Above average — CMS composite of the measures below.
The next survey window likely opens 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 Ark Healthcare & Rehabilitation At Governors House during CMS and state inspections, most recent first.
Failure to notify the MD and family of a significant change in condition occurred when a resident with protein malnutrition, CKD, dementia, and other diagnoses had an episode of black emesis. Nursing documentation showed the supervisor was notified, but there was no note confirming MD or family notification, and the APRN later saw the resident for reports of dark emesis. Facility policy required significant changes to be reported to the MD and family, with RN assessment and documentation of the notifications.
Two residents with risk factors for pressure injuries did not have Braden scale assessments and weekly skin checks completed and documented as required by facility policy. Documentation was missing for several required assessments and skin checks, and wound evaluations did not consistently include full body skin checks.
Two residents with cognitive impairments experienced disrespectful and undignified treatment by staff, including an incident where a staff member allegedly shouted and threw juice at a resident during lunch, and another where a staff member made derogatory remarks about a resident's hygiene and room odor. Staff interviews and facility documentation confirmed that these actions did not align with the facility's policy requiring residents to be treated with respect and dignity.
A resident with intellectual disability and behavioral needs was involved in an incident where a staff member allegedly shouted and threw juice at them during a meal. Another staff member witnessed the event but did not report it immediately, waiting several days and only notifying the DON after encouragement from a colleague. Facility policy required immediate reporting of abuse allegations, but this was not followed, resulting in a delayed response to the incident.
A resident with cerebral vascular infarction, pleural effusion, and hemiplegia, identified as moderately cognitively impaired and at risk for pressure ulcers, did not have a care plan including interventions for skin breakdown or heel off-loading. A DTI wound on the left heel was observed, leading to physician orders for heel offloading cushion and skin prep application. Nursing staff interviews revealed a lack of heel off-loading prior to the DTI development and highlighted the necessity of a care plan for pressure ulcer prevention upon admission. The facility's policies for Care Plan and Skin Assessment and Pressure Ulcer Prevention were not fully implemented in this case.
The facility did not ensure annual review of its Infection Prevention Control Program (IPCP) policies and procedures by the Administrator, Medical Director, and Director of Nursing, as evidenced by missing signatures on the policy manual. Additionally, the facility failed to maintain an updated list of residents with Multidrug Resistant Organisms (MDRO). Discrepancies were found in the MDRO list, and the Director of Admissions was unaware of the current list, despite claims to the contrary.
The facility failed to respond to pharmacy recommendations for PRN psychotropic medications for two residents, leading to deficiencies in medication management. Despite multiple recommendations, the facility did not include stop dates or reassess the need for these medications, resulting in non-compliance with guidelines.
The facility failed to comply with regulations regarding PRN psychotropic medications for two residents, leading to prolonged administration without proper reassessment or documentation. Despite pharmacy recommendations and facility policy requiring a 14-day limit, the medications were administered over several months without appropriate oversight.
A resident's upper dentures were missing for about a week, but the issue was not reported by staff, preventing the initiation of a grievance. The resident had multiple medical conditions and required assistance for daily activities. Interviews revealed that staff were unaware of the missing dentures, and a nurse aide assumed someone else had reported it.
The facility failed to initiate Resident Care Plans for two residents with specific medical conditions and corresponding medication use. One resident with A-fib did not have an RCP for their anticoagulant medication, and another resident with diabetes did not have an RCP for their diabetic medications. These oversights were confirmed by an RN and were not identified during a Resident Care Conference.
The facility failed to update the RCP for a resident regarding the discontinuation of anti-embolism stockings and the initiation of interventions following multiple falls. The RCP was not revised to reflect new interventions required for the resident's care, including reminders to lock the wheelchair and the use of rubber sole shoes, until after the surveyor's inquiry.
The facility failed to document a treatment refusal for a resident with dementia and did not verify gastrostomy tube placement before administering medication to another resident with severe malnutrition and a malignant neoplasm. The DNS did not document the refusal in the nursing notes, and an LPN administered medication without checking tube placement, contrary to facility policy.
The facility failed to complete an RN assessment after an allegation of mistreatment, obtain physician orders for multiple hospital transfers, and transcribe RN pronouncement orders before pronouncing a resident dead. These deficiencies were confirmed by the DNS and involved staff.
The facility failed to apply a hip abduction splint daily for a resident with cerebral vascular infarction, as directed by the physician. The error was due to an incorrect entry by a former travel PT, resulting in the splint not being included in the treatment admission record. Observations and staff interviews confirmed the deficiency.
A resident with respiratory conditions was using oxygen therapy without a physician's order, contrary to facility policy. Nursing staff were unable to locate any active or discontinued orders for the oxygen administration, despite the resident having been on oxygen for several weeks.
The facility failed to administer the Influenza vaccine to a resident after receiving consent and did not document offering the Pneumonia vaccine to another resident. One resident was hospitalized for Influenza, and another had no record of being offered the Pneumonia vaccine, with the facility directing short-term rehab residents to their primary care physicians for the vaccine.
The facility failed to ensure that two residents were educated and given the opportunity to consent or decline the COVID-19 vaccine upon admission. Both residents, who were moderately cognitively impaired and dependent on assistance, were not offered the vaccine or provided with education about it, and there was no documentation of their vaccination status.
The facility failed to ensure that required training and inservices were completed for two LPNs and one RN. The review revealed that new employee orientation and mandatory training on Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health were not documented. The Administrator confirmed the oversight and mentioned that the responsible person had resigned.
The facility failed to ensure that a newly hired nurse aide completed the required training and inservices, including Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health. The Administrator confirmed the lapse and noted that the person responsible for the training had resigned.
The facility failed to notify the state Ombudsman of hospital transfers for four residents, despite being aware of the requirement. The Social Worker could not explain why these residents were not included in the notification list, and the facility lacked a policy for such notifications.
The facility failed to document bed hold notifications for residents hospitalized, with staff interviews revealing confusion about responsibilities and incomplete or missing documentation for multiple residents.
The facility failed to ensure the accuracy of its direct care staffing information submitted to CMS for Quarter 3 of 2023, with PBJ submissions identifying excessively low weekend staffing. The Administrator noted that actual staffing levels were not low and indicated a need to review the contracted company's reporting procedures.
The facility failed to review infection control policies annually and did not calculate or analyze monthly antibiotic use percentages as required. Both the current and previous Infection Preventionists were unaware of these requirements.
Failure to Notify Physician and Family of Black Emesis
Penalty
Summary
The facility failed to notify the physician and/or family of a significant change in condition for Resident #70 after the resident had an episode of vomiting that consisted of a good amount of black substance. Resident #70 had diagnoses including protein malnutrition, chronic kidney disease, benign neoplasm of the meninges, and dementia, and the quarterly MDS identified moderate cognitive impairment with extensive assistance needed for bed mobility, toileting, hygiene, transfers, and ambulation. The resident’s care plan identified a nutritional problem or potential nutritional problem related to kidney disease, neoplasm of meninges, and dementia, with interventions to monitor, record, and report signs and symptoms of malnutrition and to obtain and monitor tests as needed. A nurse’s note documented the vomiting episode and that the supervisor was notified, but review of nursing notes from that time period did not identify any notification to the physician and/or family. The APRN later documented that the resident had been seen for reports of vomiting over the weekend with dark emesis, and that the resident denied gastrointestinal discomfort, pain, or tenderness, with appetite having resumed after the episode. The DNS stated that black emesis should be an immediate notification to the physician and responsible party and that the notes should show whether they were notified, while APRN #1 stated that black emesis could be a sign of bleeding in the intestinal organ and would expect immediate physician notification. The facility policy required significant changes in condition to be reported to the physician and family, with RN assessment and documentation of both the assessment and the notifications.
Failure to Complete and Document Braden Scale Assessments and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that Braden scale assessments and weekly skin checks were documented and completed according to facility policy for two residents reviewed for pressure injuries. For one resident with peripheral vascular disease and dementia, the clinical record did not show that Braden scale assessments were completed weekly during the first month of admission, missing two out of four required assessments. Additionally, the care plan required weekly skin checks, but documentation was incomplete. For another resident with a history of stroke, diabetes, and gastrostomy, the care plan required Braden scale assessments on admission and per protocol, as well as weekly skin checks. The medical record lacked documentation of a skin check for one week and missed a Braden scale assessment for another week during the first month. Further, several weeks lacked documentation of weekly skin checks, and wound evaluations did not consistently indicate that a full body skin check was performed. Facility policy and interviews confirmed that these assessments and documentation were required but not completed as specified.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, as required by resident rights regulations. One resident with intellectual disability, autism, and anxiety, who required assistance with activities of daily living and had a history of impulsive behaviors, was involved in an incident during lunch where a nursing assistant allegedly shouted at the resident and threw a cup of juice at their face. The incident was reported by another nursing assistant, who stated that the staff member yelled at the resident and made a derogatory comment before leaving the dining room. The accused staff member denied the allegations, stating that the juice was spilled accidentally when the resident squeezed the cup, and that her exclamation was a reaction to being soaked. The facility did not substantiate the abuse allegation due to lack of additional witnesses, but staff interviews confirmed that the resident's clothing was not wet and the incident was reported eight days after it occurred. Another resident, who had pressure injuries and required maximal assistance for personal hygiene, reported that a nursing assistant made a disrespectful comment about the resident's personal hygiene and the odor in their room. The resident stated that the nursing assistant screamed at them and accused them of making false accusations, while also making derogatory remarks about the resident and the room. The nursing assistant admitted to making a comment about the room's smell in the hallway, believing the resident could not hear, but acknowledged that the comment was inappropriate. Interviews with other staff confirmed that the comment was made as the nursing assistant left the room with the resident's dinner tray. Facility policy directs that residents have the right to be treated with respect, kindness, and dignity. In both cases, staff actions and comments failed to uphold these standards, resulting in residents being subjected to disrespectful and undignified treatment. The incidents were documented through facility reportable event forms, staff interviews, and resident statements, demonstrating a failure to consistently honor residents' rights to a dignified existence and respectful communication.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
Staff failed to report an allegation of staff-to-resident abuse in a timely manner for a resident with intellectual disability, autism, and anxiety who required assistance with activities of daily living. During a lunch period, a nursing assistant was observed by another staff member to have shouted at the resident and thrown a cup of juice at the resident's face, accompanied by a verbal outburst. The observing staff member did not immediately report the incident, citing discomfort and being new to the unit. Instead, he continued his shift and only reported the incident several days later after being encouraged by another staff member. The delay in reporting was further compounded when the staff member who was informed of the incident also failed to immediately notify supervisory staff, assuming the original observer would do so. The incident was ultimately reported to the Director of Nursing eight days after it occurred. Facility policy required immediate reporting of any witnessed or known abuse to supervisory staff, the DON, and the Administrator, which was not followed in this case. Interviews confirmed that both staff members involved in the delayed reporting acknowledged their failure to report the incident as required.
Deficiency in Heel Off-Loading for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure off-loading of the heels was implemented to prevent a pressure ulcer for Resident #39, who was admitted with a diagnosis of cerebral vascular infarction, pleural effusion, and hemiplegia. Despite being identified as moderately cognitively impaired and at risk for developing a pressure ulcer, the Resident Care Plan did not include interventions for skin breakdown or off-loading of heels. A DTI wound on the left heel was observed on 11/3/23, leading to subsequent physician orders for heel offloading cushion and skin prep application. Interviews with nursing staff revealed a lack of off-loading heels prior to the DTI development and highlighted the necessity of a care plan for pressure ulcer prevention upon admission. The facility's policies for Care Plan and Skin Assessment and Pressure Ulcer Prevention were not fully implemented in Resident #39's case, as evidenced by the delayed initiation of interventions to prevent pressure ulcers. The observations and interviews indicated a gap in care planning and implementation, with staff acknowledging the importance of off-loading heels, repositioning, and regular skin checks for residents at risk of skin breakdown.
Infection Control Policy Review and MDRO List Management Deficiencies
Penalty
Summary
The facility failed to ensure that its Infection Prevention Control Program (IPCP) policies and procedures were reviewed annually by the Administrator, Medical Director, and Director of Nursing, as evidenced by the absence of signatures on the policy manual reviewed on 3/1/24. Additionally, the facility did not maintain an updated list of residents with Multidrug Resistant Organisms (MDRO), with discrepancies noted in the MDRO list last updated on 4/14/23. Despite RN #7 indicating that the Director of Admissions had a current list of MDRO residents, an interview with the Director of Admissions on 3/1/24 revealed she had no knowledge of such a list. Subsequently, the facility completed an updated MDRO log on 3/4/24.
Failure to Respond to Pharmacy Recommendations for PRN Psychotropic Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations related to PRN psychotropic medications for two residents. Resident #7, diagnosed with Alzheimer's disease, anxiety disorder, and Type 2 diabetes, was prescribed Ativan 0.5 mg PRN for anxiety prior to showers without a stop date. Despite pharmacy recommendations on multiple occasions indicating that PRN psychotropic drugs are limited to 14 days, the facility did not act on these recommendations. The Director of Nursing Services (DNS) was unable to locate the signed pharmacy recommendations and could not explain why the approved order was not placed in the medical records. Resident #43, diagnosed with dementia and depressive episodes, was prescribed Trazodone 25 mg PRN for agitation and Ativan 0.5 mg PRN for anxiety, both without a stop date. The resident received these medications on several occasions, but the orders were renewed monthly without reassessment. Pharmacy recommendations to include a stop date or reassess the need for these medications were repeatedly ignored. The DNS and the prescribing physician could not provide a reason for the lack of response to these recommendations. Interviews with the pharmacy consultant and the DNS confirmed that the facility did not follow the guidelines for PRN psychotropic medications, which require a reassessment or a stop date after 14 days. The facility's failure to act on pharmacy recommendations and properly document and reassess the use of PRN psychotropic medications led to the identified deficiencies for both residents.
Failure to Adhere to PRN Psychotropic Medication Guidelines
Penalty
Summary
The facility failed to comply with regulations regarding the administration of PRN psychotropic medications for two residents. Resident #7, diagnosed with Alzheimer's disease, anxiety disorder, and Type 2 diabetes, was prescribed Ativan 0.5 mg PRN for anxiety/agitation prior to showers without a stop date. Despite pharmacy recommendations to limit PRN usage to 14 days, the medication was administered multiple times over several months without proper reassessment or documentation. The Director of Nursing Services (DNS) was unable to provide a reason for the oversight, and the psychiatrist's note directing a 14-day limit was not seen by the DNS. Resident #43, diagnosed with dementia, depressive episodes, and a history of fractures, was prescribed Trazodone 25 mg PRN for agitation and Ativan 0.5 mg PRN for anxiety, both without a 14-day stop date. The resident received these medications on multiple occasions, and although the PRN orders were renewed monthly, there was no documentation of reassessment or rationale for continued use. Interviews with the medical director and pharmacy consultant confirmed awareness of the 14-day limit, but the orders were not appropriately managed. The facility's policy on psychotropic medication PRN usage requires renewal every 14 days, with a new order and documented rationale for continued use. The failure to adhere to this policy resulted in prolonged administration of psychotropic medications without proper oversight, contributing to the identified deficiencies in the care of Residents #7 and #43.
Failure to Report Missing Dentures
Penalty
Summary
The facility failed to report missing dentures for Resident #19, who had diagnoses including unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation, and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment indicated that Resident #19 required varying levels of assistance for daily activities. On 3/4/24, Resident #19 reported that his/her upper dentures had been missing for about a week but could not recall if this was communicated to anyone. Interviews with facility staff, including an LPN, a social worker, and a nurse aide, revealed that none were aware of the missing dentures. The nurse aide noticed the dentures were missing but did not report it, assuming someone else had already done so. This failure to report prevented the initiation of a grievance to resolve the issue.
Failure to Initiate Resident Care Plans for Specific Diagnoses and Medications
Penalty
Summary
The facility failed to initiate a Resident Care Plan (RCP) for two residents with specific medical conditions and corresponding medication use. Resident #2, diagnosed with Atrial Fibrillation (A-fib), dementia, and hypothyroidism, had a physician's order to administer Apixaban for A-fib. However, the RCP did not reflect the A-fib diagnosis or the use of the anticoagulant medication. This oversight was confirmed during an interview with RN #1, who acknowledged the missing RCP for the anticoagulant medication. Similarly, Resident #58, admitted with diagnoses including type 2 diabetes mellitus, morbid obesity, and Raynaud's syndrome, had physician's orders for Toujeo and Mounjaro to manage diabetes. The RCP for this resident also failed to include a care plan for diabetes or the use of diabetic medications. RN #1 confirmed that the RCP for diabetes was not initiated upon admission and was not identified during a Resident Care Conference. The facility's Care Planning policy mandates a comprehensive care plan within 7 days of the resident assessment, which was not adhered to in these cases.
Failure to Update Resident Care Plan After Falls and Discontinuation of Anti-Embolism Stockings
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for Resident #15 regarding the discontinuation of anti-embolism stockings and the initiation of interventions following multiple falls. Resident #15, who had diagnoses including dementia, a history of falling, and difficulty walking, had a physician's order for Thrombo-Embolus Deterrent (Ted) stockings that was not updated in the RCP even after the resident stopped using them. Additionally, after a fall resulting in a hip fracture and subsequent hospitalization, the RCP was not updated to reflect the new interventions required for the resident's care upon readmission to the facility. This included the failure to remove the intervention for Ted stockings from the RCP despite the absence of a current physician's order and the resident no longer utilizing them. The intervention was only removed after the surveyor's inquiry. Furthermore, the RCP was not updated to include the intervention to remind the resident to lock the wheelchair when stationary, which was identified as a corrective action following another fall that resulted in thoracic fractures. This intervention was also added to the RCP only after the surveyor's inquiry. Lastly, the RCP did not include the intervention for the resident to wear rubber sole shoes, which was identified as a corrective action following another fall with reported spine pain. This intervention was added to the RCP only after the surveyor's inquiry.
Failure to Document Treatment Refusal and Verify Gastrostomy Tube Placement
Penalty
Summary
The facility failed to complete a nurse's note for the refusal of treatment for Resident #15, who had diagnoses including dementia, depression, and anxiety disorder. The resident's care plan included interventions for urinary incontinence and decreased communication skills. A reportable event form indicated that the resident reported inappropriate touching overnight, leading to an investigation. Despite the family member's refusal to send the resident to the ER for evaluation, the Director of Nursing Services (DNS) did not document this refusal in the nursing notes, only on the reportable event form. A late entry nursing note was added later after surveyor inquiry to document the refusal chronologically. The facility also failed to check the placement of a gastrostomy tube before administering medication and feeding for Resident #33, who had diagnoses including Parkinson's disease, severe protein-calorie malnutrition, and a malignant neoplasm of the head and neck. The resident's care plan required checking tube placement before each use. During an observation, an LPN administered medication through the gastrostomy tube without verifying its placement, contrary to facility policy. The LPN was unaware of the requirement to check tube placement each time it was accessed, indicating a lack of adherence to the facility's enteral tube policy.
Failure to Complete RN Assessment, Obtain Physician Orders, and Transcribe RN Pronouncement Orders
Penalty
Summary
The facility failed to complete an assessment by a Registered Nurse (RN) after an allegation of mistreatment for a resident diagnosed with dementia, depression, and anxiety disorder. The resident reported inappropriate touching to a family member, which led to an investigation. Despite the facility's policy requiring an immediate examination by a licensed nurse or physician, no RN assessment was completed. The Director of Nursing Services (DNS) acknowledged the oversight but could not provide a reason for the failure to conduct the assessment. For another resident with chronic obstructive pulmonary disease, heart failure, and respiratory failure, the facility failed to obtain physician orders for multiple hospital transfers. The resident was transferred to the hospital on three separate occasions without corresponding physician orders in the clinical record. The DNS confirmed that the clinical record should have included physician orders for each transfer, as per facility policy, but these were not recorded. Additionally, the facility did not transcribe RN pronouncement orders before an RN pronounced a resident dead. The resident, who had diagnoses including Hodgkin's lymphoma and chronic obstructive pulmonary disease, was found not breathing and was pronounced dead by an RN. However, the RN pronouncement order was only placed in the electronic health record after the pronouncement. The DNS and the RN involved confirmed that the order was not in place at the time of death, contrary to the facility's expectations and policies.
Failure to Apply Hip Abduction Splint as Directed
Penalty
Summary
The facility failed to ensure that a hip abduction splint was applied daily as directed by the physician for Resident #39, who was admitted with diagnoses including cerebral vascular infarction, pleural effusion, and lung cancer. The resident was moderately cognitively impaired and required assistance with various activities of daily living. A physician order dated 11/7/23 directed the application of a hip abduction splint when the resident was in a wheelchair, but this was not documented in the treatment admission record (TAR) from 11/7/23 through 2/28/24. Observations on 2/28/24 confirmed that the resident was in a wheelchair without the splint, and staff interviews revealed that the splint was not included in the TAR due to an error by a former travel Physical Therapist. The Rehab Director confirmed that the order for the hip abduction splint was incorrectly entered into the computer system, resulting in the splint not being applied as required. The resident needed the splint for proper positioning due to a condition called wind swept, where the resident sat to one side. The facility's policy on splints indicated that therapists should coordinate with the interdisciplinary team to determine splinting needs and monitor appropriate use. However, this coordination and training for staff did not occur, leading to the deficiency in care for Resident #39.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for Resident #55, who had diagnoses including respiratory failure with hypoxia, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD). The resident's care plan indicated the need for supplemental oxygen, and observations confirmed the resident was using oxygen at 2.0 liters per minute (lpm) via a nasal cannula on multiple occasions. However, both LPN #6 and RN #2 were unable to locate any active or discontinued physician orders for the oxygen therapy, despite the resident having been on oxygen for several weeks. Interviews with the nursing staff revealed that the resident had recently visited a pulmonary physician, and it was suggested that the order might not have been transcribed. The facility's policy on the use of oxygen required a verified physician's order before administration, which was not adhered to in this case. The deficiency was identified during a surveyor interview, and it was confirmed that no physician's order was present in the clinical record at the time of the observations.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that a resident was provided with the Influenza vaccine after receiving consent. Resident #26, who was admitted with heart disease, dementia, and diabetes, had consented to receive the Influenza vaccine for the 2023/2024 season. However, after recovering from Covid-19, the resident was not administered the vaccine, leading to hospitalization for Influenza. This oversight was identified during an interview and review of the facility's immunization tracking with the Infection Control Nurses on 3/1/24. Additionally, the facility did not ensure that another resident or their representative was educated and given the opportunity to consent or decline the Pneumonia vaccination upon admission and subsequent to admission. Resident #39, admitted with cerebral infarction, pleural effusion, and lung cancer, had no documentation indicating they were offered the Pneumonia vaccine. The facility's practice of not offering pneumonia vaccines to residents in the short-term rehab unit and directing them to their primary care physician was confirmed during an interview with the Infection Control Nurse on 3/1/24.
Failure to Offer COVID-19 Vaccine and Education to Residents
Penalty
Summary
The facility failed to ensure that residents or their representatives were educated and given the opportunity to consent or decline the COVID-19 vaccine upon admission. Specifically, two residents, one with an autoimmune disease, sepsis, and kidney issues, and another with chronic obstructive pulmonary disease, sepsis, and congestive heart failure, were not offered the COVID-19 vaccine or provided with education about it. Both residents were identified as moderately cognitively impaired and dependent on assistance for various activities of daily living. Interviews with the facility's Infection Preventionists and a review of the facility's immunization tracking revealed that neither resident was offered the COVID-19 vaccine upon admission or at any time since. Additionally, there was no documentation indicating that the residents or their representatives were educated about or given the opportunity to receive or decline the vaccine. The facility's policy states that all residents should be offered vaccines unless medically contraindicated, and any refusals should be documented, which was not done in these cases.
Failure to Complete Required Employee Training
Penalty
Summary
The facility failed to ensure that the required employee training and inservices were completed for three staff members: two Licensed Practical Nurses (LPNs) and one Registered Nurse (RN). The review of the facility's documentation and employee files revealed that the new employee orientation training, as well as mandatory training on Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health, were not completed and documented for these employees. The employees had been working in the facility for several months without the required training being verified in their files. During an interview and record review with the facility Administrator, it was confirmed that the required training should have been completed upon hire. However, the Administrator was unable to provide documentation that the training had been completed for the three employees. The Administrator also mentioned that the person responsible for conducting the training had resigned, which may have contributed to the oversight. The facility's policy mandates that all newly hired personnel must attend a 10-hour orientation program within their first five days of employment, which was not adhered to in these cases.
Failure to Complete Required Training for Newly Hired Nurse Aide
Penalty
Summary
The facility failed to ensure that the required employee training and inservices were completed for one of the two nurse aides reviewed. The nurse aide in question was hired on 9/28/23 and had worked in the facility from that date to the present. However, a review of her employee file revealed that no documentation of the required inservices, including Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health, had been provided. During an interview and record review with the facility Administrator on 3/6/24, it was confirmed that the required training should have been completed upon hire, but no documentation was available. The Administrator was unaware of the reason for this lapse and noted that the person responsible for conducting the training had resigned. Facility policy mandates that all newly hired personnel must attend a 10-hour orientation program within their first five days of employment.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide the required notification of transfer/discharge to the state Ombudsman's office for four residents who were hospitalized. Resident #18, diagnosed with Parkinson's disease and other conditions, was hospitalized after pulling out a PEG tube but there was no documentation of notification to the Ombudsman. Resident #19, with a history of cerebral infarction and diabetes, was transferred to the hospital due to chest pain, but again, no notification was documented. Resident #43, suffering from dementia and other ailments, was also transferred to the hospital without the required notification. Lastly, Resident #59, with diagnoses including metabolic encephalopathy and dementia, was sent to the hospital for abdominal pain, but the Ombudsman was not notified. Interviews and record reviews with the facility's Social Worker revealed that although he was aware of the requirement to notify the Ombudsman, he had not done so for these residents. The Social Worker mentioned that he generated a report for the Ombudsman from the electronic health record system but could not explain why these residents did not appear on the list. Additionally, the facility could not provide a policy for notification of the Ombudsman when a resident is admitted to the hospital.
Failure to Document Bed Hold Notifications
Penalty
Summary
The facility failed to provide documentation that the bed hold notice was given to residents or their representatives upon hospitalization. For Resident #18, who had diagnoses including Parkinson's disease and cognitive communication deficit, there was no documentation of bed hold notification when the resident was hospitalized after pulling out a PEG tube. Similarly, Resident #19, who had intact cognition and required assistance with various activities, was transferred to the hospital due to chest pain, but there was no record of bed hold notification during the hospitalization period. Interviews with staff revealed confusion about responsibilities for notifying residents or their representatives about the bed hold policy, with the Social Worker, Business Office Manager, and Admissions Director each indicating it was not their responsibility or that they did not document the notification in the medical record. Resident #55, who had chronic obstructive pulmonary disease and heart failure, was hospitalized multiple times, but the facility failed to document bed hold notifications for these hospitalizations. The Resident Bed Hold Documentation Forms were either incomplete or missing for some hospitalizations. For Resident #59, who had acute cholecystitis and dementia, the facility did not provide a written bed hold notice or document the bed hold status in the clinical record when the resident was sent to the hospital. Interviews with the Social Worker and Business Office Manager confirmed that they did not handle bed hold notifications, and the facility's Administrator and Admissions Assistant acknowledged that the bed hold policy was not followed. The facility's Bed Hold Notice and Readmission Process policy requires that a copy of the bed hold policy be provided to the resident at the time of transfer and that the Business Office Manager or designee follow up with a phone call to verify the bed hold. This conversation should be documented in the resident's medical record. However, the facility failed to adhere to this policy for the residents reviewed, resulting in a lack of documentation and communication regarding bed hold notifications during hospitalizations.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of its direct care staffing information submitted to CMS for Quarter 3 of 2023. The Payroll Based Journal (PBJ) submissions for this period identified excessively low weekend staffing. During an interview, the Administrator stated that the facility provides payroll hours for both their employees and agency employees to a contracted company, which then submits the data to CMS. The Administrator also noted that the staffing levels were not actually low during this period, and the long-term care facility company identified the low staffing pattern submissions, indicating a need to review the contracted company's reporting procedures.
Failure to Review Infection Control Policies and Analyze Antibiotic Use
Penalty
Summary
The facility failed to ensure that the policies related to infection control and antibiotic stewardship were reviewed on an annual basis and that data was kept and analyzed according to federal regulations. During a review of the facility's infection control policy and procedure manual with the current and previous Infection Preventionists, it was found that the manual had not been reviewed annually. Additionally, the antibiotic stewardship program did not include the calculation of monthly antibiotic use percentages, nor were these percentages reviewed with the Quality Assurance program on a quarterly basis. Both Infection Preventionists were unaware of the requirement to keep and analyze these percentages, as well as the need for annual review and signatures from the Medical Director, Director of Nursing, and the Administrator on the infection control and intravenous policies and procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 708 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Simsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mclean Health Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Caleb Hitchcock Health Center | 4.1 mi | ★★★★★ | 11 | 0 |
| Seabury | 6 mi | ★★★★★ | 0 | 0 |
| Bloomfield Center For Nursing & Rehabilitation | 6.2 mi | ★★★★★ | 2 | 0 |
| Cherry Brook Health Care Center | 6.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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