Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Civita Care Sheriden Woods during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, impaired cognition, generalized weakness, poor balance, visual deficits, and a documented fall history was care planned and ordered as an assist of one for ADLs and toilet transfers. A NA assisted the resident to sit on the bedside to use a urinal, then, after the resident requested privacy, pulled the privacy curtain and left the resident sitting at the bedside, out of line of sight, to care for the roommate, despite knowing the resident’s fall risk and inconsistent call-bell use. Within minutes, the NA heard a noise and found the resident on the floor by the bed with active head bleeding and the urinal on the floor, then left the resident unattended again to walk down the hall to notify an RN instead of immediately calling for help. Nursing documentation and staff interviews confirmed that the resident sustained facial lacerations requiring hospital treatment and that the resident should not have been left unsupervised behind the curtain while using the urinal.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a left wrist fracture had an initial care plan and RCC completed at admission, identifying fall risk and related interventions. A subsequent quarterly MDS showed severely impaired cognition and need for substantial assistance with mobility, but no RCC was documented to coincide with that assessment, and the next RCC was not held until more than a month later. The MDS coordinator acknowledged RCCs are required at least quarterly and that one should have been scheduled around the time of the quarterly MDS, but there was no documentation that the planned RCC occurred or that invitations were sent while the coordinator was on vacation. The DON confirmed RCCs must correlate with MDS dates and be documented, and facility policy required quarterly care plan review with resident/representative notification and participation, yet no separate RCC policy was provided.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a prior wrist fracture was initially assessed as not at risk to low fall risk, but the care plan documented fall risk due to cognitive impairment and generalized weakness, with interventions such as call light within reach and assistance with transfers. A subsequent quarterly MDS showed severely impaired cognition (BIMS 3) and need for substantial assistance with mobility, yet no Fall Risk Evaluation was completed for several months, including around the time of the quarterly assessment. The resident later experienced a fall, was found on the floor with a reddened hip and, later, a bump on the head and inability to move the neck, and was transferred to the ED, where an acute displaced type II odontoid fracture was diagnosed. The DON reported that Fall Risk Evaluations were expected on admission, quarterly, and with changes in condition, but no specific policy on Fall Risk Evaluations was available.
Two residents with significant cognitive and mobility impairments experienced falls, and in both cases the assigned RNs failed to document complete post-fall nursing assessments in the medical record as required by facility policy. For one resident with Parkinson’s disease and a history of falls, the RN recorded discovery of the resident on the floor with a facial laceration, EMS transfer, and provider/representative notification, but did not document range of motion (ROM), neurological findings, or a full assessment via SBAR. For another resident with dementia, prior wrist fracture, and severe cognitive impairment, the RN documented the resident on the floor with a reddened hip, vital signs, and provider notification, but did not document ROM, additional injury assessment, new monitoring orders, or an SBAR. Both RNs later stated they had performed full assessments but had not recorded their findings, contrary to the facility’s Falls Protocol and charting policies requiring detailed documentation of post-fall assessments and changes in condition.
The facility failed to consistently provide substantial evening snacks to residents. Surveyors observed that the snack shelf and snack cart often contained only beverages and minimal crackers, with no other substantial snack items available, and the café refrigerator held a limited number of Jello, pudding, or fruit cups despite a resident capacity of 125. The FSD reported that snacks were delivered weekly but routinely ran out early in the week due to a reduced snack budget, and the Administrator was aware of the shortage. The dietician stated that snack availability had significantly declined since a change in ownership, that requests for additional snacks were not approved, and that snacks needed for diabetics or residents who did not eat meals for caloric supplementation were not always available.
Failure to Prevent and Monitor Pressure Injuries: Two residents with significant risk factors and existing skin breakdown did not receive timely, resident-specific pressure injury prevention and wound monitoring. One resident with diabetes, CHF, incontinence, and limited mobility had a sacral/coccyx wound that was not tracked with weekly skin checks and was observed with delayed incontinent care, a saturated dressing, and worsening skin damage. Another resident with Parkinson’s disease, scoliosis, kyphosis, and malnutrition lacked a positioning plan for the chin/mandible area and developed a facility-acquired pressure injury that progressed while ordered wound and positioning interventions were delayed or not fully implemented.
Control drug reconciliation was not maintained. Review of the narcotic receipt/disposition records found multiple yellow sheets in the 2025 binder that were not matched to the white copies, including records for oxycodone, pregabalin, morphine, and lorazepam. Review of prior reconciled records also found remaining amounts of morphine solution and lorazepam tablets with no evidence of where the medication was located. The DNS said the process had been disorganized, had been delegated to other RNs, and that some white sheets may have gone home with residents or staff.
Failure to Follow Up on Consultant Pharmacist Recommendations: A resident with Lewy body neurocognitive disorder, dementia, anxiety, and mood disorder was receiving psychotropic medication, but the facility did not timely act on consultant pharmacist recommendations from the monthly DMR. The record lacked evidence of follow-up on a recommendation to check a valproic acid level, an AIMS test was completed later than recommended, and behavioral monitoring with target behaviors was not initiated until months after it was suggested. Interviews showed the reviews were expected to be addressed within 30 days, and the facility policy required the physician or designee to respond and document agreement or disagreement.
Improper Refrigerated Food Storage and Labeling: Surveyors observed thawing turkeys stored above liquid eggs and milk in the walk-in cooler, along with multiple condiments and food items that were missing complete open dates, expiration dates, or use instructions. The FSD stated meat should be thawed on the bottom shelf and acknowledged the facility lacked a policy for shelf life of food items; the facility’s food storage guide required certain condiments to be used within 60 days of opening or by the manufacturer’s expiration date.
The facility failed to consistently implement its infection control program. A resident on droplet precautions was observed without staff PPE, with hand hygiene not performed between residents and shared equipment not cleaned before reuse, while precaution carts were not fully stocked. Another resident with draining pressure injuries was not placed on EBP, and two roommates were not cohorted according to MDRO policy. The facility also lacked documented annual policy review, quarterly environmental rounds, monthly infection trend analysis, and implementation of its water management plan.
COVID-19 Vaccine Consent and Documentation Not Completed: The facility failed to properly offer, document, and track COVID-19 booster vaccination status for multiple residents. One cognitively intact resident with CKD, DM2, and COPD had no record that the vaccine was offered or prior immunization assessed; another resident with UTI, COPD, and DM2 had an incomplete vaccine education form with the COVID-19 section left blank; and a third resident with dementia, depression, and HTN had verbal consent from the RP documented, but no provider order, administration record, or clear refusal documentation for the booster.
A resident with dementia, depression, and mood disorder who used a wheelchair and required limited assistance for care was receiving incontinent care from three NAs when the resident became combative and refused care. Two NAs held the resident’s arms while the third provided care, and one NA slapped the resident’s arm and used profanity, as witnessed by two staff. The witnesses did not immediately report the incident, and all three NAs continued working for additional days before the allegation was brought to an RN and investigated, contrary to facility policy requiring immediate action to prevent abuse.
A resident with dementia and mood disorders, who required limited assistance with ADLs and used a wheelchair, became combative and refused incontinent care while three NAs attempted to change a soaked brief and bedding. During this care, one NA allegedly slapped the resident’s arm while using profanity, and two other NAs reported witnessing the slapping but did not immediately report the incident, each assuming the other would do so. The event was not brought to an RN supervisor until days later, and only then was the DNS notified and an investigation initiated, resulting in a substantiated abuse finding. This sequence of delayed reporting and notification failed to meet requirements for timely reporting of alleged abuse to the state survey agency.
The facility failed to ensure code status orders and advance directive consents matched residents’ wishes. One cognitively intact resident had a care plan and signed code status form indicating DNR/DNI, but no physician order reflected that status. Another resident had a full code order, but the chart lacked a signed code status form even though the responsible party stated the resident’s wishes were DNR/DNI. Staff interviews confirmed code status should be documented in the chart and physician orders, and that the order should match the consent.
Late Medication Administration: A resident with seizure disorder, diabetes, and HTN reported that meds were routinely passed late, with morning doses sometimes given in the afternoon. Record review showed repeated late administration of scheduled meds such as Keppra, Bactrim DS, Glipizide, and Gabapentin over multiple days. During observation, an LPN was still completing the morning med pass well after it began and attributed delays to interruptions and staffing issues, while the DNS, nursing supervisor, and APRN were unaware the late passes were occurring consistently.
A resident who was dependent on staff for ADLs, incontinent, and at high risk for skin impairment was left without timely incontinent care and later found with a urine-saturated dressing and worsening sacral/coccyx skin breakdown. Surveyors observed the resident had not been cleaned up for the day, had not been changed since night shift, and reported soreness from sitting in wet briefs due to staffing constraints. Staff interviews confirmed the dressing had been placed on the night shift, was saturated with urine, and that the wound had not been monitored as expected.
Failure to Provide Needed Foot Care: A resident with DM, MS, and paraplegia did not receive podiatry services for trimming of overgrown toenails despite orders for diabetic foot care, weekly skin checks, and podiatry as needed. Staff observations showed multiple toenails extending beyond the toes, but the issue was not consistently identified or communicated, and the resident had not been seen by the podiatrist since admission.
Delayed PRN Pain Medication Administration: A resident with chronic pain and osteoarthritis requested PRN morphine for pain, but the medication was not given until well after the request. The resident said the pain medication was still pending after the initial request, while an LPN stated the resident had asked for it around 10:00 AM and another LPN acknowledged she had forgotten about it. The MAR showed the morphine was administered later that day, and the APRN stated she would expect a resident not to wait longer than 15 minutes unless the nurse was handling an emergency.
A resident with CKD, DM2, and COPD was admitted cognitively intact, but the facility failed to document that influenza and pneumococcal vaccines were offered or that prior immunization status was assessed on admission. The IP nurse could not produce vaccine records or consent documentation and stated the consent review and vaccine history check were not completed as required by policy.
A resident with osteoarthritis, rheumatoid arthritis, and non-ambulatory status, who required a two-person stand-pivot transfer with a walker per care card and provider order, was transferred by a single NA who did not use a gait belt or walker. The NA assisted the resident to stand from a wheelchair using the bed rail and instructed the resident to pivot toward the bed, during which a pop/grinding sound was heard from the left knee and the resident experienced immediate pain. Initial nursing assessment noted pain with movement but no visible swelling or redness, and the provider was not notified until hours later when swelling and continued pain were reported by an LPN. A STAT X-ray subsequently revealed an acute comminuted fracture of the distal left femoral shaft, and the resident required hospital transfer and surgical repair.
A resident with osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder had a current physician order for bed mobility assist of two and transfer assist of two with a rolling walker, and therapy discharge documentation showed the resident performing stand-pivot transfers with assist of two. Despite this, the resident’s care plan, last reviewed by the IDT and MDS nurse, continued to list the resident as a total lift for transfers and was not revised to reflect the updated mobility status and orders, contrary to the facility’s comprehensive care planning policy requiring ongoing review and revision with condition changes.
A resident with osteoarthritis and rheumatoid arthritis, who had a PRN order for acetaminophen every six hours for pain, sustained a left distal femur fracture during a transfer and experienced significant pain with movement. Initial PRN acetaminophen given in the late afternoon was documented as effective, but when the resident later yelled out in pain and swelling was observed, an LPN did not administer another PRN dose despite the order parameters. During the night, another LPN observed ongoing discomfort but delayed giving acetaminophen until early morning, assuming it had already been given and not checking the MAR. The early-morning dose was documented as ineffective for 10/10 pain, and although this unrelieved pain was reported to a supervisor, the provider was not notified and no additional pain medication was obtained before the resident was sent to the hospital. The facility’s pain policy requiring frequent reassessment of acute pain, MAR review, and reporting of prolonged unrelieved pain was not followed.
The facility did not complete required annual performance evaluations for a nurse aide working the 3–11 PM shift. Review of the aide’s personnel file showed a hire date more than a decade earlier and a last documented evaluation several years ago, with no evidence of subsequent yearly evaluations. The Administrator reported that all employees must receive annual evaluations based on their hire-date anniversary and that HR was responsible for notifying when evaluations were due, routing them to nursing supervisors, and ensuring they were filed. Facility policy specified that evaluations should summarize counseling sessions to identify trends, review job description performance ratings with the employee, and be filed per policy, but this process was not followed for the identified aide.
A resident in hospice care with Alzheimer's and other conditions did not receive prescribed medications due to facility errors. Lorazepam and Atropine were not administered as ordered because of pharmacy delivery issues and miscommunication. Nurses documented medication administration without actually giving it, and oral Acetaminophen was improperly continued despite swallowing difficulties. These failures led to inadequate symptom management during the resident's end-of-life care.
A resident in hospice care did not receive prescribed Lorazepam due to unavailability, yet two LPNs inaccurately documented its administration in the e-MAR. The nurses failed to correct the documentation or notify the supervisor, leading to a deficiency in accurate clinical record-keeping.
A resident with COPD and nicotine dependence experienced multiple documented smoking incidents, including possessing cigarettes and smoking on facility grounds, despite having a care plan addressing smoking cessation. The care plan was not updated to reflect these incidents or to include new interventions, and facility leadership confirmed the lack of timely care plan revision.
A resident with COPD and nicotine dependence was repeatedly found in possession of or using smoking materials independently, despite facility policies prohibiting this. Staff documented the incidents but did not complete required accident/incident reports or investigations, nor did they report the events to the State Agency as mandated by policy.
Two residents experienced misappropriation of their controlled medications, including Morphine and Lacosamide, along with missing controlled substance records. In both cases, medications were removed from secure storage without authorization, and the facility was unable to account for the missing drugs or identify the responsible party, violating policies against misappropriation of resident property.
A resident with mobility and incontinence issues was not treated with dignity and respect by a nurse aide, who yelled at the resident after an incontinence episode, threw items around the room, and failed to assist the resident back to bed. The incident was witnessed by a roommate and confirmed by staff interviews, in violation of the facility's policy on resident rights.
The facility failed to ensure congruence between physician's orders and advanced directive forms for several residents, leading to discrepancies in code status documentation. For instance, a resident's advanced directive indicated DNR, but the care plan and physician's orders showed full code. Another resident's code status was changed by a Probate Decree, but this was not updated in the clinical record until later. Additionally, a resident's desire for CPR was not reflected in the physician's orders, and the facility did not verify the authority of the POA to make medical decisions.
A resident with dementia and other conditions was prescribed Gabapentin 300 mg, but the intent was 100 mg twice daily. The pharmacy consultant failed to identify this discrepancy during monthly reviews. An LPN administered the incorrect dosage, and the pharmacy provider did not follow protocol to clarify the order, leading to a deficiency in medication management.
A resident with severe cognitive impairment and physical limitations was found with excessively long and thick fingernails, indicating a deficiency in personal hygiene care. Despite care plans and physician's orders for regular nail maintenance, staff failed to adequately address the resident's nail condition. Interviews revealed a lack of awareness and communication among staff, leading to neglect in nail care.
A resident with multiple health issues had a wound on the right great toe that was not assessed by an RN upon initial observation, nor monitored weekly as required. Interviews with staff revealed that the wound nurse was not informed, leading to a lack of proper monitoring, contrary to facility policy and state regulations.
A facility failed to ensure that a resident's pressure ulcer was assessed by an RN as required by policy. The resident, at risk for pressure ulcers, had a new deep tissue injury on the right heel initially assessed by an LPN. The wound was not assessed by an RN until much later, despite policy requirements for initial and weekly RN assessments.
A facility failed to discuss and provide a written summary of a baseline care plan to a resident admitted with Covid-19, atrial fibrillation, hypertension, and polyarthritis. Despite the policy to develop a care plan within 48 hours, there was no documentation of the interdisciplinary team meeting with the resident or their representative to discuss the plan. Interviews with staff confirmed the oversight.
The facility failed to maintain complete and accessible medical records for laboratory results for three residents. Despite having multiple blood tests conducted, the results were not present in the residents' records. Staff interviews revealed a lack of clarity and accountability in handling and filing these results, leading to incomplete medical documentation.
A facility failed to maintain complete hospice documentation for a resident with dementia and other conditions. Despite being admitted to hospice care, the resident's clinical record lacked necessary documentation, including interdisciplinary team notes and care plans. Interviews with staff revealed confusion about the location and organization of hospice records, exacerbated by changes in the hospice company's filing system.
Failure to Supervise High Fall-Risk Resident During Bedside Urinal Use
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an accident for a cognitively impaired, fall‑risk resident during bedside urinal use. The resident had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition (BIMS 11), impaired balance, unsteady gait, visual difficulty, and a documented history of falls including a prior fall with injury since admission. The care plan and physician orders identified the resident as an assist of one for ADLs and toilet transfers, with interventions including assistance for toileting at wheelchair level using a grab bar, use of simple language, reorientation as needed, and instruction to ask for assistance before transferring or ambulating. On the day of the incident, a nursing assistant (NA) entered the resident’s room when the resident requested to use a urinal. The NA assisted the resident to sit on the bedside to use the urinal. When the resident was unable to urinate, the resident requested privacy. Despite knowing the resident required assist of one for ADLs and toileting, had a history of falls, was sometimes confused, and had a history of not using the call bell, the NA pulled the privacy curtain around the bed, left the resident sitting on the bedside behind the curtain and out of her line of sight, and went to provide care to the roommate. Approximately two minutes later, the NA heard a bang, opened the curtain, and found the resident on the floor beside the bed with active bleeding from the head and the urinal on the floor. After discovering the resident on the floor, the NA briefly asked if the resident was okay and then left the resident unattended again while she walked down the hallway to notify the RN, without calling out for help or using the call bell. Subsequent nursing notes documented that the resident was found seated on the floor with a laceration to the face and active bleeding from the forehead, and that EMS was notified and the resident was transferred to the hospital, where multiple forehead lacerations were repaired with absorbable sutures. Interviews with the LPN, RN, and DON confirmed that, based on the resident’s plan of care and known fall risk, the resident should not have been left out of sight behind a privacy curtain while sitting on the bedside to use the urinal, and that the NA did not maintain appropriate supervision or immediately seek assistance while the resident was actively bleeding on the floor.
Failure to Complete and Document Quarterly Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure Resident Care Conferences (RCCs) were completed at least quarterly and in conjunction with the required quarterly MDS assessment for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction, and the care plan dated 11/19/25 identified the resident as being at risk for falls due to new admission status, cognitive impairment, and generalized weakness. An RCC and interdisciplinary care plan meeting were documented on 11/19/25, and the quarterly MDS dated 2/3/26 showed severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. However, review of the clinical record from 11/20/25 through 3/8/26 did not show that an RCC was scheduled or held to correspond with the 2/3/26 MDS. The Interdisciplinary Care Plan Meeting Documentation showed the next RCC for this resident occurred on 3/9/26, more than one month after the quarterly MDS. The MDS Coordinator (RN #3) stated that RCCs are to be completed at least quarterly with review of the resident care plan and acknowledged that the resident should have had an RCC scheduled around the time of the 2/3/26 MDS. RN #3 reported an RCC was initially scheduled for 2/19/26 but could not provide documentation that the meeting occurred or that invitations were sent to the resident or representative, noting she had been on vacation when invitations should have been sent. The DON confirmed that all residents are to have quarterly RCCs that correlate with the MDS date and be documented in the clinical record, and that if an RCC is rescheduled, there should be documentation explaining the reason and new date. Review of the Comprehensive Care Planning policy showed requirements for informing residents of their right to participate in care planning, providing advance notice of conferences, documenting when participation is not practicable, and reviewing and updating the care plan at least quarterly with the MDS; no separate RCC policy was provided despite request.
Failure to Complete Quarterly Fall Risk Evaluation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not completing a required Fall Risk Evaluation at least quarterly for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction. A Fall Risk Evaluation dated 10/30/25 identified the resident as not at risk to low fall risk, while the Resident Care Plan dated 11/19/25 documented that the resident was at risk for falls due to new admission status, cognitive impairment, and generalized weakness, with interventions such as keeping the call light within reach, orienting to surroundings, and instructing the resident to ask for assistance before transfers or ambulation. A quarterly MDS assessment later identified severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. Despite these findings, review of the clinical record showed no Fall Risk Evaluation was completed between 10/31/25 and 2/9/26, including around the time of the quarterly MDS. On 2/10/26 at 1:31 AM, an RN documented that the resident had fallen and was found on the floor on the right side, with a reddened right hip but denying pain; vital signs were obtained and the provider was notified, but there were no documented orders for monitoring the reddened hip. Later that day, the DON documented that the resident had sustained a fall and was later noted to have a bump on the right side of the head and inability to move the neck, though still denying pain or discomfort, and the resident was evaluated by an APRN and transferred to the ED. Hospital records showed an admission from 2/10/26 through 2/16/26 for an acute displaced type II odontoid fracture following the fall. The DON stated that all residents should have a Fall Risk Evaluation on admission, quarterly, and with a change in condition, and acknowledged that this resident should have had a Fall Risk Evaluation completed around the time of the quarterly MDS. The facility’s Falls Protocol policy referenced review and documentation of fall risk factors and evaluation of falls, but a specific policy on Fall Risk Evaluations was not available.
Failure to Document Complete Post-Fall Nursing Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete and document nursing assessments in the medical records at the time of residents’ falls, as required by facility policy and professional standards. For Resident #1, who had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition, and a history of falls, the care plan identified multiple fall risks and required assistance with ADLs and toileting. After a fall on 2/7/26, RN #1 documented that the resident was found seated on the floor attempting to get up, with a facial laceration and bleeding, that EMS was notified, the resident remained on the floor until EMS arrival, and that the resident was transferred to the hospital. The note also documented notification of the on-call provider and the resident’s representative. However, the clinical record for Resident #1 did not include documentation that range of motion (ROM) was assessed for additional injuries or pain following the fall, and there was no completed Situation, Background, Assessment, Recommendation (SBAR) form to show that a full assessment had been performed. In interview, RN #1 stated she had performed a full assessment, including ROM and neurological signs, but acknowledged she did not document her findings and that the assessment should have been documented before the end of her shift. This lack of documentation conflicted with the facility’s Falls Protocol policy, which directed nurses to assess and document vital signs, recent injury, musculoskeletal function including changes in ROM or weight bearing, cognition and neurological status, pain, and details of the fall. For Resident #2, who had a scaphoid fracture of the left wrist, weakness, Alzheimer’s disease, aphasia following cerebral infarction, severe cognitive impairment, and required substantial assistance with mobility, the care plan identified fall risk related to new admission, cognitive impairment, and generalized weakness. After a fall on 2/10/26, RN #2 documented that the resident was found on the right side on the floor, with the right hip reddened from lying on it, and that the resident denied pain; vital signs were obtained and the provider was notified. The record did not show any new orders for monitoring the reddened hip, did not document that ROM was assessed for further injuries, and did not contain an SBAR documenting a full assessment. Later documentation by the DON noted that the resident was subsequently found with a bump on the right side of the head and inability to move the neck, and hospital records showed admission for an acute displaced type II odontoid fracture. In interview, RN #2 stated she had performed a full assessment including movement and ROM but did not document it, and the DON confirmed that both RNs should have documented full post-fall assessments in the nurse’s notes or SBARs in accordance with the facility’s Falls Protocol and Charting Documentation policies.
Failure to Provide Substantial and Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a substantial evening snack on a daily basis, as required by regulation and facility policy. Surveyor observations of the dietary department’s dry storage room on multiple dates showed that the designated snack shelf contained only a small quantity of items, such as one box of crackers and several 1-liter bottles of cola, with no chips, cookies, crackers, or other substantial snacks available. On another observation, there were no snacks available to residents at all. Review of the snack cart revealed it typically contained only a coffee carafe, a bottle of ginger ale, and at most a single or partial package of crackers, with no other food items present for residents. Further observations of the café refrigerator showed fewer than 20 containers of Jello, pudding, or fruit cups available for a facility with a capacity of 125 residents. In interviews, the Food Service Director (FSD) reported that snacks were delivered weekly on Thursdays but routinely ran out by Mondays due to a reduced snack budget of $315 per week. The Administrator acknowledged awareness of the lack of snacks and that the FSD had raised concerns. The dietician reported that snack availability had significantly declined since a change in ownership, that requests to purchase more snacks were not approved, and that snacks needed for residents who are diabetic or who did not eat meals were not always available, despite their importance for caloric supplementation.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for two residents with pressure injury risk factors and existing skin breakdown. One resident was readmitted with diagnoses including type 2 diabetes, Sjogren syndrome, and congestive heart failure, was dependent for transfers and toileting, incontinent of bladder and bowel, and had a Norton Plus score of 11 indicating high risk. The record showed an order for triad paste to the buttocks, a care plan identifying risk for skin breakdown related to decreased mobility and moisture, and later documentation of blanchable erythema, denuded areas, and moisture associated skin deterioration. However, the wound was not monitored and assessed on a weekly basis, the record did not show size or drainage changes, and the wound nurse and wound APRN did not assess the sacral area until later in the course of the wound. The same resident was observed with delayed incontinent care and a saturated dressing. On 2/26/26, the resident was still in bed and had not been cleaned up for the day, stated that he or she had not been changed since night shift, and reported ongoing rectal and back soreness. The resident’s skin was observed with an open sacral/coccyx wound with yellow drainage, slough, irregular and partially macerated edges, and discolored scarred surrounding skin. Staff interviews confirmed the dressing had been placed on night shift and was saturated with urine, and the nursing supervisor acknowledged the chart did not show weekly skin audits or monitoring of the sacral wound. The wound APRN later stated the area should have been seen earlier and that moisture-associated skin issues are more susceptible to developing a pressure injury. The facility also failed to implement resident-specific positioning interventions for another resident with Parkinson’s disease, thoracogenic scoliosis, kyphosis, and severe protein calorie malnutrition. That resident was admitted with a heel DTI and coccyx pressure ulcer, had a Norton Plus score of 16 on admission and later 12, and was dependent for multiple ADLs. The care plan addressed general pressure injury risk, but it did not include a resident-specific positioning plan related to the scoliosis and kyphosis. The resident later developed a facility-acquired stage 2 pressure injury to the left inferior mandible/chin, which progressed to a stage 4 injury. Interviews showed the resident used a neck pillow and collar brought from home, but there was no physician order or positioning intervention in place on admission for the neck/chin area, and therapy staff stated the collar was not the appropriate size and could cause pressure. The record also showed delays in implementing wound care recommendations and in carrying out positioning-related interventions such as pillows in the wheelchair and side-to-side positioning in bed.
Control Drug Reconciliation Records Not Matched
Penalty
Summary
The facility failed to ensure a control drug reconciliation process was in place. Review of the 2024 and 2025 control drug and receipt program found 9 yellow control drug and receipt disposition records in the 2025 binder that were not matched with the corresponding white control drug and receipt disposition records, including records for oxycodone IR 5 mg, pregabalin 200 mg, morphine ER 30 mg, oxycodone 10 mg, lorazepam concentrate 2 mg/ml, and morphine concentrate 20 mg/ml. Review of the 2024 reconciled control drug receipt dispositions also identified morphine solution 100 mg/5 ml received with a remainder of 14.5 ml and lorazepam 1 mg tablets received with a remainder of 23 tablets, with no evidence of where the remaining medication was located. During interview, the DNS stated the control drug receipt disposition process had been "a mess" since she started in October 2025. She said the process was for the yellow copy of the narcotic sheet to be placed in a binder until the white copy came to the nursing office to be matched, and that she had delegated reconciliation to RN #6 and then to RN #3, who had been auditing and organizing the records. The DNS stated some medications may have gone home with residents and sometimes the white sheet was taken home. RN #3 reported she could not locate the white sheets for the listed medications, could not locate the medications on the floor, and could not locate the 2024 destruction log. LPN #3, corporate, stated she was unaware of the narcotic reconciliation issues and that when ownership changed in December 2025, the DNS remained in position so there was no need to change ownership of the narcotic medication.
Failure to Follow Up on Consultant Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to follow up on consultant pharmacist recommendations from the monthly drug regimen review for Resident #114, whose diagnoses included neurocognitive disorder with Lewy bodies, dementia, anxiety disorder, and mood disorder. The quarterly MDS identified the resident as severely cognitively impaired, with no behavior, and as independent for bed mobility, transfers, dressing, and personal hygiene, while also noting that the resident ambulated short distances. The care plan identified psychotropic medication use related to anxiety and included monitoring for side effects and adverse reactions such as unsteady gait, tardive dyskinesia, shuffling gait, and rigid muscles. Review of the drug regimen reviews showed that a recommendation to check a valproic acid level was made, but there was no indication that the recommendation was reviewed by the physician or APRN, and the clinical record did not identify a valproic acid level for 2024 or 2025. Another review recommended an AIMS test due to psychotropic medication use, and the clinical record showed an AIMS test was completed later. A subsequent review recommended adding behavioral monitoring with appropriate target behaviors, but the clinical record did not identify initiation of behavior monitoring until approximately 3.5 months later. Interviews with the consultant pharmacist company, the DNS, and the APRN indicated that medication reviews were received by email or in the APRN book, were to be followed up within 30 days, and that if a recommendation was not followed up on, it meant the APRN did not receive the drug review. The facility policy directed the attending physician or licensed designee to respond to the drug regimen review within 30 days or more promptly and to document agreement or disagreement with the recommendation.
Improper Refrigerated Food Storage and Labeling
Penalty
Summary
Food items were not stored and labeled in accordance with professional standards in the facility’s walk-in refrigerator. On 2/19/2026 at 10:15 AM, surveyors observed two turkeys thawing on the second shelf with visible drainage from the thawing turkeys on the shelf above cartons of liquid eggs and cartons of milk. The same observation identified multiple refrigerated food items and condiments with missing or incomplete dating, including slaw dressing, barbeque sauce, ranch salad dressing, an opened jar of maraschino cherries with visible crusting around the cap, relish, and teriyaki sauce. Several items had received dates and opened dates without a year, and expiration dates or directions for use after opening could not be located on the containers. During interviews, the FSD stated that meat items should be thawed on the bottom shelf of the walk-in refrigerator and that she was unaware of how long a condiment could be used after opening if there was no expiration date. The FSD later stated that the jars should be labeled with the date opened and that, based on an online search and the dates present, the condiments should have been discarded because they were received in 2024. The FSD also stated the facility did not have a policy regarding shelf life of food items. The facility’s policy required food items without manufacturer expiration dates to be dated, monitored, and discarded according to established food safety standards, and the refrigerated food storage guide stated items such as mayonnaise, BBQ sauce, mustard, and ketchup could be stored for 60 days from opening or until the manufacturer’s expiration date, whichever came first.
Infection Control Program Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program across multiple areas of practice. Survey findings showed that infection surveillance data were not consistently analyzed for trends, infection prevention policies and procedures were not reviewed annually, environmental rounds were not documented as completed quarterly, and the facility did not follow its water management plan for Legionella and other waterborne pathogens. Documentation reviewed with the Infection Preventionist showed missing monthly surveillance infection report analyses for several periods and no documentation of quarterly infection reports for at least one quarter. For Resident #49, who was admitted with diagnoses including a right radius fracture, long-term anticoagulant use, and difficulty walking, the record showed droplet precautions were ordered for a respiratory illness with cough, congestion, and fever. During observation, staff entered the room without PPE, moved a chair scale from the droplet room to another resident’s room without cleaning it, and did not perform hand hygiene between residents. A nurse also exited the droplet room and returned a thermometer to the cart without wiping it down. Precaution carts outside rooms were observed with incomplete PPE supplies, and staff interviews confirmed uncertainty about PPE use, hand hygiene, and equipment cleaning expectations. The facility also failed to appropriately identify Resident #37 for Enhanced Barrier Precautions despite having pressure injuries with drainage and ongoing wound care orders. The EBP log did not include the resident, and no EBP order or signage was posted outside the room. In addition, the facility did not cohort residents with a known MDRO according to policy: Resident #117 had a history of ESBL and CRE, while Resident #77 was roomed with that resident even though the facility policy stated residents with CRE should be placed in a single room or cohorted with another resident with CRE. The water management plan was also not implemented as documented, with the Director of Maintenance stating there was no documentation of flushing low-flow areas, cleaning ice machines, flushing eyewash stations, or maintaining the required logs, and a prior water sample had detected Legionella species in a fixture.
COVID-19 Vaccine Consent and Documentation Not Completed
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccine was administered as requested by the resident or responsible party and offered on admission for three sampled residents. The deficiency was identified through review of clinical records, facility policy, facility documentation, and interview with the Infection Preventionist nurse. The facility policy stated that the COVID-19 vaccine would be offered to all residents unless medically contraindicated or previously immunized, and that consent or refusal would be documented in the medical record. Resident #5 was admitted in January 2026 with chronic kidney disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The admission MDS identified the resident as cognitively intact and not up to date with COVID-19 vaccination. Review of the immunization and clinical records with the IP nurse failed to identify documentation that the COVID-19 vaccine was offered or that prior immunization was assessed. The IP nurse stated that consent forms were obtained on admission by the admitting supervisor and then reviewed by the IP nurse, but he was unable to provide documentation of the resident’s COVID-19 vaccine records and stated the consent forms had not been reviewed with the resident. Resident #8 was admitted in November 2025 with urinary tract infection, COPD, and type 2 diabetes mellitus, and was also identified on the admission MDS as cognitively intact and not up to date with COVID-19 vaccination. The admission vaccination education form documented consent and information for influenza and pneumococcal vaccines, but the COVID-19 section was not completed for consent or refusal. The IP nurse stated the COVID-19 section had not been reviewed or completed with the resident and that the resident should have been followed up for the booster on admission; a later nurse’s note documented that the resident was eligible and declined. Resident #50 was admitted in October 2025 with dementia, depression, and hypertension, and the admission MDS identified severely impaired cognition and not up to date with COVID-19 vaccination. A nurse’s note documented that the vaccine was discussed with the responsible party, verbal consent was obtained, and the APRN was updated, but the physician order record did not contain an order for the 2025-2026 COVID-19 booster. The clinical record also did not show administration or refusal documentation, and the IP nurse stated the resident had refused and that the refusal should have been documented in the electronic record.
Failure to Protect Resident From Physical Abuse and Delay in Reporting Incident
Penalty
Summary
The deficiency involves a resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder who was moderately cognitively impaired, used a wheelchair, and required limited assistance with mobility and personal care. The resident’s care plan identified a risk for refusing care and not waiting for assistance with transfers, with interventions including use of two staff for care and transfers, calm and gentle approach, and clear explanations. During an evening episode of incontinent care, three NAs entered the resident’s room when the resident did not want to be changed and became combative, swinging arms and feet. Two NAs held the resident’s arms while a third NA provided care. During this care, one NA slapped the resident hard on the arm and used an expletive, according to two staff witness statements, while the resident continued to resist by kicking and slapping. The deficiency also includes the failure of two staff members to immediately report the witnessed physical abuse. Both NAs who observed the slapping did not report the incident at the time it occurred, despite one believing the other would report it, and there was no discussion between them about reporting. As a result, the alleged abuser and the two witnesses continued to work in the facility for two additional days before the allegation was reported to the Nursing Supervisor near the end of a later shift. The facility’s policy required protections for residents through written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and called for an immediate investigation when suspicion or reports of abuse occur, but the delay in reporting and the occurrence of the slapping incident demonstrate a failure to ensure the resident was free from mistreatment.
Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse to the state survey agency. A resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder was moderately cognitively impaired, required limited assistance with ADLs, and used a wheelchair. The resident’s care plan identified risk for refusing care and not waiting for assistance with transfers, with interventions including assistance of two staff for care and transfers and use of a calm, gentle approach. During provision of incontinent care, the resident became combative and refused care while staff attempted to change a soaked brief and bedding. According to written statements, three NAs entered the resident’s room to provide care. One NA held the resident’s arms so another NA could change the brief, and a third NA assisted in holding the resident’s arms. One NA was alleged to have slapped the resident hard on the arm while using an expletive, and two NAs reported witnessing the slapping. One NA stated she should have reported the incident when it happened, and another NA stated she did not report the incident because she thought the other NA would report it, although they had not discussed reporting. The involved NAs continued to work in the facility on subsequent days because the allegation was not reported at the time of occurrence. The incident was alleged to have occurred several days before it was brought to the attention of the RN Nursing Supervisor, who was notified toward the end of a later shift that an NA had slapped the resident during care. The Nursing Supervisor documented that two NAs confirmed the allegation and that the incident had occurred days earlier, with no noted signs or symptoms of injury. The DNS was later notified via text message and began an investigation, during which statements were obtained and the allegation was ultimately substantiated based on two staff witnesses. The facility’s policy required immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation, but the delay in reporting by staff and the delayed notification to the state survey agency constituted a failure to ensure timely reporting of the abuse allegation.
Missing code status orders and advance directive consents
Penalty
Summary
The facility failed to ensure that physician orders were in place and that consents were obtained to reflect residents’ wishes regarding advance directives and cardiopulmonary code status. For one resident with systemic lupus erythematosus, depression, and hypothyroidism, the quarterly MDS identified the resident as cognitively intact and independent with several activities of daily living. The care plan identified an established advance directive for DNR/DNI/RNP, and the clinical record contained an Advance Directive Declaration Code Status form signed by the responsible party and APRN indicating DNR and DNI, but the physician’s orders for the reviewed period did not include a code status order. Interviews with nursing staff showed that in a life-threatening emergency they would check the resident’s code status, and staff identified that code status should appear in the electronic record, physical chart, and physician’s orders. One LPN stated that if no code status order was present, CPR would be started while another staff member checked the code status form, and CPR would stop if the form showed DNR/DNI. The DNS stated that the nurse is to check physician orders first, that code status is obtained on admission, and that the physician’s order should match the consent obtained from the resident or responsible party; if code status is not obtained or unknown, the resident is considered full code. For another resident admitted in November 2025 with Type 2 diabetes mellitus, multiple sclerosis, and paraplegia, the admission MDS identified the resident as cognitively intact and dependent for several ADLs. The physician’s order indicated full code, but the physical chart and electronic record did not contain a signed Advance Directive Declaration Code Status form showing the resident’s wishes. The resident’s responsible party stated the resident’s wishes were DNR/DNI and reported no contact from the facility regarding advance directives, while the social worker stated she should have contacted the responsible party from admission if nursing was unable to obtain consent. The DNS stated the resident should have had a consent in the chart by that time and that the physician’s order should match the code status consent.
Late Medication Administration
Penalty
Summary
The nursing facility failed to ensure medications were passed on time for a resident with diagnoses including hypertension, type 2 diabetes, cirrhosis of the liver, and seizures. The resident’s quarterly MDS identified the resident as cognitively intact, without behaviors, and requiring limited assistance with bed mobility, transfers, dressing, and personal hygiene. The care plan identified the resident as at risk for seizures and included interventions such as keeping the call light within reach and administering medications as ordered. Review of the physician’s orders for March 2026 showed scheduled medications including Keppra 500 mg twice daily for withdrawal seizures, Bactrim DS 800-160 mg twice daily, Glipizide 5 mg in the morning, and Gabapentin 600 mg three times daily for pain. Review of the electronic medication administration record for 1/1/26 through 2/26/26 showed repeated late administrations of these medications, including morning doses given late by more than an hour on multiple days and some doses given close to the next scheduled dose. Examples included Bactrim, Glipizide, Keppra, and Gabapentin being administered well after their scheduled times on numerous occasions throughout the review period. The resident stated that medications were passed late on a consistent basis, with morning medications sometimes given in the afternoon. On observation of the unit, an LPN was still completing the morning medication pass at 10:15 AM after starting at 7:30 AM and still had nine residents remaining. The LPN attributed delays to staff and resident interruptions and noted that short staffing or interruptions were likely on other days. The DNS, nursing supervisor, and APRN each stated they were unaware medications were being passed late on a consistent basis, and the APRN noted concern that medications may need to be rescheduled if given near the next dose. The facility’s medication administration protocol identified the need to verify orders and avoid distractions and interruptions during medication preparation and administration.
Delayed Incontinent Care and Inadequate Wound Monitoring
Penalty
Summary
The facility failed to ensure timely incontinent care for a resident who was dependent on staff for transfers, toileting hygiene, and other activities of daily living and who was at high risk for skin impairment. The resident had diagnoses including type 2 diabetes mellitus, Sjogren syndrome, and chronic combined systolic and diastolic heart failure, and the clinical record showed moderately impaired cognition, frequent bowel incontinence, and always incontinent bladder status. The care plan identified risk for skin breakdown related to decreased mobility and moisture, with interventions including turning and repositioning about every 2 hours, skin inspection during care, and use of an alternating pressure mattress. The resident developed moisture-associated skin deterioration and later a sacral/coccyx wound. A wound nurse note described blanchable erythema with small superficial denuded areas on the buttocks, and later nursing documentation described loose, liquid bowel movements with malodorous odor and sacral skin irritation consistent with incontinence-associated dermatitis. During survey observation, the resident stated he/she had not been cleaned up for the day and had not been changed since night shift, and also reported soreness related to sitting in wet briefs due to staffing constraints on some days. The resident also stated that Aquaphor was on the bedside table but was not being applied to the rectum and back, and that pillows were being placed under the hips to relieve pressure. Surveyors observed the resident in bed with an old dressing that had been placed on the night shift and was saturated with urine. The resident’s skin showed an open area to the sacral/coccyx region with yellow drainage and slough, irregular and partially macerated wound edges, and discolored, scarred surrounding skin. Staff interviews confirmed this was the first time that day the resident had received care, that the dressing had been saturated with urine, and that staff could not identify when incontinent care had last been provided. Additional interviews showed the wound had not been monitored as expected, the wound APRN had not seen the sacral wound until later, and the facility’s chart lacked weekly skin audit documentation for the resident.
Failure to Provide Needed Foot Care
Penalty
Summary
The facility failed to ensure appropriate foot care for a resident with type 2 diabetes mellitus, multiple sclerosis, and paraplegia who was cognitively intact, dependent on staff for dressing, personal hygiene, footwear, transfers, and was non-ambulatory. The resident’s care plan identified diabetes-related interventions including podiatry consult as ordered and skin audits per facility protocol, and physician orders directed podiatry care as needed along with diabetic foot care and weekly skin checks on shower days. However, review of the clinical record did not identify that the resident had been seen by the podiatrist since admission. Observations showed the resident’s toenails were not trimmed. On 2/24/26, the resident was observed lying in bed with uncovered feet and toenails on the left foot that appeared to need trimming. On 2/26/26, a nurse aide observed the resident in bed and noted multiple toenails on both feet extended greater than 0.5 cm over the tips of the toes, with one toenail thick at the tip. The resident stated staff had been told the toenails needed trimming and that the resident would need to be placed on the podiatry list. Interviews and record review showed the issue was not communicated or acted upon through the facility’s usual process. The nurse aide said she had reported the toenails to a nurse about two weeks earlier but could not recall which nurse. The charge nurse stated she was unaware the toenails needed trimming and said she would have placed the resident on the podiatrist list if informed. The unit secretary stated she was responsible for scheduling podiatry appointments and had only been told on 2/26/26 that the resident needed to be placed on the podiatry list. The DNS stated there was no way staff did not notice the toenails, and the evening shift charge nurse later acknowledged she had completed some weekly skin checks without removing the resident’s socks to inspect the toenails.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure timely pain medication administration for a resident with diagnoses including primary osteoarthritis of the left shoulder, pain disorder with related psychological factors, chronic pain syndrome, and unilateral primary osteoarthritis of the right knee. The resident’s quarterly MDS identified the resident as cognitively intact, using a walker and wheelchair for mobility, and requiring limited assistance with bed mobility and varying levels of assistance with transfers and dressing. The care plan identified the resident as at risk for pain related to pain medication therapy and directed staff to administer analgesics as ordered, monitor side effects, review medication efficacy, and assess whether pain intensity was acceptable to the resident. The physician’s order for morphine sulfate oral solution 20 mg/ml, 0.25 ml every 8 hours as needed for pain, was discontinued and restarted the same day as every 6 hours. The resident reported requesting the PRN morphine from an LPN at 10:00 AM for pain rated 6 and was still waiting for the medication when interviewed later that morning. The LPN stated the resident requested the medication between 10:00 AM and 11:00 AM and that he went to pass it within 5 minutes, but the MAR showed the morphine was not administered until 12:31 PM. The resident later stated the medication was received about two hours after the initial request, after noon and after speaking with the surveyor. Another LPN acknowledged the resident had requested the medication around 10:00 AM but said she had not had time to pass it and had forgotten about it.
Failure to Offer and Assess Flu and Pneumococcal Vaccines on Admission
Penalty
Summary
The facility failed to ensure that Resident #5 was offered and assessed for pneumococcal and influenza immunization upon admission, as required by facility policy. Resident #5 was admitted in January 2026 with diagnoses including chronic kidney disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The admission MDS assessment identified the resident as cognitively intact and noted that the influenza vaccine had not been received because it was not offered. Review of the resident’s immunization and clinical records with the Infection Preventionist nurse failed to identify documentation that the influenza vaccine or pneumococcal vaccine had been offered or that prior immunization history had been assessed. The Infection Preventionist nurse stated that consent forms were not reviewed with the resident and that he was unable to provide documentation of the resident’s pneumococcal and influenza vaccine records. He explained that consents are obtained on admission by the admitting supervisor and then reviewed by the IP nurse, who checks the CT wiz database for prior vaccination history before the physician orders the appropriate vaccine. He also stated that he would review the vaccine consents with the resident because this should have been completed on admission.
Improper One-Person Transfer Without Gait Belt Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for transfers was transferred per protocol, resulting in a preventable accident and an acute comminuted fracture of the left distal femoral shaft. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and was non-ambulatory at baseline. An annual MDS showed a BIMS score of 12/15 with some memory deficits, partial assistance needed for bed mobility and transfers, and wheelchair use for mobility. Therapy staff and the DON confirmed that, at the time of the incident, the resident required an assist of two for stand-pivot transfers with a walker per the care card and physician’s order. On the day of the incident, the resident reported feeling very tired and falling asleep in the wheelchair, with left foot discomfort. A nurse aide observed the resident leaning forward in the wheelchair with hands on the side rail and believed the resident was trying to stand. Although the aide knew the resident required two-person assistance and a walker for stand-pivot transfers, she did not call for help, did not use the call bell, did not apply a gait belt, and did not use the walker. Instead, she assisted the resident to stand while the resident held the side rail and instructed the resident to pivot toward the bed. As the resident attempted to pivot on the left leg, both the resident and the aide heard a pop or grinding sound from the left knee, and the resident experienced immediate pain. The aide then maneuvered the resident onto the edge of the bed and into bed without a fall occurring. Following the incident, the resident complained of pain with movement of the left leg and knee. The 3–11 PM RN supervisor assessed the resident around 4:15 PM but did not observe redness or swelling and did not immediately notify the provider. Later that evening, after the charge LPN reported swelling and continued pain, the RN supervisor reassessed the resident and contacted the provider, who ordered a STAT left knee X-ray, ice, and continued PRN Tylenol. The X-ray obtained early the next morning showed an acute comminuted fracture of the distal shaft of the left femur, and the resident was subsequently transferred to the hospital, where surgical intervention with open reduction internal fixation was performed. The incident was documented on the facility’s reportable incident form as occurring during a transfer performed by the 3–11 PM nurse aide, with a pop sound heard and increased left knee pain, and was identified as a preventable accident reflecting a breakdown in supervision and adherence to established protocols.
Failure to Update Mobility Care Plan to Match Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s mobility care plan to reflect a current physician’s order. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and had a BIMS score of 12/15 indicating some memory recall deficits. A physician’s order dated 3/2/25, and still current, directed that the resident receive bed mobility assistance of two and transfer assistance of two with a rolling walker. The annual MDS identified that the resident required partial assistance with bed mobility and transfers and used a wheelchair for mobility. However, the Resident Care Plan initiated on 1/6/24 and last reviewed on 1/16/26 identified the resident as requiring assistance with mobility due to decreased strength and listed interventions indicating the resident was a total lift for transfers, which did not match the physician’s order. Interviews and record reviews confirmed that the care plan had not been updated despite changes in the resident’s mobility status and existing orders. The PT and OT reported that the resident had been on therapy services until 12/18/25 and was discharged at that time as an assist of two for stand-pivot transfers between bed and wheelchair, consistent with the 3/2/25 activity orders. They stated they would have notified the charge nurse of the resident’s transfer status and that therapy staff do not update care plans, leaving that responsibility to nursing. They acknowledged the mobility care plan last reviewed on 1/16/26 was incorrect and that the resident had not required a total lift for transfers since 3/2025. The DON confirmed that the mobility care plan should have matched the 3/2/25 physician’s order and that both the IDT and the MDS nurse were responsible for reviewing and revising care plans, including during care plan meetings. The facility’s Comprehensive Care Planning policy directed that care plans be revised as residents’ conditions change and be reviewed and updated at significant changes and at least quarterly, but this was not done for this resident’s mobility care plan.
Failure to Provide Timely and Effective PRN Pain Management After Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely pain management to a resident following an injury that resulted in a left distal femur fracture. The resident had diagnoses of osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder, and had a standing PRN order for acetaminophen 325 mg, three tablets by mouth every six hours as needed for pain. The care plan identified the resident as having potential for pain related to arthritis, with interventions including administering medications as prescribed and monitoring effectiveness. On the date of the incident, during a transfer by a nurse aide, a popping sound was heard and the resident reported increased left knee pain. The nurse supervisor directed the charge nurse to obtain vital signs and administer acetaminophen around 4:15 PM, which was documented as effective at that time. Later that evening, around 10:40 PM, the charge nurse noted the resident yelled out in pain when the left leg was lifted and observed swelling of the left knee. Despite recognizing the resident’s pain at that time, the charge nurse did not administer another dose of acetaminophen, even though more than six hours had elapsed since the prior dose and the medication was ordered every six hours as needed. The provider was notified and ordered a STAT x-ray, continuation of PRN Tylenol, and application of ice. During the overnight shift, the oncoming LPN was informed that the resident had been in pain at the end of the prior shift and observed that the resident appeared uncomfortable throughout the night. However, this nurse did not administer acetaminophen until 5:12 AM, assuming the prior nurse had already given it and failing to verify the last administration time on the MAR. After the 5:12 AM dose, the resident continued to appear restless and uncomfortable during care, and the acetaminophen was documented as ineffective for a pain level of 10/10. Although the nurse reported the unrelieved pain to the nursing supervisor, there was no documentation that the provider was notified of the ineffective pain control or that any additional or alternative pain medication was obtained prior to the resident’s transfer to the hospital later that morning. The facility’s pain policy required acute pain to be assessed every 30–60 minutes until relief was obtained, review of the MAR to determine PRN use and effectiveness, and reporting of significant changes in pain level and prolonged, unrelieved pain to the practitioner. These steps were not followed, resulting in prolonged unrelieved pain for the resident after the injury and prior to hospital transfer.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete required annual performance evaluations for at least one nurse aide. Review of the personnel file for a 3–11 PM nurse aide (NA #1) showed a hire date of 11/26/12 and documented that the last performance evaluation was completed on 12/18/22, with no evidence that yearly evaluations were completed in 2023, 2024, or 2025. The Administrator stated that each employee was required to have an annual performance evaluation based on their hire-date anniversary and explained that, although the facility currently had no Human Resources (HR) staff member, HR had been expected to notify when evaluations were due, distribute them to nursing supervisors for completion, and ensure they were filed in the employee record. Facility policy titled “How to Complete the Performance Evaluation” indicated that the facility reviews and summarizes employee counseling sessions to identify trends and patterns, reviews job description performance ratings with the employee to ensure understanding of performance expectations, and files the performance evaluation per facility policy, but this process was not carried out for NA #1 for multiple consecutive years. No resident medical history or condition was described in relation to this deficiency.
Failure to Administer Prescribed Medications for Hospice Resident
Penalty
Summary
The facility failed to administer medications as prescribed for a resident receiving palliative care, leading to a deficiency in care. The resident, who had Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort during the end-of-life process. Despite physician orders for Lorazepam and Atropine to manage anxiety and secretions, these medications were not administered as prescribed due to a lack of delivery from the pharmacy and miscommunication regarding the medication orders. The report highlights several instances where the facility's staff did not follow proper procedures. On two occasions, nurses documented the administration of Lorazepam without actually administering it, failing to correct their records or notify supervisors. Additionally, the facility did not ensure that the necessary prescriptions were sent to the pharmacy, resulting in the unavailability of Lorazepam and Atropine. The pharmacy's requests for clarification on the Atropine order went unanswered, and the medication was not delivered to the resident. Furthermore, the facility continued to administer oral Acetaminophen despite hospice recommendations to discontinue all oral medications due to the resident's inability to swallow. This oversight was compounded by the discontinuation of a rectal Tylenol order, which was intended for pain management. The lack of communication and failure to adhere to medication orders contributed to the resident not receiving the necessary care to manage symptoms effectively during the end-of-life stage.
Inaccurate Medication Documentation for Palliative Care Resident
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident receiving palliative care, leading to a deficiency. The resident, diagnosed with Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort. On a particular day, the hospice recommended discontinuing all scheduled medications and starting Morphine, Lorazepam, and Atropine for comfort care. However, the electronic Medication Administration Record (e-MAR) inaccurately reflected that Lorazepam was administered twice when it was not available, and the nurses involved did not correct the documentation or notify the appropriate personnel. The deficiency was further compounded by the lack of communication and proper documentation procedures. One LPN signed the e-MAR before realizing the medication was unavailable and failed to strike off her signature or notify the supervisor. Another LPN also signed for the administration of Lorazepam without it being available and did not follow up with the necessary steps to rectify the situation. The Assistant Director of Nursing Services (ADNS) confirmed that the nurses should have corrected the e-MAR and informed the nursing supervisor to ensure the resident received the prescribed medications. The facility did not provide a policy to guide the staff on handling such situations, contributing to the deficiency.
Failure to Update Care Plan After Repeated Smoking Incidents
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was updated to address known smoking incidents for a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident was cognitively intact and independent in mobility, with a care plan that initially included interventions such as instruction on the facility smoking policy, securing smoking materials, offering a nicotine patch, and addressing smoking cessation. However, clinical record reviews revealed multiple incidents where the resident possessed smoking materials, was observed smoking on facility grounds, and smoked while using a nicotine patch. Despite these documented incidents on three separate occasions, the care plan was not revised to reflect the new behaviors or to include additional interventions to prevent recurrence. An interview with the Assistant Director of Nursing confirmed that the care plan had not been updated following these events, and the facility was unable to provide a policy regarding the review and revision of comprehensive care plans.
Failure to Investigate and Report Resident Smoking Incidents
Penalty
Summary
The facility failed to ensure timely investigation of known smoking incidents involving a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident, who was cognitively intact and independent in mobility, had a care plan that included instructions about the facility smoking policy, securing smoking materials, and offering nicotine patches. Despite this, nursing progress notes documented three separate occasions where the resident was found in possession of smoking materials or observed smoking independently on facility property. On each occasion, staff either removed the items or educated the resident, but no formal accident/incident reports or investigations were completed as required by facility policy. Additionally, the facility did not submit reportable events to the State Agency for any of these incidents. Interviews with facility leadership confirmed that no investigations were conducted to determine how the resident obtained smoking paraphernalia or to implement interventions to prevent recurrence. Facility policies clearly stated that residents were not permitted to possess smoking materials or smoke independently, and that all accidents and incidents must be documented and reported. However, these procedures were not followed in response to the documented smoking incidents.
Failure to Safeguard Residents' Controlled Medications and Records
Penalty
Summary
The facility failed to protect residents from the wrongful use or removal of their controlled medications and associated documentation. For one resident with Alzheimer's disease and colon cancer, an unopened bottle of Morphine Sulfate prescribed for pain and shortness of breath was discovered missing from the controlled medication box when the resident required a dose for comfort. The investigation revealed that the previous Director of Nursing had removed the controlled medications, including Morphine and Oxycodone from the emergency and drug destruction boxes, without authorization. The incident was not reported immediately upon discovery, and the missing medication was only reported to the current Director of Nursing the following day. In a separate incident, another resident with epilepsy and dementia was found to be missing a significant quantity of Lacosamide tablets, along with the controlled substance disposition record. The missing medication was identified during a routine narcotics count, and the investigation confirmed that a total of eighty-eight tablets were unaccounted for, but could not determine who was responsible for their removal. Both incidents were reported to the Department of Consumer Protection, Drug Enforcement Division, and were in violation of the facility's policy prohibiting misappropriation of resident property.
Failure to Treat Resident with Dignity and Respect During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of knee replacement, mobility difficulties, and incontinence was not treated with dignity and respect by a staff member. The resident, who was alert and oriented, required substantial assistance with personal hygiene and toileting. According to facility documentation and interviews, the resident reported that a nurse aide became upset and yelled at the resident after an episode of incontinence. The aide was also described as throwing items around the resident's side of the room and failing to assist the resident back to bed after providing care. The incident was witnessed by the resident's roommate. Interviews with facility staff confirmed that the resident alleged verbal abuse and disrespectful behavior from the nurse aide, including being yelled at for soiling themselves. The nurse aide acknowledged that the resident was upset and yelling, and called the charge nurse to intervene. The charge nurse also confirmed that the resident reported being yelled at by the aide. Facility policy states that residents have the right to be treated with consideration, respect, and dignity, which was not upheld in this instance.
Inconsistent Advanced Directive Documentation
Penalty
Summary
The facility failed to ensure that the physician's orders and the signed advanced directive forms were congruent for several residents, leading to discrepancies in their code status documentation. For Resident #33, there was a mismatch between the advanced directive form indicating a Do Not Resuscitate (DNR) status and the care plan and physician's orders, which indicated a full code status. Despite the resident's decision to change their code status to full code, the physical clinical record was not updated to reflect this change, as confirmed by interviews with staff. Resident #51's case involved a change in code status from full code to DNR and Do Not Intubate (DNI) as per a Probate Order Decree. However, the care plan and advanced directive form did not reflect this change until after surveyor inquiry. Similarly, Resident #69's advanced directive form indicated a DNR status, but the care plan and physician's orders showed a full code status. The facility was unable to provide a Probate Court order to support this change, highlighting a lack of documentation and communication. For Resident #78, a Probate Decree changed the code status to DNR/DNI, but this was not reflected in the resident's clinical record until after the decree was received. The facility's process for updating code status was not followed, as the order was entered before receiving the decree. Resident #107's case involved a discrepancy between the advanced directive form and the physician's orders, with the resident expressing a desire for CPR despite the orders indicating DNR/DNI. The facility failed to verify the authority of the Power of Attorney to make medical decisions, leading to further confusion in the resident's code status documentation.
Pharmacy Consultant Fails to Identify Medication Order Discrepancy
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified a discrepancy in a written physician's order for a resident with diagnoses including dementia, psychotic disturbance, type 2 diabetes mellitus, and pain. The resident's quarterly MDS assessment indicated moderately impaired cognition and required assistance with certain activities of daily living. A physician's order directed the administration of Gabapentin 300 mg, but the intent was to administer 100 mg twice daily. Despite monthly pharmacy regimen reviews, no recommendations addressed the discrepancy in the Gabapentin order. During a medication pass, an LPN was observed preparing three 100 mg Gabapentin capsules for the resident, contrary to the physician's order. Interviews with the Pharmacist Consultant Supervisor and the APRN who wrote the order revealed that the pharmacy consultant should have identified the confusing order and recommended clarification. The pharmacy provider's pharmacist acknowledged that the protocol to notify the facility of the discrepancy was not followed, as there was no record of communication, and the order was never corrected. The facility's pharmacy policy indicated that issues should be communicated and suggestions made for service improvement, which was not adhered to in this case.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident with severe cognitive impairment and physical limitations, leading to a deficiency in personal hygiene. The resident, who required total assistance with activities of daily living due to conditions such as dementia, anxiety, and a contracture of the right hand, was observed with excessively long and thick fingernails. Despite a care plan and physician's orders that included regular washing of hands and nails, the resident's nails were not adequately maintained. Observations revealed that the resident's right middle fingernail was particularly long, thick, and curved, indicating neglect in nail care. Interviews with staff revealed a lack of awareness and communication regarding the resident's nail condition. A nurse aide reported trimming the resident's nails two weeks prior but did not address the thick and discolored middle fingernail, assuming it was the responsibility of the charge nurse. The charge nurse and other staff members were either unaware of the nail condition or assumed it was being managed through routine washing. The facility's policies on nail care and weekly body audits were not effectively implemented, as evidenced by the failure to address the resident's nail condition during these assessments.
Failure to Assess and Monitor Resident's Wound
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a non-pressure related wound for a resident with multiple diagnoses, including heart failure and venous insufficiency. The resident's care plan included interventions for skin inspection and treatment, but the clinical record review revealed that the wound on the resident's right great toe was not initially assessed by a registered nurse upon observation, nor were there any documented weekly assessments as required by the facility's policy and state regulations. Interviews with facility staff, including two LPNs and the Director of Nursing Services (DNS), confirmed that the wound nurse was not informed of the resident's wound, resulting in a lack of weekly monitoring. The facility's policy mandates that non-pressure wounds be assessed and documented to ensure optimal outcomes, but this was not adhered to in the case of the resident's wound, leading to the identified deficiency.
Failure to Ensure RN Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the initial and weekly assessments of a wound for Resident #27 were completed by a registered nurse (RN), as required by their policy. Resident #27, who had diagnoses including type 1 diabetes mellitus and was at risk for pressure ulcers, was admitted with an unstageable pressure injury. The care plan included interventions such as weekly skin inspections and pressure-reducing measures. However, when a new deep tissue injury (DTI) was identified on the resident's right heel, it was initially assessed by an LPN instead of an RN, contrary to the facility's policy. The LPN responsible for wound care documented the assessments of the right heel wound on multiple occasions, but an RN did not assess the wound until much later. The Wound Specialist (APRN) also assessed the wound, but not until two weeks after the initial identification by the LPN. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the wound should have been assessed by an RN initially and weekly, as per the facility's policy. This oversight led to a deficiency in the care provided to Resident #27.
Failure to Discuss Baseline Care Plan with Resident
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was discussed and provided to a resident and/or their representative. Resident #120, who was admitted with diagnoses including Covid-19, atrial fibrillation, hypertension, and polyarthritis, had their baseline care plan completed on January 13, 2024. The admission MDS assessment indicated that the resident had intact cognition and required extensive assistance for various activities of daily living. Despite the facility's policy to develop a care plan within 48 hours of admission, there was no documentation that the interdisciplinary team discussed this plan with the resident or their representative. Interviews with facility staff, including the RN nursing supervisor, the Admissions Coordinator, and the DNS, revealed that the interdisciplinary team, which includes rehabilitation, nursing, and social work staff, typically meets with residents and/or their representatives within 72 hours of admission to discuss the care plan. However, in this case, the Admissions Coordinator could not find any documentation indicating that such a discussion took place for Resident #120. The DNS confirmed that the interdisciplinary team did not discuss the baseline care plan with the resident or their representative, leading to the identified deficiency.
Incomplete Medical Records for Laboratory Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic medical records were readily accessible and complete in the residents' physical charts and/or electronic medical record systems. For Resident #9, who had diagnoses including anxiety disorder and bipolar disorder, the last laboratory testing results in the medical record were from June 2023, despite having blood work drawn on nine occasions between November 2023 and March 2024. The Advanced Practice Registered Nurse (APRN) reviewed the results but was unaware of their subsequent handling, indicating a breakdown in the process of filing or uploading these results into the medical record system. Similarly, Resident #64, with diagnoses such as chronic obstructive pulmonary disease and type 2 diabetes mellitus, had no laboratory or diagnostic testing results in their clinical records for the past year, despite having blood work drawn on seven occasions. The Assistant Director of Nursing Services (ADNS) provided documentation from the laboratory company, but the results were not present in the resident's records, highlighting a failure in maintaining complete and accessible medical records. Resident #74, diagnosed with conditions including atrial fibrillation and hypertension, also lacked laboratory testing results in their clinical records for the past year, despite having blood work drawn on eight occasions. The facility's policy required complete and accurately documented medical records, but the process for reviewing and filing laboratory results was not effectively implemented, as evidenced by the absence of these results in the residents' records. Interviews with staff revealed a lack of clarity and accountability in the handling and filing of laboratory results, contributing to the deficiency.
Deficiency in Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that the clinical record for a resident receiving hospice care contained the necessary hospice documentation. The resident, who had diagnoses including senile degeneration of the brain, dementia, and abnormal weight loss, was admitted to hospice care as per a physician's order. Despite this, the clinical record lacked interdisciplinary team notes, the plan of care, and the Certificate/Recertification of Terminal Illness for specified periods. This deficiency was identified during a review of the clinical record and facility documentation. Interviews with facility staff, including an LPN, social workers, the Director of Nursing Services (DNS), and the Executive Director of Hospice, revealed confusion and uncertainty regarding the location and organization of hospice documentation. The hospice company was in the process of changing its filing system, which contributed to the missing documentation. The Executive Director of Hospice was unable to explain the absence of the required documentation for the resident. The facility's Medical Record policy mandates that all medical records be complete, accurately documented, and readily accessible, which was not adhered to in this case.
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.
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What surveyors actually found near you
We read the 774 citations issued within 25 miles in the last 12 months — including the 8 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bristol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Green Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Pines At Bristol For Nursing & Rehabilitation, The | 1.1 mi | ★★★★★ | 3 | 0 |
| Ingraham Manor Rehab And Nursing | 1.4 mi | ★★★★★ | 6 | 1 |
| Countryside Manor Of Bristol | 2.8 mi | — | 0 | 0 |
| Apple Rehab Farmington Valley | 3.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.