kept within reach, and the DNS acknowledged that it was the responsibility of nursing staff or the NA to ensure the call light was always in reach. The facility also failed to develop a comprehensive care plan for a resident with quadriplegia and OSA. The resident’s MDS identified the resident as cognitively intact, dependent for eating, bed mobility, transfers, and wheeling the motorized wheelchair, with functional limitations in both upper and lower extremities. The care plan did not initially include a focus for quadriplegia or OSA, and it described the resident with interventions that staff later identified as not person-centered for the resident’s condition. Staff interviews stated the care plan should have reflected total dependence for all ADLs, use of a specialized call bell activated with the chin, assistance from 2 to 3 staff members for incontinent care, transfers, and mobility, and interventions related to positioning and respiratory care. After surveyor inquiry, the care plan was updated to note the resident could move the head and used a soft touch call bell at the neck, but it still did not include specific quadriplegia-related interventions such as extremity positioning, hand splints, or guidance about pillow placement, and it did not include oxygen therapy when out of bed to the wheelchair.
Failure to Hold Quarterly Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to complete quarterly interdisciplinary resident care plan meetings for 4 of 4 residents reviewed for care planning. The facility policy stated that a care conference was to be held on or before day 21 from admission and then at least quarterly, with the resident and/or family/responsible party invited to attend. Review of the care plan signature sheets and resident records showed that quarterly care plan meetings had not been held for the residents reviewed, despite each having active care plans and ongoing interdisciplinary needs. Resident #5 had diagnoses including obstructive and reflex uropathy, hypotension, and prostate cancer, and the annual MDS identified an indwelling catheter, cognitive intactness, and dependence for transfers. The care plan addressed a suprapubic tube due to obstructive uropathy and risk for UTI, with interventions to observe urine and perform suprapubic tube site care. The care plan signature sheet showed quarterly care plan meetings had not been held since 12/10/24. Resident #28 had diagnoses including COPD, dementia, and epilepsy, and the quarterly MDS identified moderate cognitive impairment and need for assistance with mobility and transfers. The care plan addressed impaired cognition related to dementia, but the signature sheet showed quarterly care plan meetings had not been held since 12/12/24. Resident #31 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, anoxic brain damage, and epilepsy, and the quarterly MDS identified memory problems and dependence for self-care and transfers. The care plan addressed impaired memory, recall, decision-making, and communication, but the last care plan meeting documented by the facility was 5/23/24, and the resident representative stated the last meeting attended was in November 2024 with only the social worker present. Resident #41 had diagnoses including anxiety, hypertension, and psychoactive substance dependence, and the quarterly MDS identified cognitive intactness and independence in several ADLs. The care plan sign-in sheet showed meetings were held on 7/11/23, 1/11/24, 3/26/24, 10/3/24, and 7/30/25, with quarterly meetings not held in October 2023, July 2024, January 2025, and April 2025. Interviews with MDS staff, social work, and nursing staff confirmed quarterly care plan meetings were expected, that the IDT should participate, and that the facility could not explain why the meetings were not conducted as required.
Incomplete Fluid Intake Monitoring for Residents with Urinary Issues
Penalty
Summary
The facility failed to ensure adequate fluid intake was documented and monitored for two residents who had urinary issues and were being followed for urinary tract infections. One resident had obstructive and reflex uropathy, a suprapubic tube, a history of catheter obstruction from sediment, hematuria, hypotension, and prostate cancer. The other resident had heart failure, diabetes, hypertension, recurrent UTIs, dysuria, and was receiving antibiotics for a UTI. Both residents had care plans that included fluid encouragement and intake/output monitoring, and both had fluid goals identified by the dietitian. For the resident with the suprapubic tube, the clinical record showed repeated gaps in intake/output documentation across multiple shifts and days. Nursing notes documented that fluid intake was encouraged, but the intake/output record failed to capture fluid intake for all shifts on some days and did not consistently total 24-hour intake on others. The dietitian later identified a fluid goal of 2,550 ml in 24 hours, but the quarterly nutrition note did not reflect the estimated fluid goal or whether the resident was meeting it. APRN notes described catheter-related complications including sediment accumulation and hematuria, and the resident was observed with reddish urine in the drainage bag while stating that a UTI was uncomfortable. For the resident with recurrent UTIs, the intake/output binder also showed incomplete documentation, with fluid intake recorded on some shifts but missing on others, and no documentation after a certain point in the record reviewed. The resident’s care plan directed fluids, I&O monitoring, and monitoring for UTI symptoms, and the dietitian identified a fluid goal of 1,600 ml in 24 hours. Staff interviews showed that nurse aides relied on the I&O binder to know which residents required documentation, while an LPN stated she would not know a resident needed I&Os unless there was an order in the EMR. The DON also stated she believed daily totals were documented in the EMR, but the regional clinical director was unable to locate or print I&O documentation in the EMR for residents on any unit.
Failure to Ensure CPAP Management Orders Were in Place
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was cited after the facility failed to ensure physician orders were in place for the cleaning and management of a resident’s CPAP machine. Resident #84 had diagnoses including quadriplegia, obstructive sleep apnea, and morbid obesity. The resident’s admission assessment identified the resident as cognitively intact, dependent for bed mobility, and requiring the assist of 2 staff members for transfers with a mechanical lift. A physician progress note stated the resident had OSA and significant hypercarbic respiratory symptoms in the past and should continue using the CPAP machine throughout the day. The admission MDS did not identify oxygen therapy or CPAP use, and the resident care plan did not identify OSA or CPAP use. During observations on multiple dates, Resident #84 was seen lying supine in bed with the head of bed flat while wearing the CPAP, and the resident stated the CPAP was used all day long. The clinical record did not contain physician orders for cleaning the CPAP machine, filling the water reservoir, or changing the CPAP tubing. A later physician order directed cleaning of the CPAP headgear monthly and as needed. The DNS stated it was the admitting nurse’s responsibility to ensure orders were in place for CPAP management, including machine settings, donning/doffing of the mask, cleaning, and filling the water reservoir.
Incorrect Dialysis Access Orders
Penalty
Summary
The facility failed to obtain accurate physician orders for a resident’s dialysis access site. Resident #45 had diagnoses including Type 2 diabetes mellitus and end stage renal disease with dependence on renal dialysis. The hospital W-10 identified a double-lumen right subclavian vein hemodialysis catheter, and the care plan also described a right chest double-lumen catheter used for dialysis. However, physician orders and the TAR directed staff to remove the dressing from a “fistula” on the right upper chest 8 hours after dialysis, even though the resident did not have a fistula as the access site. The resident’s record also included orders to check the dialysis site after return to the facility, but the documented treatment instructions remained inconsistent with the actual access type. During interview, the DNS confirmed the chart reflected incorrect fistula-related orders and stated they should have been changed to catheter-related orders. The dialysis facility clinical coordinator confirmed the resident received dialysis via a double-lumen right subclavian vein CVC and stated that removing the dressing 8 hours after treatment was inappropriate for this type of access.
Medication administration errors exceeded the acceptable rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with a surveyor-calculated error rate of 17.86% based on medication administration observations for three residents. The deficiency involved incorrect administration of ordered medications, failure to follow ordered timing and preparation instructions, and failure to complete required follow-up when medications were unavailable. For one resident with a central nervous system autoimmune condition, constipation, and depression, an LPN administered Betaseron by injection. During observation, the LPN prepared the medication by attaching the vial to the syringe assembly and administered the injection, but the vial remained partially filled with cloudy liquid afterward. The LPN stated that the remaining liquid was just leftover water and that there was always some water left in the vial after administration. The manufacturer instructions reviewed by surveyors described a different preparation process, including reconstituting the medication, drawing the full solution into the syringe, removing air bubbles, and then administering the injection. Interviews showed the LPN had learned the process only by shadowing other nurses and had not received written or video instruction. For another resident with dementia, alcohol abuse with withdrawal, and GERD, an LPN prepared scheduled oral medications but two ordered medications were unavailable in the medication cart. The LPN documented the medications as unavailable and ordered them from the pharmacy, but did not notify the nurse supervisor or provider, and did not communicate the omission to the oncoming shift. The record also lacked documentation and notification to the provider and pharmacy for the missed medications. Interviews confirmed that the expected process was to notify the supervisor, pharmacy, and provider when medications were unavailable. For a third resident with GERD, type 2 diabetes, muscle weakness, unsteadiness on feet, and a history of falls, an LPN administered Sucralfate and Cilostazol after the resident had finished lunch, even though the orders required Sucralfate before meals and Cilostazol on an empty stomach. The LPN acknowledged she had grouped the resident’s afternoon medications together and made a mistake by giving those medications after the meal. The MAR showed both medications were signed as administered, and the DNS and pharmacy consultant confirmed that the medications should have been given according to the ordered timing and administration instructions.
Ice Machine Not Cleaned per Manufacturer Guidelines
Penalty
Summary
The facility failed to clean the only ice machine according to manufacturer guidelines. On observation, surveyors found diffusely scattered black spots inside the ice machine on a white plastic piece, and the machine was filled with ice, limiting visibility of other surfaces. The service record on the machine showed the last chemical cleaning by the refrigeration company occurred on 11/12/24 and the water filter was changed on 12/2/24, with no further entries after that date. The refrigeration company dispatcher stated the company had last cleaned the ice machine on 11/11/24, that this was the only ice machine serviced by the company, and that the corporate officials had cancelled the maintenance contract earlier in the year. Facility staff were unclear who was responsible for cleaning the ice machine. A corporate RN stated it was cleaned and/or serviced by either the refrigeration company or the foodservice company, while the Administrator thought maintenance or housekeeping was cleaning it and was not certain of the schedule. The Director of Maintenance stated his staff had not been cleaning or checking the machine and believed the refrigeration company was responsible. The Regional Maintenance Director stated the manufacturer guidelines required cleaning at least every 6 months, but he could not identify why this had not occurred. The manufacturer manual stated the facility was responsible for maintaining the ice machine and directed detailed descaling and sanitizing every 6 months, but no facility policy for cleaning the ice machine was provided.
Incomplete neurological assessments after repeated unwitnessed falls
Penalty
Summary
The facility failed to ensure neurological assessments were completed for Resident #56 after multiple unwitnessed falls and a head injury. Resident #56 had diagnoses including Parkinson’s disease, peripheral vascular disease, and hypertension, and was described as severely cognitively impaired with extensive assistance needs for bathing, transfers, toileting, and personal care. The resident’s care plan identified a fall risk with interventions for toileting before dinner and encouraging the resident to ask for help with transfers and toileting. After an unwitnessed fall in the lounge, nursing documentation stated neurological assessments were initiated per facility protocol, but review of the record with the DNS did not identify completed neurological assessments. Additional unwitnessed falls occurred in another resident’s room, near the nurse’s desk, and by the bed, and review of the neurological assessment flow sheet showed many assessments were not completed. One nursing note documented that the responsible party refused hospital evaluation for a neurological assessment after a fall. Another fall involved the resident hitting the head on a wall and sustaining a forehead contusion/laceration, with documentation that neurological status was observed and the resident was sent to the emergency room, but the record did not identify completed neurological assessments before or after return from the hospital. The record also showed a later unwitnessed fall with head redness and a raised area to the back of the head, after which the resident was sent to the emergency room and returned with a hematoma. The DNS stated neurological assessments were initiated at the time of the fall but were not restarted after the resident returned from the hospital, even though the resident would have required every 4 hour neurological assessments at that time. The facility’s neurological checks policy required checks after head injury or unwitnessed falls when the resident could not accurately report whether a head injury occurred, and the DON stated the failure to complete multiple neurological assessments for a resident with multiple unwitnessed falls had not been identified or reviewed during QAPI meetings.
Improper Storage and Labeling of Resident Personal Care Items
Penalty
Summary
The facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy in multiple resident bathrooms across 3 nursing units. During observations, surveyors found bedpans, basins, and a urinal in private and shared bathrooms that were unlabeled and uncovered, with several items placed on the bathroom floor, on top of toilets, or at the back of toilets. In Unit 100, a private bathroom contained four unlabeled, uncovered bedpans in different locations, and a shared bathroom contained one unlabeled, uncovered bedpan at the back of the toilet. In Unit 300, a shared bathroom contained one unlabeled, uncovered bedpan on the floor and two unlabeled, uncovered basins beside the toilet. On Unit 200, a private bathroom contained one unlabeled, uncovered wash basin on the floor behind the toilet, and a shared bathroom contained one unlabeled, uncovered wash basin on top of the toilet, one unbagged and unlabeled urinal hanging next to the toilet, and one wash basin on the floor labeled with the name of a resident who was not present in either room. The IP RN stated it was facility policy for bedpans, basins, urinals, and oxygen/nebulizer masks to be labeled and covered, and identified the NA as responsible for following the policy. The NA stated the items should be labeled and covered according to policy but could not explain why the policy was not followed or who was responsible for ensuring the items were stored per policy. The DON was unable to identify the facility policy for resident bedpans, basins, and urinals.
Advance Directive Orders and Documentation Not Completed
Penalty
Summary
The facility failed to obtain a physician’s order for advance directives for one resident and failed to ensure advance directives were discussed and the required documentation was completed for another resident. The report identifies that the facility’s policy required licensed nursing staff and/or the attending physician to review advance directives with the capable resident or appropriate decision maker, have the form signed and dated by the person who reviewed it, and obtain a physician’s order. It also required documentation of choices in the care plan and review on a quarterly or as-needed basis when changes occurred. For one resident with diagnoses including dementia, anxiety, and hypertension, the quarterly MDS identified severe cognitive impairment. The care plan included advance directives per physician orders, and a Medical Interventions Form signed by the responsible party directed DNR, DNI, no artificial nutrition including tube feedings and TPN, and allowed IV fluids and hospitalization. However, the clinical record did not contain a physician’s order matching the advance directives on the form. The DNS stated that the nursing supervisor was responsible for reviewing advance directives on admission or readmission and obtaining the physician’s order, and that the order was missed when the resident was readmitted and prior orders were discontinued. For another resident readmitted with diagnoses including type 2 diabetes mellitus, heart failure, and hyperlipidemia, the hospital discharge summary listed full code. The record included a face sheet identifying the resident as responsible for self, while a nursing assessment identified cognitive impairment and full code status. A medical interventions consent form was available to surveyors but was incomplete, lacking resident/responsible party and physician signatures. Nursing documentation stated the resident signed a DNR form, but that paperwork was not found in the electronic or paper record and was not provided when requested. Multiple APRN and physician notes documented full code status and the resident’s fluctuating mental status, but none reflected a discussion of advance directives. The resident later stated he/she did not recall any discussion about advance directives at admission or afterward. The DNS stated nursing was responsible for discussing advance directives on admission and that, if family could not be contacted, the resident would remain full code until a decision was discussed and documented.
Failure to Notify Provider of Medication Omissions
Penalty
Summary
The facility failed to notify the provider of medication omissions for Resident #88, who had unspecified dementia, alcohol abuse with withdrawal, and GERD with esophagitis. During medication administration observation, the LPN prepared and gave the resident’s scheduled oral medications except for B12 active oral chewable tablet and Pantoprazole 40 mg, which were unavailable in the medication cart. The LPN documented the medications as unavailable and ordered them through the pharmacy, but the clinical record did not show documentation or notification to the provider for the missed medications. Interviews with the RN supervisor, LPN, and DNS confirmed that when ordered medications are unavailable, the nurse should check overflow stock, notify the supervisor, pharmacy, and provider, and document the omission and notifications in the resident’s record. The RN supervisor stated she was not notified on the shift, and the LPN stated she forgot to notify the supervisor and provider because she became busy with other residents. The facility policy also directed staff to notify the physician immediately, inform the resident or responsible party, contact the pharmacy, and document all actions taken when a medication is not available at the time of administration.
Incomplete and Late Baseline Care Plan Documentation
Penalty
Summary
The facility failed to formulate a baseline care plan (BCP) that addressed all required areas for Resident #84 within the required timeframe after admission. Resident #84 was admitted with diagnoses including quadriplegia, obstructive sleep apnea, and morbid obesity. The nursing admission assessment identified the resident as cognitively intact, requiring assistance with eating, being dependent for bed mobility, and needing 2 staff members with a mechanical lift for transfers. A handwritten BCP dated 3/31/25 identified the resident as alert and admitted for long-term care with a goal of remaining in the facility, but it did not include individualized care needs such as dietary needs, use of a special call bell due to inability to move extremities, morbid obesity, need for 2-3 staff members for bed mobility, transfers, and incontinent care, or anticoagulant, opioid, and psychotropic medications. The record also showed the BCP did not include a signature and date showing it was discontinued after completion of the comprehensive resident care plan or any updates before that completion. A 72 Hour Meeting/Discharge Planning Meeting assessment completed by RN #11 was dated 4/7/25 at 1:16 PM, which was 7 days after admission and therefore late. That assessment was not fully completed, with 26 of 35 questions left blank, and it did not identify interdisciplinary participation or the names of social services or rehabilitation staff who participated. The handwritten BCP also lacked a signature from the resident and/or responsible party documenting review of the BCP and receipt of the BCP summary.
Missed neuro checks after falls and medications left at bedside
Penalty
Summary
The facility failed to complete neurological assessments after unwitnessed falls for a resident with Parkinson’s disease, peripheral vascular disease, hypertension, and severe cognitive impairment. The resident was admitted requiring extensive assistance with bathing, transferring, personal care, toileting, and later was identified as having multiple falls since admission. Facility accident and incident reports documented several unwitnessed falls, including events in the lounge, another resident’s room, the hallway, beside the bed, and while standing up in the hallway during dinner. Nursing notes repeatedly documented that neurological assessments were initiated or should be monitored per protocol, but review of the neurological assessment flow sheet with the DNS showed that many of the required assessments were not completed. The record showed multiple instances where the required neurological checks were not carried out after falls, including after falls with no visible injury, after a fall with a forehead laceration and transfer to the ER, after a fall with a head bump and return from the hospital, and after a fall where the resident was noted to be confused, restless, and refusing vital checks. In one instance, the neurological check form had a handwritten note stating the resident refused neuro checks, and the DNS stated that if a resident refused, staff should continue attempting the assessments and that writing only "resident refused" on the form was not acceptable. The DNS review identified several neurological assessments were not completed across the documented fall events, and after one hospital return the neurological assessments were not restarted even though they should have resumed. The facility also failed to administer medications according to standards of practice for another resident with dementia, depression, and anxiety disorder. The resident had physician orders for multiple morning oral medications, including buspirone, pantoprazole, gabapentin, metoprolol, thiamine, folic acid, vitamin B12, furosemide, multivitamin, cholecalciferol, and potassium. During a tour, surveyors observed a clear plastic medication cup on the resident’s bedside table containing 10 tablets and 1 capsule. The resident stated the medications were likely left from the previous day, and an LPN and RN both confirmed the medications should not have been left at the bedside and that the nurse should have stayed with the resident to ensure the medications were swallowed. The DNS later documented that the medications were found at the bedside, that the APRN was notified, and that the resident had no ill effects after the medication error.
Failure to Follow Compression Stocking Order
Penalty
Summary
Failure to provide treatment and care according to physician orders occurred for a resident with Parkinson disease, peripheral vascular disease, and hypertension who also had bilateral pitting edema and severe cognitive impairment. The resident’s care plan identified bilateral pitting edema and included monitoring for changes such as blue, red, swollen, or hot extremities, along with encouragement and assistance with frequent position changes. A physician order dated 4/23/25 directed staff to apply compression stockings in the morning and remove them at hours of sleep every day and evening shift for edema. During observations on 7/29/25 and 7/30/25, the resident was seen out of bed without compression stockings and wearing only nonskid socks, including while in a recliner chair. Interviews with nursing staff showed the compression stockings were not listed on the resident care card or resident care plan, and staff stated they relied on the care card for direction. One LPN reported the resident should have had 2 pairs of compression stockings but none were found in the room, and the resident refused to wear them that morning. Other nursing assistants stated they were not aware the resident was to wear compression stockings while out of bed. The DON and an RN stated the resident had an order for compression stockings and the resident care card should have been updated to reflect the order.
Medications Left Unsecured at Resident Bedside
Penalty
Summary
The facility failed to properly secure medications when a clear plastic medication cup containing multiple oral medications was found on a resident’s bedside table during a tour. The resident had diagnoses including dementia, depression, and anxiety disorder, and the quarterly MDS identified the resident as moderately cognitively impaired. The care plan noted impaired memory, recall, and decision-making skills, with interventions to use simple terms and offer gentle reminders. The clinical record did not identify the resident as able to self-administer oral medications. Physician orders showed the resident had multiple scheduled morning medications, including buspirone, pantoprazole, gabapentin, metoprolol, thiamine mononitrate, folic acid, B12, furosemide, multivitamin, cholecalciferol, and potassium supplement. During the observation, the resident stated the medications in the cup were likely morning medications left there by the nurse because the resident had been out of the room, and further stated they appeared to be from the previous day. An LPN later confirmed the medications found in the room were not the ones she had administered and said she had not noticed them on the bedside table earlier. The nursing supervisor also observed the medication cup at the bedside and stated the medications should not have been left there and that the nurse should have stayed with the resident to ensure the medications were swallowed before leaving the room. The facility’s reportable event form and medication error report documented that all AM medications were found in a cup in the resident’s room and that the nurse should have ensured the medications were taken before leaving. The DNS later confirmed the medications were found at the bedside, that the APRN was notified, and that the resident was responsible for self, while also confirming the resident was not identified as able to self-administer oral medications.
Failure to Send Quarterly Personal Funds Statements to Resident Representative
Penalty
Summary
The facility failed to provide quarterly statements for Resident #31’s personal funds account to the resident representative, even though the resident was severely cognitively impaired. Resident #31 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, anoxic brain damage, and focal epilepsy. The quarterly MDS identified the resident as severely cognitively impaired and dependent on staff for self-care and transfers, and the care plan documented impaired memory, recall, decision-making, and difficulty understanding and expressing speech. Resident #31’s admission record listed Person #1 as the resident representative, and Person #1 stated they had not received a quarterly statement for the resident’s personal funds account since admission. The Regional Business Office Manager confirmed that personal funds statements were mailed monthly and that Resident #31’s statements had been sent to the resident rather than to Person #1, despite the resident’s severe cognitive impairment. The resident trust account balance was $170.33, and the facility policy required quarterly accounting to the resident or responsible party.
Failure to Provide Bed-Hold Notice After Hospital Transfers
Penalty
Summary
The facility failed to ensure a Notice Regarding Reservation of a Resident's Bed was provided to the resident representative when two residents were transferred to the hospital. For Resident #27, who had diagnoses including dementia, bipolar schizoaffective disorder, and hypertension, the quarterly MDS identified severe cognitive impairment and the care plan addressed risk for mood and behavior changes. After the resident became screaming, yelling, and expressed suicidal ideations, RN #8 notified the APRN and the resident was sent to the hospital; the nursing note documented that the resident representative/family member was notified of the transfer, but it did not identify that the bed-hold notice was provided. For Resident #28, who had diagnoses including COPD, dementia, and epilepsy, the quarterly MDS identified the resident as cognitively intact and requiring assistance with mobility and transfers. After the resident developed respiratory distress, had a chest x-ray showing a left basilar infiltrate, and had an elevated white blood cell count, RN #12 documented that the APRN directed transfer to the hospital and would notify the family, but the note did not identify that a Notice Regarding Reservation of a Resident's Bed was provided to the resident representative or family. Review of nursing notes for both residents after their transfers did not identify that the notice had been provided or mailed. Interviews showed RN #1 believed the notice was a new form and said she would give a copy to social services, while SW #1 stated she did not receive any such forms and was not familiar with the notice. The DON stated the notice should be sent with the resident in a red envelope and that the resident representative would be told about it during the transfer notification call, and also stated a copy should be made and placed in the chart or documented in the EMR; however, the record did not show that this occurred.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment when Resident #56 entered hospice services. Resident #56 had diagnoses including Parkinson disease, peripheral vascular disease, and hypertension. The quarterly MDS identified the resident as severely cognitively impaired, independent for eating, dependent for oral hygiene, showering, and dressing, and requiring moderate assistance for transfers. Physician orders on 6/18/25 directed a hospice consultation, and a social worker note on 6/19/25 documented that the resident was approved for hospice services for Parkinson's disease, with hospice planning to meet with the family at the facility to review and sign consent forms to begin services on 6/20/25. A social worker note on 6/20/25 identified that hospice services started, and nursing notes later that day documented that the resident was admitted to hospice services. The resident care plan dated 6/25/25 included hospice care interventions such as providing emotional support to the patient and family and controlling pain and symptoms while maintaining dignity. During interview, RN #8 stated the last MDS completed was the quarterly assessment on 5/28/25 and that a Significant Change assessment was not completed when the resident transferred to hospice care because she did not think hospice was a significant change. RN #9 stated a Significant Change assessment should have been completed when the resident transferred to hospice services and noted that the RAI Manual allows up to 14 days to complete the assessment, but she was unsure why it was not completed within 14 days of 6/20/25.
Failure to Update Care Plan After Resident Readmission with New Transfer Needs
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for a resident upon readmission after the resident sustained a facility-acquired right femur fracture due to a fall. The resident, who had diagnoses including COPD, depression, and benign paroxysmal vertigo, was previously identified as a fall risk and had interventions in place such as calling for assistance when dizzy and using a call bell. After the fall, which occurred when the resident missed the wheelchair while attempting to sit, the RCP was updated to include use of a gait belt and instructing the resident to feel for wheelchair arms before sitting. However, following the resident's return from the hospital after surgery, new physician and therapy orders specified non-weight bearing status and transfer with a mechanical lift and assistance of two staff, but these changes were not reflected in the RCP or the Resident Care Card (RCC) in a timely manner. Staff interviews revealed confusion regarding the resident's current transfer status, with some staff relying on outdated RCC information and awaiting clarification before providing care. The facility's care planning policy required that care plans and care cards be updated as needed to reflect changes in the resident's status, but this was not done promptly after the resident's readmission and change in transfer needs. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed that the care plan and RCC did not direct staff to the updated transfer requirements following the resident's injury and hospital stay.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to ensure and maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations across several units. Surveyors noted soiled floors, peeling paint, leaking or non-functional sinks and faucets, stained sinks, closet doors off hinges and stained, broken or missing shower room floor tiles, dark substances covering shower room floor edges, and non-functioning bathroom lights. These deficiencies were observed in resident rooms, shower rooms, hallways, and nurses' stations on units 100, 200, and 300. Residents reported dissatisfaction with the facility's appearance and lack of repairs, stating that maintenance projects were started but not completed, and that requests for repairs had not resulted in visible improvements. Interviews with staff revealed further issues contributing to the deficiency. The Director of Maintenance, who had been in the role for four months, reported a lack of training and absence of maintenance logs or records from the previous director. The Director of Housekeeping/Laundry indicated staffing shortages and challenges in maintaining cleanliness, with cleaning schedules not consistently followed. The Interim Administrator acknowledged responsibility for the facility's condition and stated that the new Director of Maintenance and Corporate Project Manager were assessing repair needs. Additional observations confirmed ongoing cleanliness and maintenance issues, with staff unable to verify when cleaning last occurred and supervisors acknowledging the inadequacy of current cleaning efforts. The facility was unable to provide a policy for building maintenance when requested.
Failure to Ensure Complete IV Antibiotic Administration Due to Lack of Line Flushing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) antibiotics for a resident diagnosed with bilateral ankle osteomyelitis. Specifically, the facility did not secure or implement an order to flush the IV line after administering ceftriaxone, resulting in incomplete delivery of the prescribed medication. Review of the clinical records and medication administration records showed that, for three consecutive days, there was no order or documentation to flush the IV tubing after the antibiotic was given, and the tubing containing residual medication was discarded. This led to the resident not receiving the full dosage of antibiotics as prescribed. Interviews with the resident, the DON, and the pharmacist confirmed that the issue was brought to the attention of facility leadership after the resident and their responsible party noticed the problem. The pharmacist calculated that approximately 24% of the medication was not administered each day due to the lack of flushing, totaling a significant amount of missed medication over the three days. Facility policy required medications to be administered safely and accurately according to physician orders and protocols, which was not followed in this instance.
Failure to Address Resident Grievances Regarding Broken Television Remotes
Penalty
Summary
A deficiency was identified when a resident reported that their television remote control was in disrepair, but the facility failed to act on the grievance and did not replace the remote control. During a tour of the resident units, it was observed that three residents had television remote controls with missing pieces or that had been taped together. Interviews with these residents revealed that they had reported the broken or incomplete remote controls to several staff members, but were told the controls were still working and that no replacements were available. The Regional Director of Maintenance was unaware of the issue, could not locate the maintenance logbook to verify if the problem had been addressed, and was unable to explain why the remotes had not been replaced.
Failure to Supervise and Respond to Missing Resident Results in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure timely staff supervision and appropriate response when a resident with dementia, impaired memory, and a history of substance abuse was identified as missing. The resident, who was assessed as not having the capacity to meet minimal basic needs in the community, left the premises alone despite an order requiring accompaniment by a responsible party for leave of absence. Staff were unaware of the resident's whereabouts for over six hours, during which time the resident accessed their own vehicle and left the facility unaccompanied. Multiple staff members, including the receptionist, social worker, and nursing staff, did not follow the facility's missing resident policy. The receptionist allowed the resident to go to their car alone and did not ensure their return or notify others when the resident did not come back. When the social worker and nursing supervisor realized the resident was missing, they searched only inside the facility, did not call a code overhead to alert all staff, did not search the outside grounds, and did not notify the police. The DON was present in the building during the search but also did not ensure that the required steps were taken according to policy before leaving for the day. The facility's own policy required immediate overhead paging, a thorough search of both inside and outside the facility, and prompt notification of law enforcement when a resident's whereabouts were unknown. These steps were not followed, and the resident was ultimately found by police after being involved in a motor vehicle accident and being rescued from an icy pond. The failures in supervision, timely action, and adherence to policy resulted in a finding of Immediate Jeopardy.
Failure to Protect Resident from Verbal Abuse by LPN
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of attention and concentration deficit was subjected to verbal mistreatment by an LPN. The resident, who required assistance with activities of daily living and had a care plan addressing ineffective coping and accusatory behaviors, was involved in a loud argument with the LPN at the nurse's station. During this exchange, the LPN made derogatory and inappropriate remarks about the resident's alleged drug use and criminal behavior, including calling the resident a 'crack head' and making further disparaging comments in front of other staff and residents. Multiple nursing assistants witnessed the incident but did not immediately report it to their supervisor. One nursing assistant later informed a family member about the event, which led to the incident being reported to facility management. The supervisor and DON were subsequently notified, and the facility began an investigation into the allegations. The investigation confirmed that the LPN had made inappropriate remarks to the resident. The facility's policies strictly prohibited abuse or mistreatment of any kind, including verbal abuse defined as the use of disparaging or derogatory language toward residents. Despite these policies, the incident occurred and was not promptly reported by staff who witnessed it, contributing to the deficiency in protecting the resident from verbal mistreatment.
Failure to Timely Report Alleged Verbal Abuse and Notify State Agency
Penalty
Summary
Staff failed to report an allegation of verbal abuse involving a resident with cognitive impairment and behavioral issues in a timely manner. The incident occurred when an LPN made inappropriate and derogatory comments to the resident, including references to drug use and jail, during a loud argument at the nurse's station. Multiple nursing assistants witnessed the exchange but did not immediately report the incident to their supervisor as required by facility policy. The incident was eventually brought to the attention of supervisory staff after a family member inquired about what had happened. Statements were then collected from the involved staff, and the Director of Nursing (DON) was notified later that evening. The DON confirmed that the incident was not reported to her or to the state agency within the required timeframe after the facility became aware of the allegation. Facility policy mandates immediate reporting of any witnessed or known abuse to supervisory staff and prompt notification to the state health authority within two hours of awareness. In this case, there was a delay of over 24 hours from the time the facility first became aware of the incident to when it was reported to the state agency. Interviews with staff confirmed the delay in reporting and a lack of immediate action following the incident.
Failure to Revise Care Plan for Repeated Refusals of Wound Care
Penalty
Summary
The facility failed to ensure that the care plan for a resident with chronic wounds and diabetes was revised in a timely manner to address repeated refusals of wound care and related treatments. Clinical record and documentation reviews showed that the resident refused wound dressing changes on multiple occasions, declined a therapeutic beverage intended for wound healing several times, and refused to wear prescribed offloading boots. Despite these documented refusals, the resident's care plan did not include any interventions or strategies to address or manage the refusals of care, medications, or wound treatments. Interviews with the Director of Nursing (DON) confirmed that the expectation is for residents who repeatedly refuse care to have these behaviors addressed in their care plans, with appropriate interventions documented. The DON was unaware of the resident's repeated refusals and acknowledged that the care plan should have included this information. Review of facility policy also indicated that care plans should be comprehensive and individualized, guiding caregivers to assist residents in achieving their highest practical level of well-being.
Failure to Provide Ordered Pressure Relief Device for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to act in a timely manner on a wound consultant's order and did not ensure that a low air-loss mattress was maintained in place as directed for a resident with significant wounds. The resident had a history of a non-pressure chronic left foot ulcer, diabetes mellitus, and was identified as having an unstageable ulceration and a stage four ankle/Achilles ulcer. The wound consultant ordered pressure relief devices, including a low air-loss mattress, but the order was not obtained from the attending physician, and the specialized mattress was not provided as required. Observations and interviews revealed that the resident was found on a standard mattress rather than the prescribed low air-loss mattress. Staff confirmed that the low air-loss mattress had previously been in place but was replaced with a regular mattress after the device broke, and no immediate replacement was provided despite additional mattresses being available in supply. Facility documentation and policy review indicated a lack of adherence to wound care protocols and physician orders, contributing to the deficiency.
Failure to Complete and Accurately Document Elopement Risk Assessment After Unauthorized Absence
Penalty
Summary
The facility failed to perform an elopement risk assessment after a resident returned following an unauthorized absence and did not accurately complete an elopement risk assessment after the incident. The resident in question had diagnoses including metabolic encephalopathy, dementia, depression, anxiety disorder, and a history of alcohol abuse. The care plan identified impaired memory and decision-making skills, and the resident was noted to have a history of behaviors that could place them at risk for seeking unescorted exit. Despite this, the elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. On the day of the incident, the resident left the facility premises alone, despite an order requiring accompaniment by a responsible party, and was later involved in a motor vehicle accident. The facility did not become aware of the resident's absence until several hours later, after being notified by police. Upon the resident's return, the facility did not complete an elopement risk assessment, as required by facility policy, because the hospitalization was less than 24 hours. When an assessment was eventually completed, it inaccurately documented that the resident had no history of elopement, despite the recent unauthorized absence.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 865 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Meriden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Connecticut Baptist Homes, Inc | 0.6 mi | ★★★★★ | 9 | 0 |
| Complete Care At Meriden | 1.8 mi | ★★★★★ | 13 | 0 |
| Meriden Health And Rehab | 2.6 mi | ★★★★★ | 5 | 0 |
| Bradley Home Infirmary/pavilion | 2.7 mi | ★★★★★ | 3 | 0 |
| Silver Springs Care Center | 2.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.