Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Havencare At Valerie Manor during CMS and state inspections, most recent first.
A resident with acute respiratory failure, autism, intellectual disability, and severely impaired cognition was sent to an orthopedic appointment on oxygen, but the office was not told the resident needed oxygen and staff later found the tank empty. EMS found the resident with O2 sat at 80% and transported the resident to the hospital. Facility staff gave conflicting accounts about whether a full tank was sent, and no staff member accompanied the resident despite the resident’s inability to manage the oxygen flow.
Three residents with pain and anxiety diagnoses had discontinued controlled medications (oxycodone and lorazepam) that went missing from narcotic lock boxes, along with the associated proof-of-use sheets. One resident with lumbar spine surgery and mood disorders had PRN oxycodone ordered and care planned for pain management, another resident with dementia had PRN oxycodone ordered and later discontinued, and a third resident with dementia and anxiety had PRN lorazepam ordered and discontinued. A drug audit revealed that multiple tablets of these discontinued medications, stored in the back of unit narcotic boxes for later destruction, could not be accounted for, and subsequent review showed that many nurses had access to the narcotic storage during the period between audits, with no staff member identified as responsible for the removal.
The facility failed to properly document, classify, and timely report an incident involving missing discontinued controlled medications belonging to three residents. An internal reportable event form noted that discontinued meds scheduled for destruction were missing but did not identify the affected residents or the specific drugs. Subsequent documentation showed that multiple tablets of Oxycodone and Lorazepam tied to these residents were unaccounted for, and disposition sheets were also missing. The event was reported to the State Agency 10 days after it was identified, was initially misclassified as a non-abuse event, and was not treated as potential misappropriation, despite facility policies requiring that alleged violations be reported promptly and that incident reports include the names of individuals involved and detailed event information.
The facility failed to maintain proper control and accountability of discontinued narcotic medications, resulting in missing Oxycodone and Lorazepam tablets for three residents with pain, dementia, and anxiety. Discontinued controlled drugs remained in unit narcotic lock boxes instead of being promptly removed to a secured nursing office lock box, and both the white proof-of-use sheets and matching medication packs went missing. An LPN’s narcotic audits did not include MAR review, discrepancies were adjusted to match proof-of-use sheets, and required dual nurse signatures for end-of-shift narcotic counts were missing on multiple dates. These actions and omissions violated the facility’s own controlled substance handling policy and led to unaccounted-for controlled substances.
A facility-wide infection control breakdown occurred during a respiratory outbreak when residents with new cough, fever, or wheezing were not placed on droplet precautions until swab results returned, despite outbreak conditions and policy requiring immediate isolation. Staff also entered rooms under TBP signage without the N95, gown, eye protection, and gloves posted for the room, EBP signage was missing for a resident with a pressure ulcer, catheter supplies were stored uncovered and unlabeled, and the outbreak line list was inconsistent with the documented timeline.
A facility failed to develop individualized dental care plans for two residents. One resident was edentulous and reported difficulty chewing meats while waiting for dentures, but the care plan did not reflect the lack of teeth or dentures. Another resident had multiple missing and fractured teeth, dental pain, and documented refusals to see a dentist/oral surgeon, yet the care plan did not address the dental needs or refusal. The care plans focused on diet and nutrition rather than the residents’ oral health status.
Dietary staff failed to maintain clean attire and proper food handling practices. A DA was observed working in the dish room wearing a shirt with heavy fuzz, lint, and animal hair, while clean pitchers and dish lids were removed from the dishwasher dripping wet and stacked without air-drying. The facility also had food items in storage without clear expiration dates, including Teriyaki sauce with a coded date and French toast that was dated when received but lacked an expiration date.
A resident with DM, CKD, HTN, and edema was repeatedly observed without ordered TED stockings on both lower extremities. NAs did not review the care card or notify the charge nurse when the stockings could not be found, and an LPN later located the stockings in the resident’s dresser and applied them. The resident said he/she was not refusing the stockings and had not had them applied in a few days; an APRN note documented weight gain and +2 edema.
Failure to provide ordered meal supervision for a resident with dysphagia. A resident with DM2, a TIA, a PEG tube, and swallowing difficulty was ordered a mechanically altered diet with nectar-thick liquids and constant 1-to-1 supervision during meals due to choking risk. Despite this, the resident was observed eating alone in the room without supervision, and an NA stated she was unaware of the supervision requirement because it was not on the care card.
Unlabeled oxygen tubing and improper nebulizer storage were found for several residents receiving respiratory treatment. Residents with COPD, asthma, pneumonia, and other respiratory conditions were observed on continuous O2, but their tubing was not dated, and for two residents the nebulizer masks were left uncovered on the bedside table with undated tubing attached. An LPN confirmed the weekly tubing changes, labeling, dating, and proper storage had not been completed as ordered and required by policy.
Incorrect Puree Diet Served to Resident with Dysphagia: A resident with dysphagia and a physician-ordered puree diet was observed alone in bed eating a peanut butter and jelly sandwich with crusts while coughing, and was also served cubed hash browns at breakfast. OT, ST, the DNS, and the Dietary Director all identified these foods were not consistent with a puree diet, and facility policy required therapeutic diets to be prepared and served as ordered.
Failure to provide ordered adaptive eating equipment at mealtime. A resident with dementia, dysphagia, weakness, and coordination problems had an order and care plan for an inner lip plate, and the meal ticket also listed a Kennedy cup and inner lip plate. The resident was observed eating lunch in bed without the inner lip plate, and an NA served the meal without checking that the kitchen had plated it correctly. An LPN later confirmed the adaptive equipment should have been provided with the meal and that the tray should have been checked before service.
Failure to review and administer pneumococcal vaccines for two residents. One resident with HTN, dementia, and depression signed consent for PCV20, but the EMR showed no historical pneumococcal vaccines and no pending order. Another resident's admission vaccination form was left blank, showing vaccination status was not reviewed and the vaccine was not offered. An LPN/IP stated she had not completed pneumococcal vaccine review or administration due to outbreak-related time constraints, despite knowing the facility policy.
Failure to implement a QAPI plan for IPCP management. The QAA committee reviewed current QAPI plans, but the binder did not include additional PIPs started in response to infection prevention concerns identified during the survey. The Administrator was unaware of the outbreak-related QAPI that an RN said had been started, and facility records showed a PIP for rapid spread of COVID-19 and Influenza A among residents on 2 units. The facility policy required QAPI coverage of infection control, with administration responsible for the program and PIPs using PDSA and RCA.
Room Not Kept Free of Insects and in Good Repair: A resident with dementia, paranoid schizophrenia, and intellectual disabilities was found in a private room where a towel on the windowsill had a heavy accumulation of dead winged insects. Surveyors also observed a falling radiator cover, damaged wallpaper, and a discolored toilet seat. Staff, including the Administrator, Housekeeping, and Environmental Services, were unaware of the insects, and the room cleaning checklist did not include windowsills.
Unsecured Items Stored Under Medication Room Sink: Surveyors found multiple non-medication items stored under the sink in the Skyview med room, including alcohol, empty containers, masks, VHS tapes, wash basins, a phone charger, boards, sports cards, and a binder. The DNS said the cabinet should be locked and nothing should be stored there, but was unsure why the items were present and stated nursing staff likely placed them there. The DESS said he was unaware of the storage issue, and the facility policy required meds and related items to be stored in locked areas.
Two cognitively impaired residents with a history of inappropriate sexual behaviors were allowed to spend time together in a common area with care plan restrictions limiting their contact to hand holding, as consented by their court-appointed conservators. Despite these restrictions, staff observed one resident with their chest exposed and the other in contact with the exposed area, constituting non-consensual sexual contact. Staff interviews confirmed awareness of the residents' relationship and care plan limitations, but inadequate supervision led to the incident, violating facility policy to protect residents from abuse.
Nursing staff administered medications as ordered but failed to document administration in the MAR at the time of delivery, instead recording doses hours later for multiple residents with complex medical needs. This practice was identified through an internal audit and confirmed by interviews, with facility leadership and policy requiring immediate documentation.
A resident with dementia and a history of falls suffered an unwitnessed fall resulting in bilateral femur fractures. Although the care plan was eventually updated to include a bolster mattress as a fall prevention measure, this intervention was not added or implemented until several days after the incident, indicating a delay in updating and executing care plan interventions following the injury.
A nurse aide verbally abused a resident with severe cognitive impairment by loudly confronting the resident in the dining room, using inappropriate language and aggressive gestures. Multiple staff witnessed the incident, and the aide admitted to making the statement out of frustration. The event caused the resident emotional distress and was substantiated as abuse according to facility policy.
Staff did not immediately report an incident where a resident with severe cognitive impairment was observed touching another resident inappropriately. An LPN initially reported only partial details, resulting in a delay of over 16 hours before the DON notified the State Agency, which was not in accordance with the facility's abuse reporting policy.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained unexplained right foot fractures. The facility failed to conduct a thorough investigation, as required by its abuse policy, by not obtaining complete staff statements or documentation for several shifts prior to the injury, and could not provide evidence that all relevant staff were interviewed.
A resident with severe cognitive impairment and alcohol dependence was discharged home without adequate documentation, communication, or immediate support services in place. The facility did not ensure the responsible party was fully informed of the risks or that necessary discharge information was provided, resulting in the resident being hospitalized shortly after discharge.
A resident with severe cognitive impairment and multiple medical conditions was discharged from the facility with an inadequate plan, resulting in hospitalization within hours. Despite being medically cleared, the facility delayed readmission for eight days due to lack of a payer source and corporate approval, even though beds and staff were available. The resident was only readmitted after intervention from the LTC Ombudsman.
A resident with cognitive impairment and ongoing severe pain, as evidenced by daily pain reports and assessments, did not have a pain management care plan developed despite physician orders and facility policy requiring such interventions. The DON confirmed the absence of a care plan addressing the resident's pain.
A resident with multiple medical conditions was discharged home without proper medication reconciliation, resulting in the resident being sent home with medications belonging to other residents. Staff interviews confirmed that the required review and reconciliation process was not completed by the responsible LPN prior to discharge.
A resident with a biliary drain did not receive the required twice-daily flushing of the biliary tube with normal saline as specified in the hospital discharge summary. Facility documentation and physician orders only addressed cleansing and dressing the drain site, omitting the flushing procedure needed to maintain tube patency.
A resident with multiple medical conditions reported daily headaches and received Acetaminophen with inconsistent relief, but the facility did not conduct required pain evaluations or develop a care plan for pain management, as confirmed by the DON.
A resident with dementia and severe cognitive impairment, who required assistance for ambulation, was improperly restrained in a wheelchair using a gait belt by staff, restricting movement without a physician order or assessment. Staff accounts conflicted regarding who directed the restraint, but it was confirmed that the gait belt was used to prevent the resident from standing, contrary to facility policy and the resident's care plan.
A resident with severe cognitive impairment was improperly restrained in a wheelchair using a gait belt by a nursing assistant, following an LPN's direction. Another staff member witnessed the event but did not report it immediately, and the facility delayed notifying the State Agency after learning of the incident, exceeding required reporting timeframes.
The facility improperly used Resident Council funds for activities and services that should have been covered by the facility's budget, including music entertainment, art classes, and the beauty salon license fee. Residents felt obligated to vote for these expenditures, and the Administrator was unaware of the misuse, lacking oversight and a policy for fund management.
The facility failed to complete required background checks and obtain professional references for six staff members, including NAs, LPNs, and RNs, before they began working. The HR department was responsible for these tasks but did not adhere to the facility's policies, resulting in incomplete employee files and a deficiency noted during the survey.
The facility failed to change and label oxygen tubing weekly for residents requiring respiratory care, as per its policy. Several residents, including those with chronic respiratory conditions, had tubing that was not changed on schedule, and staff were unaware of the policy requirements. Observations revealed inconsistencies in documentation and improper handling of oxygen equipment.
The facility failed to conduct required performance evaluations for several nursing assistants, as outlined in their employee handbook. The HR Director acknowledged the backlog, with some evaluations missing for multiple years. The Administrator was informed of the issue, which involved incomplete employee records and unrecognized staff performance.
The facility failed to notify medical personnel of critical changes in two residents' conditions. One resident with diabetes had multiple high blood sugar readings that were not reported to the physician, despite care plan requirements. Another resident refused a medication due to its taste, but the refusal was not communicated to the physician or documented. The facility lacked a policy on medication refusal.
A facility failed to monitor vital signs for a resident with chronic conditions as per physician's orders, missing 91 out of 135 shifts. Additionally, after a resident with dementia was struck on the head, the required neurological monitoring was not conducted, with only 1 out of 20 checks documented. These deficiencies were confirmed through record reviews and staff interviews, indicating non-compliance with care protocols.
A resident with multiple pressure injuries was not provided with proper air mattress care as the facility failed to adjust the mattress settings according to the resident's weight changes. Despite a physician's order and facility policy requiring specific settings, the air mattress was incorrectly set, contributing to inadequate pressure ulcer care.
A resident with a history of malnutrition experienced significant weight loss due to inconsistent weight monitoring and receiving burnt meals. Despite physician orders for weekly weight checks, the facility failed to document weights consistently. The resident's appetite was affected by the poor meal quality, confirmed by survey observations. Staff interviews revealed communication lapses and inadequate follow-up on weight monitoring and meal quality issues.
A resident with chronic respiratory issues was found with medication left on their bedside table, contrary to the facility's policy requiring nurses to ensure medications are taken immediately. Interviews confirmed that medications should not be left unattended, and the resident had not been evaluated for self-administration. This led to a deficiency in medication storage and administration.
The facility failed to provide palatable and presentable meals, as observed when cheese ravioli served to residents was blackened and hardened. The Dietary Director admitted the ravioli was overcooked and should not have been served. Additionally, the director did not inspect the meals before serving, and the facility lacked documentation of test tray monitoring.
Insufficient Oxygen Supply and No Escort for Cognitively Impaired Resident on Appointment LOA
Penalty
Summary
The facility failed to ensure an adequate supply of oxygen was sent with a resident for a leave of absence to an orthopedic appointment, and failed to ensure a staff member accompanied the resident despite the resident’s severe cognitive impairment. The resident had diagnoses including acute respiratory failure, pulmonary embolism, pleural effusion, heart failure, autism, intellectual disability, and displaced fractures of the right tibia and right fibula. The admission MDS identified a BIMS score of 4, indicating severely impaired cognition, and the resident later returned from the hospital on oxygen after a prior transfer for lethargy, hypotension, and hypoxia. Physician orders directed oxygen at 1 liter per minute via nasal cannula, with titration up to 4 liters to maintain oxygen saturation above 90%, and later 1 to 2 liters per minute for acute respiratory failure with hypoxia. On the day of the orthopedic appointment, nursing documentation showed the resident was sent from the appointment to the hospital because of low oxygen saturation, but the record did not identify the time the resident left the facility. The orthopedic office administrator stated the office had not been told the resident required oxygen, and staff there found the oxygen tank empty after the resident had trouble breathing. EMS arrived, found an empty D-cylinder oxygen tank and an oxygen saturation of 80%, applied oxygen, and transported the resident to the hospital. Facility staff gave conflicting accounts about the oxygen tank sent with the resident. An LPN stated she sent the resident with a full E-cylinder tank and did not inform the orthopedic office that the resident was on oxygen. The DON stated it was the nurse’s responsibility to ensure the resident had enough oxygen before appointments and said the facility did not usually send a nurse with residents to appointments; for this resident, a representative from the prior living setting met the resident at the office. The Director of Rehabilitation stated she did not think the resident would have been able to change the oxygen liter flow. The facility’s oxygen policy directed staff to verify oxygen was flowing when preparing to place a resident on oxygen, and no policy was provided regarding ensuring sufficient oxygen supply on LOAs.
Misappropriation of Discontinued Controlled Medications and Missing Narcotic Records
Penalty
Summary
Surveyors identified a deficiency related to misappropriation of resident property involving controlled medications for three residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. A second resident with dementia had an order for PRN oxycodone for moderate to severe pain, later discontinued, and was care planned as at risk for pain with interventions to administer pain medication as ordered. A third resident with dementia and anxiety had an order for PRN lorazepam for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that the second resident did not receive the ordered oxycodone. A facility reportable event documented that discontinued medications scheduled for destruction appeared to be missing, but initially did not identify which residents or which medications were involved. The incident was noted to have occurred in the afternoon, and the Medical Director and Consumer Protection were notified, but local law enforcement was not initially notified. Subsequent information identified that disposition sheets for controlled medications were missing and that the medications were last seen during a prior audit. The missing medications were quantified as 37 tablets of oxycodone 5 mg and 15 tablets of lorazepam 0.5 mg. Further facility documentation and interviews clarified that the missing controlled substances were discontinued medications belonging to the three residents: nine oxycodone tablets for the first resident, 28 oxycodone tablets for the second resident, and 15 lorazepam tablets for the third resident. The proof-of-use sheets and matching medication packs were missing from narcotic lock boxes on two different units, to which approximately 30 nurses had access during the period between two audits. The medications had been moved to the back of the narcotic lock boxes for later disposal, and the facility was unable to identify which nurse removed the medications or when they were removed. A memo from the Consumer Protection drug control division confirmed a significant loss of controlled substances, a procedural lapse in not segregating discontinued medications immediately, and the inability to reconcile inventory due to missing logs, while the medications were under the security of the narcotic lock boxes.
Failure to Properly Classify and Timely Report Missing Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly identify, document, classify, and timely report an allegation of misappropriation of controlled medications belonging to multiple residents. Resident #2 had diagnoses including lumbar spine fusion, bipolar disorder, and depression, with an order for PRN Oxycodone for pain and a care plan intervention to administer pain medication as ordered. Resident #3 had dementia with severe cognitive impairment, an order for PRN Oxycodone for pain that was later discontinued, and a care plan identifying risk for pain with an intervention to administer pain medication as ordered. Resident #4 had anxiety with severely impaired cognition, a care plan for anxiety with an intervention to administer anti-anxiety medication as ordered, and a PRN Lorazepam order that was later discontinued. A facility reportable event form dated 11/20/2025 identified that discontinued medications scheduled to be destroyed appeared to be missing, but the form did not identify which residents were affected or what specific medications were involved. Additional information later documented that disposition sheets for controlled medications were missing and that the medications were last seen during an audit, with missing quantities including 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility reportable event summary identified that a drug audit had found missing narcotics scheduled for collection as discontinued medications, specifying that 9 tablets of Oxycodone for Resident #2, 28 tablets of Oxycodone for Resident #3, and 15 tablets of Lorazepam for Resident #4 were missing. The facility’s incident report for the same event stated that discontinued medications scheduled to be destroyed appeared to be missing but again did not list any of the affected residents. The State Agency online portal showed that the reportable event was submitted on 11/20/2025 for an incident identified as occurring on 11/10/2025, resulting in a 10-day delay in reporting. The event was initially misclassified as a Class C (loss of heat/water/emergency systems or evacuation) before being changed to a Class B (abuse), and the DON reported that she did not classify the incident as misappropriation, instead selecting “other,” because the medications had been discontinued and should have been destroyed. Interviews with the DON and Corporate RN #1 confirmed that the medications and related documentation were identified as missing on 11/9/2025, that the State Agency was not notified of the resident names, and that they did not consider the situation a potential misappropriation despite facility policy defining misappropriation as the deliberate misplacement or use of a resident’s belongings without consent and requiring immediate reporting of alleged violations. The facility’s Accident and Incident Policy also required that incident reports include the names of individuals involved and a detailed description of the event and resident condition, which was not done in this case.
Failure to Control and Account for Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate controls over narcotic medications, resulting in the misplacement and loss of controlled substances for multiple residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN Oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. Another resident with dementia had a PRN Oxycodone order for pain, and a third resident with dementia and anxiety had a PRN Lorazepam order for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that one resident did not receive the ordered Oxycodone. A reportable event documented that discontinued medications scheduled for destruction were missing, but the initial form did not identify which residents or which medications were involved. Later information identified that disposition sheets for controlled medications were missing and that the medications were last seen during an audit. The missing medications were specified as 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility summary further detailed that a drug audit identified missing narcotics that had been discontinued and last observed weeks to months earlier, including nine Oxycodone tablets for one resident, 28 Oxycodone tablets for another resident, and 15 Lorazepam tablets for a third resident. The investigation did not identify the person responsible for the missing medications, and the last recorded medication disposal before the loss was more than a month earlier. Interviews and documentation showed that the white controlled substance disposition records and matching medication packs were missing from the unit narcotic books and lock boxes. The medications had been moved to the back of the narcotic lock boxes on the medication carts for future removal for destruction instead of being removed immediately to a secured lock box in the nursing office, as required. The RN involved stated she did not know why the narcotics were not removed when discontinued. An LPN who conducted narcotic audits reported that her audits did not include review of the MAR and that when discrepancies were found, she adjusted counts to match the white proof-of-use sheets. Audit records showed a discrepancy in one resident’s Oxycodone count and missing required dual nurse signatures for end-of-shift narcotic counts on multiple dates and shifts. The facility’s own policy required immediate documentation of controlled substances, shift-change counts by two licensed nurses, and timely return of discontinued controlled drugs to a double-locked cabinet in the nursing office, but these procedures were not consistently followed, leading to the misappropriation of narcotics.
Infection control lapses during respiratory outbreak and precaution use
Penalty
Summary
The facility failed to implement droplet precautions for residents with new respiratory symptoms before nasal swab results were returned during a facility-wide respiratory outbreak involving COVID-19, RSV, and Influenza A. Resident #8, who had end stage renal disease, vascular dementia, diabetes, and influenza, developed cough symptoms and had a respiratory swab obtained, but the record did not show droplet precautions were started until the swab later confirmed Influenza A. Resident #39, who had Alzheimer’s disease, hypertension, and depression, developed a low-grade temperature and occasional cough; the record likewise did not show droplet precautions were implemented when symptoms first appeared, but only after the respiratory panel later confirmed Influenza. Resident #48, who had Alzheimer’s disease, Down syndrome, asthma, and influenza, was seen wheezing and coughing in the common area and had a viral swab ordered, yet droplet precautions were not documented until the respiratory panel later confirmed Influenza A. The facility also failed to ensure staff wore the PPE required by posted transmission-based precaution signage for residents on droplet/contact precautions. For the room shared by Resident #29 and Resident #103, signage directed staff to wear a gown, N95 respirator, eye protection, and gloves before entry, but a nurse aide entered wearing only a surgical mask and gown, and later reentered wearing a surgical mask with gown and gloves but still not the N95 respirator shown on the sign. For the room shared by Resident #17 and Resident #118, signage likewise directed droplet/contact PPE, but a nurse aide entered wearing only a surgical mask, and later reentered with a surgical mask, gown, and gloves while still not wearing the N95 respirator indicated on the sign. The facility further failed to post Enhanced Barrier Precautions signage for Resident #122, who had a pressure ulcer and an order for EBP related to wounds. The resident’s care plan did not identify EBP precautions or the associated PPE use, and observations on multiple occasions did not show EBP signage posted outside the room until later. For Resident #143, who had an indwelling catheter and a history of ESBL in urine, the bathroom contained multiple unlabeled, uncovered urinary leg bags, a nighttime drainage bag, and an uncovered graduated cylinder stored in the room rather than bagged and labeled. In addition, the Infection Control program documentation for the respiratory outbreak was inconsistent and inaccurate, including a master line list that listed an outbreak onset date that did not match the resident symptom and test dates, omitted an RSV table, and did not align with the timeline of events documented in the record.
Missing Dental Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and maintain dental care plans for two residents. For one resident, the clinical record showed diagnoses including COPD, diabetes, and dementia, and the MDS identified the resident as cognitively intact, independent with eating and oral hygiene, and without natural teeth or tooth fragments. The resident care plans focused on therapeutic diet and nutrition but did not identify the resident’s edentulous status or the absence of dentures, despite the resident later reporting difficulty chewing meats because they were too hard to chew and stating that dentures were being made. For the second resident, the record showed diagnoses including dementia, anxiety, and depressive disorder, and the MDS identified obvious or likely cavities or broken natural teeth. The resident had progress notes documenting agreement to see an oral surgeon for extractions and dentures, later refusals to see a dentist/oral surgeon, and a nursing note that the resident complained of pain to a left mandibular molar and was added to the dental list. A dental consultant later identified missing teeth, fractured teeth, severe demineralization, and gingivitis, and an oral health assessment documented multiple decaying or broken teeth and food particles/tartar/plaque in the mouth. Review of the care plans showed that the second resident’s plan addressed diet and nutrition but did not address the missing and fractured teeth, the need for extractions and dentures, or the resident’s refusal to follow up with dental services. Interviews with the care plan coordinator and DNS confirmed that both residents should have had dental-focused care plans, and the care plan coordinator stated that dental care plans were being audited and updated after surveyor inquiry.
Dietary attire, drying, and food dating deficiencies
Penalty
Summary
The Dietary Department failed to ensure a Dietary Aide's attire was clean during a tour with the Food Service Director. Dietary Aide #1 was observed working in the dish room removing clean items from the dishwasher while wearing a black shirt with a heavy accumulation of fuzz, lint, and animal hair on both sides. She was not wearing any overshirt or apron to contain the debris, and she stated she was unaware that her shirt had the accumulation despite having a cat. The facility also failed to ensure that items removed from the dishwasher were air-dried and that food items had expiration dates identified. During observation, 4 clean mauve plastic water pitchers were removed from the dishwasher dripping wet and stacked on the beverage station, and 17 clear dish covers/lids were observed stacked wet on the stainless-steel counter of the new tray line. The Food Service Director stated the lids should be left to air dry, but there were not enough drying racks. In the walk-in refrigerator, a 128-ounce container of Teriyaki sauce had an opened date noted, but the expiration date was in a code that the Food Service Director could not decipher. In the walk-in freezer, 20 pieces of French toast were dated with the date received but did not have an expiration date, and the Food Service Director stated the expiration date had been on the original box and was not transferred when the item was removed.
Failure to Apply Ordered Compression Stockings
Penalty
Summary
The facility failed to follow a physician’s order for compression stockings for Resident #119, who had diagnoses of Type 2 diabetes mellitus, chronic kidney disease, and hypertension and was assessed as moderately cognitively impaired with substantial to maximal assistance needed for bed mobility, toileting, and transfers. The resident’s care plan identified a risk for skin breakdown and directed compression stockings on in the morning and off at bedtime, with Ace wraps permitted if the resident refused stockings. The physician’s order also directed TED stockings daily to both lower extremities, with Ace wraps allowed if the resident refused. Survey observations and interviews showed the resident was repeatedly seated in a wheelchair or bedside chair without compression stockings in place. A nurse aide stated she could not locate the stockings and had not reviewed the NA care card or informed the charge nurse. An LPN later found the stockings in the resident’s dresser drawer and applied them, stating the aide should have notified her if the stockings could not be found. On another occasion, a different nurse aide again did not know the resident was supposed to have stockings applied and had not reviewed the NA care card, and an LPN stated she had forgotten to tell the aide to apply them. The resident stated he/she was not refusing the stockings, had not had them applied in a few days, and was unsure why. An APRN note documented weight gain and +2 edema to both lower extremities, and the DNS stated the stockings should have been applied per the physician’s order and that aides and charge nurses should have checked the resident and the care cards.
Failure to Provide Ordered Meal Supervision for Resident with Dysphagia
Penalty
Summary
The facility failed to provide supervision during meals for Resident #31, who had diagnoses including type 2 diabetes, dysphagia, a transient ischemic attack, and a PEG tube. The resident’s nutritional assessment and dietary notes identified a mechanically altered diet with nectar-thick liquids, and a physician’s order dated 12/16/25 directed a mechanically altered texture, nectar-thick consistency diet for choking risk and constant 1-to-1 supervision during meals. The resident care plan also identified aspiration and malnutrition risks and directed staff to observe and report signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, and repeated swallowing attempts. The record also showed that the resident had intact cognition and was independent with most activities of daily living, but required set up/clean up for eating and had symptoms of a swallowing disorder, including loss of food or liquid from the mouth and coughing or choking during meals or when swallowing medication. A swallow evaluation found retained food in the mouth and cheeks after meals and residue on the tongue, cheeks, and gums, supporting the need for a mechanically altered diet and nectar-thick liquids. Despite the active order for 1-to-1 meal supervision, observations on 1/13/26 and 1/14/26 showed the resident eating alone in the room without supervision. A nurse aide stated she did not provide supervision and was unaware of the requirement because it was not reflected on the care card, while the speech therapist and DNS both acknowledged the physician order for meal supervision should have been followed.
Unlabeled Oxygen Tubing and Improper Nebulizer Storage
Penalty
Summary
Safe and appropriate respiratory care was not provided for residents receiving continuous oxygen and nebulizer therapy because oxygen tubing was left unlabeled and undated, and nebulizer equipment was not stored appropriately. Resident #3 had COPD, asthma, and obstructive sleep apnea and was ordered continuous oxygen via nasal cannula with weekly tubing changes. Observations showed the resident receiving oxygen, but the tubing was unlabeled and undated, and an LPN confirmed the tubing had not been changed, labeled, or dated as required. Resident #106 had COPD, moderate persistent asthma, and dependence on supplemental oxygen and was also ordered continuous oxygen with weekly tubing changes. Observations showed the resident receiving oxygen via nasal cannula, but the oxygen tubing was unlabeled and undated. An LPN confirmed the tubing was unlabeled and undated and stated the weekly change, labeling, and dating had not been completed. Resident #114 had COPD, a history of partial lung removal, and a history of tuberculosis, and was ordered continuous oxygen plus nebulizer treatments with weekly oxygen and nebulizer tubing changes. Observations showed the resident receiving oxygen, with oxygen tubing unlabeled and undated, and a nebulizer mask stored uncovered on top of the bedside table with undated tubing attached. Resident #119 had pneumonia, dyspnea, and pulmonary hypertension and was ordered continuous oxygen plus nebulizer treatments with weekly tubing changes. Observations showed the resident receiving oxygen, with oxygen tubing unlabeled and undated, and a nebulizer mask stored uncovered on top of the bedside table with undated tubing attached. The DNS stated oxygen and nebulizer tubing should be changed weekly and dated, and masks should be bagged, while the facility policy directed masks, cannulas, and tubing to be replaced and dated weekly and stored in a plastic bag when not in use.
Incorrect Puree Diet Served to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the appropriate consistency meal per the physician’s order for a resident with dysphagia. Resident #106 had diagnoses including dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination, and the care plan identified oropharyngeal dysphagia, aspiration risk, and risk for malnutrition with interventions for aspiration precautions and safe swallowing strategies. A physician’s order in effect directed a low-fat diet with puree texture and thin liquids, and the resident’s MDS indicated the resident was cognitively intact, dependent for several activities of daily living, and receiving a therapeutic diet. During observation, Resident #106 was found alone in bed eating a peanut butter and jelly sandwich on white bread with crusts, while coughing at times. The sandwich was served on a plate still covered with plastic wrap, and the resident was taking bites from the sandwich despite the puree diet order. A later review of the meal ticket showed the resident was also served cubed hash brown potatoes for breakfast. OT #1, ST #1, the DNS, and the Dietary Director all identified that a peanut butter and jelly sandwich and cubed hash browns were not part of a puree diet and should not have been served to the resident. Facility policy required therapeutic diets to be prepared and served as prescribed and required staff to verify the correct diet before serving meals.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment at mealtime for a resident with dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination. The resident's quarterly MDS identified dependence with bed mobility, toileting, and transfers, and the care plan documented oropharyngeal dysphagia, aspiration risk, and risk for malnutrition with an intervention to provide an inner lip plate at meals. A physician's order in effect directed use of an inner lip plate at meals, and the resident's meal ticket also identified the need for a Kennedy cup and inner lip plate. During observation, the resident was seen eating lunch in bed without an inner lip plate on the tray table. A NA served and set up the resident for lunch without ensuring the meal was plated on the ordered adaptive equipment and stated she made a mistake, did not notify the kitchen, and the resident continued eating from a regular plate. An LPN later observed the resident eating lunch without the inner lip plate and stated the meal should have come up from the kitchen on the adaptive equipment and that the NA should have ensured it was present before serving the tray. OT and facility leadership confirmed the resident had weakness and hand tremors affecting nutrition and dignity, and that dietary staff and nursing staff were responsible for ensuring the meal was plated and served with the ordered inner lip plate.
Failure to Review and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure pneumococcal vaccination was administered for a resident who had consented to receive the PCV20 vaccine. Resident #126 was admitted to the short-term rehabilitation unit with diagnoses including hypertension, dementia, and depression. A Resident admission Vaccination Education form dated 1/2/26 and signed by the resident documented consent for the pneumococcal conjugate vaccine, but the electronic medical record did not show any historical pneumococcal vaccinations and did not indicate a pending pneumococcal vaccine order. The facility also failed to offer or obtain a history of pneumococcal vaccination on admission for another resident. Resident #143 was admitted to the short-term rehabilitation unit, and the Resident admission Vaccination Education form in the paper chart was blank, showing that vaccination status had not been reviewed and the pneumococcal vaccine was not offered. The Infection Preventionist stated she had not reviewed or administered any pneumococcal vaccines since taking the role in October 2025, explaining that outbreak management and time constraints prevented completion of these tasks despite awareness of the facility policy. The DON stated that residents' pneumococcal vaccination status should be reviewed, documented in the EMR, and administered when consent is obtained.
Failure to Implement QAPI for Infection Prevention and Control
Penalty
Summary
The facility failed to implement a QAPI plan related to management of the infection prevention and control program. Review of facility policy and documentation, along with interview with the Administrator, showed the QAA committee met monthly and the facility had 12 current QAPI plans in the QAPI binder, but those plans did not include additional QAPI plans that had been initiated before the survey in response to infection prevention concerns identified by surveyors during staff interviews. The Administrator stated she was unaware of a QAPI related to the facility outbreak that an RN had said was implemented in December 2025, and she was not specifically aware of concerns related to the infection prevention and control program. Facility documentation received on 2/4/26 included a PIP worksheet dated 12/29/25 identifying the problem as rapid transmission of respiratory viruses, including COVID-19 and Influenza A, among residents on 2 units. An inservice titled Outbreak Management and QAPI showed 15 of 16 staff signatures were obtained on 12/29/25 and 1 of 16 on 1/14/26, out of 180 staff members. The facility policy stated that all staff are engaged in the QAPI process, that infection control is included under clinical care, that administration is responsible for the QAPI program, and that PIPs should focus on high-risk, high-problem areas using the PDSA cycle and root cause analysis for adverse events such as facility outbreaks.
Room Not Kept Free of Insects and in Good Repair
Penalty
Summary
The facility failed to ensure Resident #66’s room was free from insects and in good repair. Resident #66 was admitted with diagnoses including paranoid schizophrenia, dementia, and intellectual disabilities, and was documented as severely cognitively impaired and needing moderate assistance with ADLs. The resident’s care plan identified an ADL deficit related to cognitive loss, dementia, paranoid schizophrenia, and intellectual disabilities, with interventions to assist with clothing, toiletries, and equipment, encourage self-performance, and provide assist and cueing. Physician orders directed independent bed mobility, transfers, supervision with ambulation off unit, and assistance with self-care. Survey observations found Resident #66 seated in a recliner near the windowsill in a private room, where a rolled white towel on the inside windowsill had a heavy accumulation of small black dead winged insects. The windowsill area was observed on multiple occasions, and the room also had a radiator cover below the window that was falling off, a section of wallpaper below the window ledge that was marred and in disrepair, and a toilet seat in the bathroom that was visibly discolored with an orange/rust stain. Interviews with the resident, Administrator, Director of Housekeeping Services, and Director of Environmental Services indicated staff were unaware of the towel with insects and no concerns had been reported. The Director of Housekeeping stated routine cleaning included emptying garbage, wiping over-bed tables and visible dirty areas, and light sweeping, and a cleaning checklist for the room did not include windowsills.
Unsecured Items Stored Under Medication Room Sink
Penalty
Summary
The facility failed to ensure that items were not stored under the sink in the Skyview Medication Room, despite facility policy that no items should be stored there. During observation of the medication room, surveyors found the cabinet under the sink containing a bottle of Harvey's Bristol Cream 750 ml that was 3/4 full, 33 empty assorted containers, 7 3M masks, 1 full box of black KN95 masks, 3 VHS tapes, 2 plastic wash basins, a phone charger labeled BB [NAME], 4 boards, 1 stack of sports cards, and 1 empty notebook binder. During interview, the DNS stated the cabinet under the sink should be locked and no items should be stored there, and said she was unsure why the items were present. She stated that nursing staff must have placed them there and that it was the responsibility of nursing and maintenance to ensure items were not stored under the sink in the medication room. The Director of Environmental Services stated he was unaware the items were being stored there. A review of Environmental Rounds completed by an LPN noted that no items were stored under the sinks in the medication rooms at that time. The Medication Storage Policy stated that medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with state and federal requirements and acceptable standards of practice.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident incident involving inappropriate sexual contact. Two residents, both with severe cognitive impairment and court-appointed Conservators of Person (COP), were care planned to spend time together in the common area holding hands, as consented by their COPs. Both residents had a history of inappropriate sexual behaviors, and their care plans specifically prohibited intimate contact or being alone together in a room. Despite these interventions, staff observed one resident with their chest exposed and the other resident in contact with the exposed area in the common area. Staff interviews confirmed that the two residents were known to have a friendly relationship and often spent time together in the common area, holding hands as permitted. However, on the day of the incident, a nursing assistant witnessed inappropriate physical contact between the residents, which was not consented to by either the residents (due to their cognitive impairment) or their COP. The staff member intervened, and the resident involved became agitated and combative when redirected. Facility documentation and interviews with clinical staff, including the LPN, APRN, and Director of Nursing, confirmed awareness of the residents' cognitive limitations and the restrictions in place regarding their interactions. The facility's policy directed that residents be protected from abuse, including non-consensual sexual contact. Despite these policies and care plan interventions, the lack of adequate supervision allowed the incident to occur, resulting in a failure to protect the residents from abuse.
Failure to Timely Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that clinical records accurately reflected the timing of medication administration for four residents reviewed. In each case, medications were administered according to physician orders, but documentation in the Medication Administration Record (MAR) was completed significantly after the actual administration time. This pattern was identified through an internal medication administration audit, which flagged late documentation for medications scheduled primarily around 9:00 A.M., with entries often made between 10:00 A.M. and 2:00 P.M. This issue affected approximately 80 residents across various units. For the residents involved, all had significant medical conditions such as dementia, failure to thrive, hypertension, diabetes, and behavioral disturbances. The MARs for these residents showed that medications, including supplements, psychotropics, and other daily treatments, were documented as being administered hours after the scheduled time. Interviews with nursing staff revealed that the delay in documentation was due to workload and the practice of signing off on the MAR after completing medication rounds for all assigned residents, rather than at the time of administration. Facility leadership, including the DON and regional nurse, confirmed that their expectation was for medications to be documented in the MAR at the time they are administered. The facility's own policy also required immediate documentation following administration. Despite the delayed documentation, there were no reports of negative outcomes or missed doses for the residents involved, as confirmed by the medical director and facility incident summaries.
Delayed Implementation of Fall Prevention Interventions After Resident Injury
Penalty
Summary
The facility failed to ensure timely implementation of care plan interventions following a resident's fall with injury. A resident with diagnoses including anxiety, dementia, history of falls, weakness, and insomnia, and with moderately impaired cognition, experienced an unwitnessed fall resulting in fractures to both femurs. Prior to the fall, the care plan identified the resident as at risk for falls and directed staff to place the call bell within reach and provide assistance with bed mobility. However, after the fall, the care plan was not promptly updated with new interventions to prevent further falls. Although pain management was added to the care plan after the incident, an intervention to use a bolster mattress was not included until two days after the fall, and the mattress itself was not applied until four days after the incident. Interviews with facility leadership confirmed that the care plan should have been updated and interventions implemented sooner, but no explanation was provided for the delay. The deficiency centers on the lack of timely care plan revision and delayed implementation of fall prevention measures following a significant injury event.
Verbal Abuse of Resident by Nurse Aide
Penalty
Summary
A deficiency occurred when a nurse aide (NA) verbally abused a resident with severe cognitive impairment, including dementia, depression, adjustment disorder, and anxiety. The resident required moderate assistance for personal hygiene and had a care plan directing staff to use a calm, gentle approach and avoid known triggers. On the morning of the incident, multiple staff members observed the NA approach the resident in the dining room, point her finger, and loudly state she would tell her supervisor to have the resident leave her "the hell alone." The NA admitted during the facility's investigation that she had become frustrated with the resident and intentionally made the statement in response to feeling targeted by the resident. Witnesses, including other nurse aides and a nursing supervisor, confirmed the NA's aggressive behavior and inappropriate language directed at the resident. The facility's policies defined such conduct as verbal and mental abuse, which is prohibited. The incident caused the resident initial emotional distress, although the resident did not recall the event later in the day. The facility's investigation substantiated the abuse based on staff interviews and documentation.
Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents with severe cognitive impairment. One resident, diagnosed with Wernicke's encephalopathy and mild cognitive impairment, was observed by an LPN with their hand on another resident's thigh and later with their hand resting against the other resident's upper chest area. Both residents had documented behavioral issues, including sexually inappropriate behavior and swearing at staff. The LPN separated the residents but did not immediately report the full extent of the incident, specifically that the hand was on the other resident's breast. The incident occurred during dinner and was documented in the nursing notes and a reportable event form. However, the State Agency was not notified until over 16 hours after the incident, contrary to the facility's policy requiring immediate reporting, but not later than two hours after an allegation of abuse. The delay in reporting was confirmed during an interview with the DON, who stated that the LPN initially reported only partial information about the incident, leading to the late notification to authorities.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown origin sustained by a resident with multiple complex medical conditions, including severe cognitive impairment, non-ambulatory status, and total dependence on staff for transfers and activities of daily living. The resident was found to have bruising and multiple fractures in the right foot, with no clear explanation for the injuries. The resident's care plan required two-person assistance and use of a mechanical lift for transfers, and the injury was discovered during a physician evaluation, which led to urgent imaging and hospital evaluation. Facility documentation indicated that a reenactment was performed to hypothesize possible causes, such as improper foot positioning during a mechanical lift transfer or entrapment with equipment attached to the bed. However, the facility was unable to produce a complete investigative record. Specifically, there was a lack of written staff statements and documentation covering five shifts within the 72-hour period prior to the identification of the injury, and it was unclear whether all relevant staff, including agency staff, were interviewed. The investigation did not provide information about the resident's care during several key shifts, and the responsible staff could not recall or explain why the investigation was incomplete. The facility's own Abuse Prohibition policy required that all allegations of abuse, including injuries of unknown origin, be thoroughly investigated, including interviewing all available witnesses and completing the investigation within five days. Despite this policy, the investigation into the resident's injury was not comprehensive, and the facility failed to meet its own standards for investigating potential abuse or neglect.
Failure to Ensure Safe and Documented Discharge for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that required discharge information was documented and communicated to the responsible party to ensure a safe and effective discharge for a resident with severe cognitive impairment and a history of alcohol dependence. The resident, who was admitted for short-term rehabilitation, had multiple diagnoses including metabolic encephalopathy, Wernicke's encephalopathy, brain atrophy, and severe cognitive impairment. The care plan indicated the resident would be discharged home after therapy, but the resident was assessed as needing 24-hour care and was noted to be disoriented, forgetful, and at risk for wandering and substance use. Despite these significant needs, the facility did not adequately document or communicate the resident's mental status, activities of daily living, or discharge instructions in the nursing discharge summary. The responsible party was not clearly informed of the risks associated with the resident returning home alone, nor was there evidence that the facility ensured immediate support or assistance would be available upon discharge. Interviews revealed that both the psychiatric APRN and the responsible party were not fully informed or involved in the discharge planning, and the responsible party expressed concerns about the resident's ability to safely return home, which were not addressed by the facility. The facility also failed to provide evidence that options for the resident to remain at the facility until additional services were available were explored or communicated. The discharge occurred without ensuring that the resident had a primary care physician or that home care services would be immediately available. As a result, the resident was discharged home alone, was later found wandering and confused, and was hospitalized approximately four hours after discharge. The facility's actions and lack of communication and documentation led to an unsafe discharge process.
Failure to Permit Timely Readmission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, following an inadequate discharge plan that resulted in the resident being hospitalized shortly after discharge. The resident, who had multiple diagnoses including metabolic encephalopathy, alcohol dependence, brain atrophy, Wernicke's encephalopathy, adjustment disorder, anxiety, depression, diabetes, and hypothyroidism, was admitted for short-term rehabilitation with plans for discharge home. The care plan included discharge planning meetings and involvement of family, but documentation shows ongoing concerns about the resident's cognitive status, substance use, and lack of a long-term payer source. Despite these concerns, the facility proceeded with discharge, and the resident was found lost and disoriented on the street within hours, leading to hospital admission. Hospital documentation indicated that the resident was discharged from the facility to an unsafe situation, with the facility aware of the resident's cognitive impairment and risk factors. The hospital case manager attempted to coordinate the resident's return, but the facility initially refused readmission, citing the absence of a legal decision maker and a long-term payer source. The facility had available beds and staff to provide care, but required corporate approval for readmission due to payment concerns, resulting in delays. As a result, the resident remained in the hospital for an additional eight days after being medically cleared for return to the facility. The facility eventually readmitted the resident after intervention from the Long-Term Care Ombudsman and plans to apply for conservatorship. The facility's own policy indicated that priority admission should be granted to individuals discharged from the facility within fifteen days, but this was not followed in the resident's case.
Failure to Develop Pain Management Care Plan
Penalty
Summary
A resident with significant cognitive impairment and a history of a cervical vertebra fracture, as well as pain in the left ankle and foot, was admitted to the facility. The resident required extensive assistance with activities of daily living and had physician orders for Tramadol to manage severe pain. Documentation showed that the resident reported pain daily, and pain assessments indicated both non-verbal and verbal expressions of pain, with pain levels frequently rated as 6 out of 10. Despite these findings and the facility's policy requiring the development and implementation of pain management interventions, there was no evidence that a pain management care plan was created for this resident. The Director of Nursing confirmed during an interview and record review that a pain management care plan had not been developed to address the resident's ongoing pain.
Failure to Reconcile Medications at Discharge
Penalty
Summary
A deficiency occurred when a resident with diagnoses including perforated gastric ulcer, peripheral vascular disease, and essential hypertension was discharged home without proper reconciliation of their medications. The resident, who was cognitively intact and required assistance with self-care and medication administration, was supposed to have their discharge medications reviewed and reconciled prior to leaving the facility. However, documentation revealed that the resident was discharged with medications belonging to two other residents, and the medication reconciliation process was not completed as required. Interviews with facility staff, including a social worker, the Director of Nurses, and an LPN, confirmed that the standard procedure is to review and reconcile medications with the resident or responsible party before discharge. The LPN responsible for the discharge admitted to not reconciling the medications, resulting in the resident receiving incorrect medications upon discharge.
Failure to Follow Hospital Discharge Orders for Biliary Tube Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm of the pancreas, biliary tract disease, fatty liver, and chronic kidney disease, did not receive specialized treatment as ordered. The resident had a biliary drain following a hospital stay, with the hospital discharge summary specifying that the biliary tube should be flushed with 10cc normal saline twice daily to maintain patency. However, review of the facility's documentation and physician orders revealed that while there was an order to cleanse the drain site and apply a dressing, there was no order to flush the biliary tube as directed by the hospital discharge summary. Interviews with facility staff confirmed that the hospital's instructions regarding flushing the biliary tube were not followed.
Failure to Evaluate and Develop Pain Management Plan
Penalty
Summary
A resident was admitted with multiple diagnoses, including acute pulmonary edema, cellulitis, and pressure ulcers. Physician orders were in place for Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. Initial assessments indicated the resident had no cognitive impairment and was not experiencing pain at admission. However, subsequent progress notes documented that the resident reported daily headaches with pain levels ranging from 1 to 7 on a 1-10 scale over several days, and Acetaminophen was administered daily with varying effectiveness, including a report of no effect on one occasion. Despite these ongoing reports of pain, the facility failed to conduct pain evaluations or develop a care plan to address pain management during the period when the resident was experiencing and reporting pain. The facility's pain management policy required a pain evaluation, physical evaluation, and physician notification when a new onset of pain was reported, as well as the development and implementation of both pharmacological and nonpharmacological interventions. An interview with the Director of Nurses confirmed that these steps were not taken during the relevant period.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with dementia and muscle weakness, who had severely impaired cognition and required assistance for ambulation and transfers, was subjected to the inappropriate use of a physical restraint. The resident's care plan specified one-person assistance for ambulation with a rolling walker and did not include any order or assessment for the use of a restraint or seat belt in the wheelchair. Despite this, a staff member used a gait belt to secure the resident to a wheelchair, restricting the resident's ability to stand or move freely. The incident occurred when two nursing assistants found the resident in a closet and placed the resident in a wheelchair in the common area. One nursing assistant, following the direction of an LPN according to her account, applied a gait belt around both the resident and the wheelchair, clipping it within the resident's reach. There was uncertainty among staff as to whether the resident could unclip the belt independently. Interviews revealed conflicting accounts regarding who directed the use of the gait belt, but it was confirmed that the gait belt was used to prevent the resident from standing, which was not in accordance with facility policy or the resident's care plan. Facility policies reviewed indicated that gait belts are to be used only for transfer and ambulation assistance, and that physical restraints require a specific physician order and assessment. The resident had not been assessed for restraint use, and there was no physician order for such an intervention. The use of the gait belt in this manner constituted a failure to ensure the resident was free from physical restraints, as required by both facility policy and resident rights.
Failure to Timely Report and Notify Authorities of Resident Restraint Incident
Penalty
Summary
Staff failed to report an alleged incident of mistreatment in a timely manner and did not notify the State Agency within the required timeframe after becoming aware of the allegation. A resident with dementia and severely impaired cognition, who required assistance for ambulation and transfers, was found to have been restrained in a wheelchair using a gait belt by a nursing assistant, following the direction of an LPN. The gait belt was used to restrict the resident's movement, which was not in accordance with facility policy on restraint use. Another nursing assistant witnessed the event but did not immediately report it, and the incident was not brought to the attention of facility leadership until several days later, after a non-nursing staff member reported a rumor about the event. The facility became aware of the incident on the morning of 12/9/2024 but did not notify the State Agency until over three hours later, exceeding the policy requirement to report violations of mistreatment immediately, but not later than two hours after the violation. Interviews with staff and review of facility documentation confirmed that the use of the gait belt as a restraint was inappropriate and that there was a delay in both internal and external reporting of the incident.
Inappropriate Use of Resident Council Funds
Penalty
Summary
The facility failed to ensure that Resident Council funds were utilized appropriately, as evidenced by the improper use of these funds for activities and services that should have been covered by the facility's budget. Interviews with residents revealed that they felt obligated to vote in favor of using Resident Council funds for music, entertainment, and art classes, as these activities were not provided by the facility. The Administrator confirmed that the facility allocates a monthly budget for the recreation department, which includes art supplies and entertainment, but the Director of Recreation indicated that the budget was insufficient, leading to the use of Resident Council funds. The review of bank statements showed that these funds were used to pay for music entertainment and art classes, despite the facility's responsibility to cover these costs. Additionally, the Resident Council funds were used to pay for the annual licensure fee for the beauty salon chair, a cost that should have been borne by the facility. The Administrator was unaware of these expenditures and acknowledged that the facility should have covered the beauty salon license fee. The lack of oversight and a facility policy for managing Resident Council funds contributed to the inappropriate use of these funds, as the Administrator had not reviewed how the funds were being dispersed.
Failure to Complete Background Checks and References
Penalty
Summary
The facility failed to ensure that required references and background checks were completed prior to hiring six staff members, including nursing assistants, LPNs, and RNs. The Director of Human Resources (HR) was responsible for completing these checks and obtaining two professional references for each employee before they started working. However, upon review, it was found that the personnel files for all six employees lacked the necessary background check/eligibility forms and, in some cases, the required professional references. This oversight allowed these employees to begin working at the facility without the proper screening. The facility's Abuse Prohibition Policy mandates the screening of personnel for a history of abuse, which includes conducting criminal background checks and obtaining at least two reference checks. These requirements were not met, as evidenced by the incomplete employee files. The HR New Hire Checklist also specifies that pre-offer paperwork should include completed and signed references and fingerprinting information. Despite these policies, the HR department did not adhere to the procedures, resulting in the deficiency noted during the survey.
Failure to Change and Label Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing and labeling of oxygen tubing for residents requiring respiratory care. Resident #7, who was dependent on supplemental oxygen due to chronic respiratory failure and COPD, had oxygen tubing that was not changed weekly as per the physician's order and facility policy. The tubing was observed to be dated several weeks prior, and the responsible LPN was unaware of the policy requirements. Resident #16, with diagnoses including acute and chronic respiratory failure and COPD, also had issues with the timely changing of oxygen tubing. The tubing was labeled with a date that did not align with the facility's policy of weekly changes, and the resident could not recall when it was last changed. Documentation inconsistencies were noted in the treatment administration record, which did not match the observed dates on the tubing. Resident #20 and Resident #81 also experienced similar deficiencies. Resident #20's oxygen tubing was found on the floor, unlabeled, and not discarded as required by the facility's policy. Resident #81's tubing was not changed according to the weekly schedule, and the responsible LPN was unaware of why the task was overlooked. These observations indicate a systemic issue with adherence to the facility's policy on oxygen tubing maintenance.
Failure to Conduct Required Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to conduct performance evaluations for nursing assistants as required by their employee handbook and internal policies. The Director of Human Resources (HR) acknowledged that it was her responsibility to ensure all employee files were complete, including performance evaluations at 6 months and annually for employees hired before June 2023, and at 3 months and annually for those hired after. However, upon review, it was found that several nursing assistants had missing evaluations. For instance, one nursing assistant hired in 2022 lacked both the 6-month and annual evaluations due in 2023, while another hired in 2005 had not had an evaluation since 2019. Similar lapses were noted for other nursing assistants, with some not having evaluations for multiple years. The HR Director admitted awareness of the backlog in evaluations and mentioned a new Director of Nursing Services (DNS) at the facility. The Administrator, upon being informed of the issue, acknowledged the deficiency and discussed it with HR. The employee handbook, updated in June 2023, specifies that the first 90 days of employment is an introductory period during which performance should be reviewed, followed by annual evaluations. Despite these guidelines, the facility did not adhere to its own policies, resulting in incomplete employee records and unrecognized staff performance.
Failure to Notify Medical Personnel of Critical Changes
Penalty
Summary
The facility failed to notify the appropriate medical personnel and responsible parties regarding significant changes in the condition of two residents. For one resident with type 2 diabetes and end-stage renal disease, the facility did not inform the physician or APRN of blood glucose readings that exceeded the ordered parameters on multiple occasions. Despite having a care plan that required such notifications, the nursing staff did not document any communication with the physician/APRN about these elevated blood sugar levels, which were recorded on four separate dates. In another case, a resident with diabetes and mild cognitive impairment refused a prescribed medication due to its taste, but the facility did not notify the physician or document the refusal in the progress notes. The resident explicitly requested that the physician be informed of the refusal, yet there was no record of such communication. The facility also failed to provide a policy regarding the refusal of medications when requested.
Failure to Monitor Vital Signs and Neurological Status
Penalty
Summary
The facility failed to adhere to physician's orders for Resident #63, who was admitted with chronic obstructive pulmonary disease, end-stage renal disease, and congestive heart failure. The care plan required monitoring of vital signs every shift, but records from March 1 to April 22 showed that vital signs were not taken for 91 out of 135 shifts. Interviews with the LPN and DNS confirmed the inconsistency in monitoring, and the facility's policy mandates that vital signs be monitored and reported if abnormal. For Resident #94, who has Alzheimer's disease and dementia, the facility did not conduct neurological monitoring as per policy after an incident where the resident was struck on the head by another resident. The policy required frequent neurological checks following a head injury, but only 1 out of 20 required checks were documented. The DNS was unaware of the lapse in monitoring, and the facility's policy outlines specific intervals for neurological assessments following head injuries. Both deficiencies highlight a failure to follow established protocols for monitoring residents' health conditions, as evidenced by the lack of documentation and adherence to physician's orders and facility policies. These lapses were identified through clinical record reviews and staff interviews, indicating a need for improved compliance with care standards.
Failure to Properly Utilize Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper utilization of an air mattress for a resident with multiple pressure injuries. The resident, who was admitted with severe malnutrition and several pressure injuries, had a physician's order for a specialty air mattress with specific settings to be checked every shift. However, observations revealed that the air mattress pump was set incorrectly at 10/65 lbs instead of the prescribed 10/105 lbs, which was supposed to correspond to the resident's weight. This discrepancy was confirmed by a regional nurse, who noted that the settings and physician's order were incorrect and should have been adjusted according to the resident's weight changes. The facility's policy on alternating pressure air mattresses required verification of physician orders and settings according to manufacturer guidelines. Despite this, the Director of Nursing Services (DNS) indicated that the air mattress was set based on physician orders, and it was the responsibility of the nursing staff to monitor the functioning and pressure settings every shift. The wound nurse was specifically responsible for ensuring the air mattress was set according to the resident's weight. This failure to adhere to the correct settings and policy guidelines contributed to the deficiency in providing appropriate pressure ulcer care for the resident.
Failure in Weight Monitoring and Meal Quality
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional care for a resident with a history of weight loss and malnutrition. The resident was admitted with diagnoses including mild protein calorie malnutrition, weakness, and dementia, and was supposed to have their weight monitored weekly as per physician's orders. However, the clinical records showed a lack of consistent weight documentation, with a significant weight loss of 10 lbs. occurring between 2/26 and 3/4, which was not promptly addressed. The dietician's notes confirmed the weight loss and recommended increased nutritional supplements, but the facility did not consistently follow through with the required weekly weight checks. The resident reported receiving burnt meals, which affected their appetite and contributed to the weight loss. Observations by the survey team confirmed that meals served to the resident were often overcooked, with test trays showing blackened and hardened food. Despite the resident's complaints and the dietician's recommendations, the facility did not adequately address the issue of meal quality, which was a contributing factor to the resident's nutritional decline. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight monitoring and meal quality. The LPN responsible for recording the resident's weight failed to ensure a re-weight was conducted after noting a discrepancy, and the DNS was unaware of the burnt meals issue. The facility's policy required weights to be documented weekly, but this was not consistently done, leading to a failure in monitoring the resident's nutritional status effectively.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately for a resident who was admitted with chronic respiratory failure and chronic obstructive pulmonary disease. A physician's order directed the administration of Acetaminophen for pain, and the resident was last given the medication for a pain rating of 8/10. However, a medication cup containing two white tablets was observed on the resident's bedside table, which the resident indicated had been there for about a week. This indicates that the medication was not administered according to the facility's policy, which requires the nurse to remain at the bedside until the medication is taken. Interviews with nursing staff confirmed that medications should not be left at the bedside and that the nurse is expected to ensure the resident takes the medication before leaving. The facility's policies on oral medication administration and self-administration of medications were not followed, as the resident had not been evaluated for the ability to self-administer medications safely. The failure to adhere to these policies led to the deficiency observed during the survey.
Failure to Provide Palatable and Presentable Meals
Penalty
Summary
The facility failed to ensure that residents were provided with palatable and presentable meals, as observed during a survey. On one of the nursing units, test trays of cheese ravioli with tomato sauce were found to be blackened and hardened, indicating that the meals were not prepared to a satisfactory standard. During the meal service on the Skyview unit, the ravioli on the steam table was observed to be charred and blackened, with the tomato sauce appearing dry, cracked, and discolored. Out of 22 meals served, 11 were returned and exchanged for alternatives, highlighting the unacceptability of the meal quality. The Dietary Director admitted that the ravioli had been overcooked due to being left in the oven too long and acknowledged that the meals should not have been served to residents. The director also failed to inspect the test trays before providing them to the survey team and did not observe the meals prepared for residents before they were served. Additionally, the facility did not provide documentation related to test tray monitoring, which was supposed to be conducted three times weekly to ensure proper food quality and appearance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 620 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Torrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Torrington Center For Nursing & Rehabilitation Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| Wolcott Hall Nursing Center Inc | 2.8 mi | ★★★★★ | 1 | 0 |
| Havencare At Litchfield Woods | 3.5 mi | ★★★★★ | 5 | 0 |
| Cherry Brook Health Care Center | 8.2 mi | ★★★★★ | 5 | 0 |
| Cook Willow Health & Rehabilitation Center, Inc. | 11.1 mi | ★★★★★ | 14 | 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.