Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leeway, Inc during CMS and state inspections, most recent first.
Failure to Document Smoking Status and Restrictions in Care Plans: Several residents with diagnoses including COPD, nicotine dependence, anxiety, and bipolar disorder had care plans that did not reflect smoking privileges, concerns, or restrictions. One resident’s revised care plan identified supervised smoking, but did not include prior unsafe smoking incidents or behavioral contract interventions. Surveyors also observed seven residents smoking with RN, NAs, and front desk staff present, with cigarettes lit by front desk staff and extinguished in a self-extinguishing ashtray.
A resident with cardiac and cognitive conditions was sent to the ER for pacemaker-site swelling and later discharged home, but the Ombudsman notification did not include the hospitalization or the discharge to the community. Another resident with severe cognitive impairment and multiple diagnoses had repeated hospital transfers, but the facility could not produce written notice to the conservator explaining why the resident was transferred. The DON and Administrator acknowledged missing documentation for the required notifications.
Failure to develop comprehensive care plans for recurrent and new diagnoses. A resident with severe cognitive impairment and repeated hospitalizations for CHF and UTI had a care plan that addressed CHF only in limited terms and did not include the resident's recurrent UTI diagnoses or related CHF risks such as weight gain, SOB, fatigue, swelling, cough, or decreased oxygenation. Another resident was treated for a UTI after hospitalization, but no present or completed UTI care plan was found despite staff confirming one should have been initiated.
A resident with hemiplegia and cognitive intactness did not have a right hand splint applied per OT guidance, and the chart lacked an accurate MD order and updated care plan to match the current wear schedule. In a separate case, a resident with COPD and CHF had orders for weekly then monthly weights, but only one weight was documented and no ongoing weights were recorded despite continued physician notes to monitor weights.
The facility failed to keep smoking assessments and smoking-related care plans current for residents identified as smokers, and it did not document investigations for repeated smoking policy violations involving contraband, lighters, and unsafe smoking behavior. The facility also failed to document RN assessments, new fall-prevention interventions, and 72-hour post-fall monitoring for a resident with multiple falls, despite records showing repeated incidents, neuro checks, and notifications to the APRN and conservator.
Failure to initiate bladder retraining for a resident with post-stroke urinary incontinence. The resident was identified as a good candidate for bladder retraining, but the care plan did not include it, and nursing staff stated they were unaware of any bladder retraining documentation and believed therapy was responsible. A voiding pattern assessment showed the resident was never dry, and OT said therapy only worked on toilet transfers and incontinence management, not bladder retraining.
Incomplete Daily Census and Staffing Posting: Facility staff failed to post the daily census and staffing data with complete staffing for the upcoming 24-hour period and in a location easily visible to residents and visitors. The form was found in a closed glass cabinet on a top shelf, and staff stated security completed it after verifying arrivals, with no policy or procedure provided. The Administrator later acknowledged that leaving shifts blank did not allow visitors and residents to know the expected staffing for 24 hours, and no accessible posting was found on the SNF unit.
The facility failed to ensure the Infection Prevention and Control Nurse had a specialized training certificate on file. The DON reported she was covering for the Infection Prevention nurse while he was on vacation, even though she did not hold a certificate herself. Surveyors made multiple attempts to obtain the CDC infection control training certificate, but it was not produced.
A resident with multiple diagnoses, including Kaposi's sarcoma and malnutrition, had physician orders that were not signed or dated for several months. The facility's policy requires orders to be signed and renewed regularly, but the APRN was unable to sign them due to lack of access to the electronic health record system. This issue was identified during a survey, and the APRN was subsequently given access to sign orders electronically.
The facility failed to properly label and date food items in storage areas, including the refrigerator and freezer, leading to undated and open-to-air food. The Food Service Manager acknowledged the oversight, noting that prepared food should be labeled and kept for no more than three days. Additionally, a dietary aide was observed handling food without gloves, contrary to facility policy prohibiting bare hand contact with food.
A resident with severe cognitive impairment and physical limitations experienced a lack of dignified dining when a nursing assistant stood while feeding them, contrary to training emphasizing eye contact. The facility lacked a specific policy on seating during feeding, although training highlighted its importance.
Two residents with hemiplegia and other conditions were observed using slings not included in their care plans, leading to deficiencies. The Therapy Director failed to reorder a sling for one resident post-hospitalization, and the other resident's sling was applied without assessment or a physician's order. The facility's policy requires comprehensive care plans, but this was not followed, resulting in a deficiency.
The facility failed to implement physician's orders for orthostatic blood pressure monitoring for two residents on high-risk antipsychotic medications. The APRN entered orders without scheduled times, causing them to be omitted from the MAR. Staff interviews revealed systemic issues with the electronic health record system and a lack of formal training for the APRN, contributing to the oversight.
A resident with impaired cognition and multiple diagnoses was not properly assessed or offered the pneumococcal vaccine upon admission, as required by facility policy. The Infection Preventionist Nurse failed to document the resident's initial refusal and did not follow up with the conservator, leading to a deficiency in the immunization process.
Two residents were not properly assessed or offered COVID-19 vaccinations upon admission, leading to a deficiency in the facility's immunization process. The Infection Preventionist Nurse failed to document vaccination status and follow up with a conservator, contrary to facility policy.
The facility failed to provide annual competency training for its licensed staff and CNAs, with most staff lacking completed competency signoffs. The Staff Development nurse, who also serves as the MDS coordinator, reported delays in training due to other responsibilities. Only 6 out of 24 staff members had completed competencies for 2023, with no records for 2022 or 2024. The facility had been fined in 2022 for similar issues, and a skills fair was planned to address the deficiencies.
Failure to Document Smoking Status and Restrictions in Care Plans
Penalty
Summary
The facility failed to revise resident care plans to reflect smoking privileges, concerns, or restrictions for 4 of 12 residents reviewed for smoking. Resident #10 had diagnoses including necrotizing fasciitis, Fournier gangrene, and anxiety disorder, and the admission MDS identified the resident as cognitively intact with a BIMS of 14 and requiring varying levels of assistance with activities of daily living; however, the resident care plan dated 11/24/2025 did not identify smoking. Resident #15 had diagnoses including moderate protein calorie malnutrition, COPD, and nicotine dependence, was cognitively intact with a BIMS of 15, and the resident care plan dated 11/18/2025 also failed to identify smoking. Resident #23 had diagnoses including COPD, adjustment disorder with depressed mood, and nicotine dependence, was cognitively intact with a BIMS of 15, had current tobacco use, and the resident care plan dated 11/20/2025 did not identify smoking. Resident #22 had diagnoses including bipolar disorder, anxiety disorder, and nicotine dependence, was cognitively intact with a BIMS of 15, and the revised care plan dated 11/28/2025 identified the resident as a safe supervised smoker with interventions for supervised smoking and secure storage of smoking materials. However, the care plan did not identify unsafe smoking incidents on 8/1/2025, 8/13/2025, and 12/21/2025 or interventions related to a behavioral contract. During observation on 12/24/2025 at 11:11 AM, seven residents, including Residents #9, #10, #15, #17, #20, #22, and #29, were observed smoking with RN #2, NA #3, NA #4, and Front desk #2 present; each resident was given one cigarette, lit by Front desk #2, and all were observed to smoke independently and extinguish the cigarette in a self-extinguishing ashtray. The DON stated on 12/29/25 that care plans are completed by the MDS Coordinator and admission nurse and could not explain why the medical record did not reflect current smoking care plans.
Failure to Notify Ombudsman and Conservator of Transfers and Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident’s hospitalization and later discharge to the community. Resident #34 had diagnoses including chronic hepatitis and cardiomyopathy, and the admission MDS identified moderately impaired cognition. After the resident developed swelling at the pacemaker site with itching, the APRN ordered transfer to the emergency room, and the resident was sent out for evaluation. The census report showed the hospitalization and return to the facility, but the Ombudsman notification submitted by the social worker did not list that hospitalization. Resident #34 was later discharged home after completing IV antibiotics and being cleared by the infectious disease physician. Facility notes documented that the resident was safely discharged home with home care services and left by taxi, but the Ombudsman notification for routine monthly hospital discharges did not identify this discharge to the community. The Administrator stated the social worker was responsible for monthly Ombudsman notifications for residents sent to the hospital and for voluntary and involuntary discharges, and acknowledged that the discharge was not included on the submitted notifications. The facility also failed to provide written notification to the conservator for Resident #7 explaining why the resident was transferred to the hospital. Resident #7 had diagnoses including UTI, acute on chronic CHF, Alzheimer’s disease, schizophrenia, and dementia with behavioral disturbances, and the quarterly MDS showed severe cognitive impairment. The clinical record showed multiple hospital transfers, but no documentation was found that the conservator was notified in writing of the transfers or the reasons for them. The Administrator and Assistant Administrator stated they could not locate documentation of written notification to the conservator.
Failure to Develop Comprehensive Care Plans for Recurrent and New Diagnoses
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident with recurrent diagnoses and repeated hospitalizations. Resident #7 had diagnoses including UTI, acute on chronic CHF, Alzheimer's disease, schizophrenia, and dementia with other behavioral disturbances, and the quarterly MDS identified severe cognitive impairment with a BIMS score of 7. The resident's care plan addressed CHF only with interventions to encourage adequate nutrition, offer small frequent feedings, give cardiac medications as ordered, and monitor intake and output, but it did not identify risks such as rapid weight gain, shortness of breath, fatigue, increased swelling, increased cough, or decreased oxygenation. The care plan also did not identify the resident's recurring UTI diagnoses, despite three hospitalizations for UTI complications in the prior six months and three hospitalizations related to CHF complications during the same period. The facility also failed to develop and implement a care plan for another resident after a new UTI diagnosis following hospitalization. Resident #2 had diagnoses including CKD, BPH, and endocarditis, and the quarterly MDS identified moderate cognitive impairment with a BIMS score of 11 and substantial to maximal assistance needs for toileting hygiene, toilet transfer, and lower body dressing. A hospital transport handoff and physician order indicated treatment with Cefuroxime for a UTI, but the resident's care plan did not identify a UTI care plan. Review of the current and completed care plans confirmed no present or completed UTI care plan, and staff interviewed stated the care plan should have been initiated but could not explain why it was not done.
Failure to Follow Splint Orders and Obtain Ordered Weights
Penalty
Summary
The facility failed to ensure Resident #4’s right hand splint was applied according to OT recommendations, failed to have an accurate physician’s order reflecting the OT wear schedule, and failed to revise the care plan to include the current OT recommendation. Resident #4 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, schizophrenia, and metabolic encephalopathy. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 13 and noted functional limitation in range of motion on one side for both upper and lower extremities. OT documentation showed the resident was to tolerate the right hand splint for 2 hours with no signs of impaired skin integrity and to wear it per a schedule. Subsequent OT and clarification notes changed the wear schedule to evening care and morning care, and later to nighttime use. However, the physician’s orders in the chart did not reflect the current splint wear schedule, and the care plan continued to list only that the resident used a right hand splint for contracture as tolerated. During observation, the resident was in the dining room without the splint on while in the wheelchair, and later the splint was found on the nightstand with the resident stating it had not been worn all night. The facility also failed to follow physician’s orders for Resident #5, who had emphysema, COPD, and CHF. Orders directed weekly weights for 4 weeks, then monthly weights, and the care plan included obtaining weights as ordered. The record showed only one weight was obtained, and no weights were documented in the TAR for September through December 2025. Although hospice paperwork discontinued laboratory and x-ray orders, it did not clearly discontinue weights when reviewed, and the resident’s physician notes continued to state that weights would be monitored.
Smoking oversight and fall response documentation failures
Penalty
Summary
The facility failed to complete smoking assessments quarterly and failed to keep smoking-related care plans current for residents identified as smokers. One resident with necrotizing fasciitis, Fournier gangrene, and anxiety disorder had an admission nursing assessment that showed the smoking evaluation was incomplete, and the resident care plan did not identify smoking. Another resident with an above-the-knee amputation, neuro muscular bladder dysfunction, and systolic CHF was identified as an everyday smoker on a smoking evaluation, but no additional smoking evaluations were found in the record, and the resident care plan identified the resident as a safe supervised smoker without a current quarterly smoking assessment. The DNS stated the smoking assessments were completed on admission, quarterly, and with changes, but could not explain why the record did not reflect current assessments or care plan documentation. The facility also failed to investigate allegations of smoking non-compliance and failed to develop an intervention to ensure smoking materials given to residents on social leave of absence were verified and returned to nursing staff. A resident with bipolar disorder, anxiety disorder, and diabetes had repeated incidents involving smoking policy violations, including smoking in the room, hiding smoking paraphernalia, and obtaining cigarettes or money from others. The record included notes that the resident had been restricted to supervised smoking and supervised leave of absence because of ongoing safety concerns, and a behavioral contract was later issued for repeated violations involving contraband, smoking-related items, and unsafe conduct. During a later incident, the resident was observed with a cigarette and lighter in the room, and staff confiscated the items, but the DNS stated the medical record did not accurately reflect the incident and late-entry notes were added. The DNS also stated the record failed to reflect an investigation for earlier smoking incidents, and front desk staff reported that lighters were not always documented and there was no policy on giving out and receiving back lighters. For a resident with hemiplegia and hemiparesis following cerebral infarction, schizophrenia, and metabolic encephalopathy, the facility failed to assess the resident after falls, failed to implement measures to prevent future falls, and failed to monitor the resident for 72 hours after falls per facility practice. The resident had multiple falls documented throughout the year, including falls from a wheelchair and while reaching or transferring. After some falls, the record showed neurological checks, notification of the APRN or conservator, and x-rays ordered, but the care plan did not show new interventions after certain falls. For other falls, the medical record did not show an RN assessment after the fall, and one fall lacked a 72-hour follow-up nurse note. The DNS stated that an RN assessment was to be completed after every fall, interventions were to be added to the care plan when possible, and follow-up notes were to be completed for 72 hours after a fall, but could not identify why these items were missing from the record.
Failure to Initiate Bladder Retraining for a Post-Stroke Resident
Penalty
Summary
The facility failed to ensure Resident #23 was started on a bladder retraining program after assessments identified the resident as a good candidate for bladder retraining. Resident #23 was admitted in October 2025 for short term rehabilitation with diagnoses including a new cerebral infarction (stroke) with left side weakness, adjustment disorder with depressed mood, and cognitive communication deficit. The admission MDS identified the resident as cognitively intact, requiring moderate assistance with toileting transfers, frequently incontinent, and not on a urinary toileting trial plan. The Bladder and Bowel Screener also identified the resident as a good candidate for bladder retraining, but the care plan only addressed occasional bladder incontinence with interventions such as establishing voiding patterns, checking for incontinence every 2 hours, and monitoring for signs and symptoms of a UTI. The care plan did not reflect a bladder retraining program, and the physician's orders later identified Resident #23 as independent with toileting. The resident stated there had been a recent decline in urinary function and that urine control had been poor since the stroke. A three-day voiding pattern assessment showed 35 voiding occurrences with the resident very wet 20 times, a little wet 15 times, and never dry. An LPN stated she was unaware of any bladder retraining for the resident, believed therapy would be responsible, could not locate any bladder retraining documentation, and said nursing did not perform bladder retraining. The OT stated therapy did not perform bladder retraining and that nursing was responsible for it, while therapy worked with the resident on toilet transfers and managing incontinence independently for discharge home.
Incomplete Daily Census and Staffing Posting
Penalty
Summary
The facility failed to ensure the daily census and staffing data was posted with complete staffing for the upcoming 24-hour period and in a location easily visible to residents and visitors. On 12/24/2025 at 1:02 PM, an observation and interview with the front desk supervisor and security/front desk staff found the daily facility census and staffing form located far to the right on the top shelf inside a tall, closed glass cabinet. Security/front desk staff stated that security personnel completed the form after verifying each staff member had arrived for the shift, and that there was no policy or procedure they had been told by the administrator to ensure the form was accurate. They also stated that security staff were on duty 24 hours and that prior daily sheets were kept in a binder behind the security reception desk. Review of the binder showed prior 24-hour census staffing sheets completed for all 3 shifts, but an observation and interview with the Administrator and Administrator in training on 12/30/2025 at 11:08 AM found the posted daily census staffing sheet in the same cabinet location with only the 7-3 PM shift staffing and the daily census data. The Administrator in training stated the 11-7 AM shift was responsible for completing the form for the 24 hours, and the Administrator stated the way it was being completed was more accurate than posting the full 24 hours at a time. The Administrator also acknowledged that leaving shifts blank did not allow visitors and residents to know the expected staffing for 24 hours. Further observation on the skilled nursing unit found no posting of the daily census and staffing that allowed residents on the unit easy access to the data, especially if they were unable to leave the unit. The Administrator later provided a form labeled as the proper way to fill out a daily census log for the display case, and no facility policy or procedure was provided.
Missing Infection Preventionist Training Certificate
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program because the Infection Prevention and Control Nurse did not have a specialized training certificate on file. During an interview with the DNS, it was identified that the Infection Prevention nurse was on vacation and the DNS was covering for him from time to time even though she did not hold a certificate herself. The DNS stated that the Infection Prevention nurse had started working at the facility on 4/25/22 and had told her he completed CDC training, but the certificate was not available at the time of review. Surveyors made multiple attempts to obtain a copy of the specialized infection control training certificate during the initial entrance, during review of the infection control task, prior to leaving the facility, and again on 12/31/25, but were unsuccessful.
Failure to Sign and Date Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's physician orders were signed and dated in a timely manner. The resident, who was admitted within the past six months, had diagnoses including Kaposi's sarcoma, malnutrition, neoplasm-related pain, anemia, and depression. The admission MDS assessment indicated that the resident required extensive assistance with various activities and was non-ambulatory. A review of the physician's orders from January 2024 through June 4, 2024, revealed that the orders were not signed or dated during this period. According to the facility's policy, admission orders should be signed and renewed every thirty days for ninety days, and then every sixty days thereafter. Interviews conducted during the survey revealed that the Director of Nursing Services (DNS) believed the provider was signing the orders after reviewing them. However, the Advanced Practice Registered Nurse (APRN) stated that he was reviewing the orders but was unable to sign them due to a lack of access to the electronic health record system. This issue was addressed after the surveyor's inquiry, allowing the APRN to sign the orders electronically. The facility's Physician Visit policy requires that attending physicians make visits in accordance with state and federal regulations, and non-physician practitioners may perform required visits and sign orders as permitted by these regulations.
Food Labeling and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in various storage areas, including the reach-in refrigerator, walk-in freezer, and dry storage area. Observations revealed numerous food items, such as sandwiches, eggs, and mixed vegetables, that were undated and unlabeled. The Food Service Manager acknowledged that all prepared food should be labeled with the date of preparation and kept for no more than three days. Additionally, food removed from another container should be labeled with the original expiration date. The manager was unaware of why the staff had not labeled or dated the food items. Further inspection of the walk-in freezer uncovered several food items, including hot dogs, shepherd's pie, and noodles, that were either undated or open to air. The Food Service Manager admitted that these items should be labeled when opened and discarded if they exceed six months in the freezer. In the dry storage area, expired and undated items such as ranch dressing mix and ravioli cans were found. The manager noted that expired items should have been discarded and attempted to rotate the emergency supply into use. During food preparation, a dietary aide was observed handling green beans without gloves, using his hand to guide them into a metal bin. The Food Service Manager confirmed that bare hand contact with food is prohibited and that gloves should be worn when handling food directly. The facility's policies on food receiving, storage, preparation, and service emphasize the importance of labeling, dating, and maintaining hygienic practices to prevent foodborne illness.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with severe cognitive impairment and multiple physical limitations, including muscle weakness and contractures. The resident required extensive assistance with activities of daily living, including eating. During a lunch observation, the resident was served a meal later than two other residents at the same table, and the meal remained covered in front of the resident for several minutes before a nursing assistant (NA) began assisting with feeding. The NA stood while feeding the resident, contrary to the facility's training on maintaining eye contact during dining. The NA acknowledged awareness of the requirement to be seated while feeding residents but cited difficulty due to her height compared to the resident's. The facility lacked a specific policy mandating that aides sit while assisting residents during meals, although training emphasized the importance of eye contact. The administrator intervened during the observation to instruct the NA to sit, which allowed the NA to continue assisting the resident appropriately.
Deficiency in Care Plan Inclusion of Assistive Devices
Penalty
Summary
The facility failed to ensure that the use of assistive devices was included in the comprehensive care plans for two residents, leading to deficiencies in their care. Resident #17, who has diagnoses including Type 2 diabetes mellitus, hemiplegia, and blindness in one eye, was observed using a sling on the left arm without it being included in the care plan. The Therapy Director acknowledged that the sling order was not reordered after the resident's hospitalization, and the occupational therapist missed including it in the evaluation. The care plan was not updated to reflect the use of the sling until after surveyor inquiry. Resident #26, with diagnoses including hemiplegia and muscle weakness, was observed using a sling on the right arm, which was not included in the care plan. The Therapy Director applied the sling during therapy without notifying occupational therapy or assessing its use. The resident's care plan did not initially include the use of the sling, and there was no physician's order for it. The Therapy Director and other staff were uncertain about the need for a physician's order for the sling, and the MDS Coordinator assumed therapy orders were signed without verifying with the doctor. Interviews with the DNS and Administrator revealed that the expectation was for the use of slings to be addressed in the care plans. The facility's policy requires comprehensive, person-centered care plans with measurable objectives to meet residents' needs, but this was not adhered to in these cases. The lack of inclusion of assistive devices in the care plans for these residents highlights a deficiency in the facility's adherence to its own policies and procedures.
Failure to Implement Physician's Orders for Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were transcribed and accurately implemented for two residents, leading to a deficiency in medication management. Resident #2, who had multiple diagnoses including bipolar disorder and end-stage renal disease, was prescribed Lurasidone for bipolar disorder. The Psychiatric Nurse Practitioner (APRN) ordered weekly orthostatic blood pressure monitoring due to the potential side effects of the medication. However, the clinical record showed that these blood pressure checks were not completed as ordered because the APRN did not specify a time for the checks, resulting in the orders not appearing on the Medication Administration Record (MAR). Similarly, Resident #5, diagnosed with schizophrenia and other conditions, was prescribed Zyprexa, which also required orthostatic blood pressure monitoring due to its potential side effects. The APRN agreed with a pharmacist's recommendation for weekly monitoring, but again, the clinical record lacked evidence that these checks were performed. The issue arose from the APRN entering orders into the electronic health record without scheduled times, leading to the omission of these orders from the MAR. Interviews with facility staff, including the Charge Nurse and the Director of Nursing Services (DNS), revealed systemic issues with the electronic health record system and a lack of formal training for the APRN in entering orders. The facility's process for checking orders did not include verifying entries in the electronic system, contributing to the oversight. The DNS acknowledged the problem and indicated that the facility was aware of the issue with orthostatic blood pressure orders and was working to address it.
Failure to Document and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and assess for the pneumococcal vaccine for a resident upon admission, as required by their policy. The resident, who was admitted in March 2024, had diagnoses including a disorder of the immune mechanism, schizophrenia, and post-traumatic stress disorder, and was identified as having moderately impaired cognition. Upon review of the immunization records, it was found that there was no documentation indicating that the pneumococcal vaccine was offered or assessed for past immunization. The Infection Preventionist Nurse (RN #2) admitted to asking the resident if they wanted the pneumococcal vaccine, which the resident initially refused, but failed to document this encounter in the clinical record. RN #2 also did not follow up with social services to contact the resident's conservator regarding the vaccination status, which was part of his responsibility. The facility's policy required that each resident be assessed for pneumococcal immunization upon admission and offered the vaccine within thirty days unless medically contraindicated, with documentation of any refusal in the medical record.
Failure to Offer and Document COVID-19 Vaccination Upon Admission
Penalty
Summary
The facility failed to offer and assess COVID-19 immunizations upon admission for two residents, leading to a deficiency in their immunization process. Resident #2, admitted with multiple health conditions including a disorder of the immune mechanism, type 2 diabetes mellitus, end-stage renal disease, and congestive heart failure, did not have a documented offer or assessment of COVID-19 vaccination upon admission. The Infection Preventionist Nurse (RN #2) acknowledged the oversight, admitting that he did not review the resident's vaccination status as required by the facility's policy. Similarly, Resident #26, who had moderately impaired cognition and was admitted with diagnoses including a disorder of the immune mechanism, schizophrenia, and post-traumatic stress disorder, was not properly assessed for COVID-19 vaccination. Although RN #2 claimed to have asked the resident about the vaccine, he failed to document the encounter and did not follow up with the resident's conservator. This lack of documentation and follow-up resulted in a failure to adhere to the facility's policy of offering vaccinations upon admission.
Failure to Ensure Annual Competency Training for Staff
Penalty
Summary
The facility failed to ensure that their licensed staff and CNAs received annual competency training, as evidenced by a review of the competency training binder which showed that the majority of staff had not completed their competency signoffs. The Staff Development nurse, who has been in the position since April 2023, reported that no training or competency records were handed over to her when she assumed the role. She also indicated that her responsibilities as the MDS coordinator and other tasks have delayed the training process. Out of 24 staff members, only 6 had completed competencies for 2023, and there were no records for 2022 or 2024. The facility uses Relias for certain trainings, but the system's effectiveness in ensuring compliance was not evident. Interviews with the previous Staff Development nurse and the Administrator revealed that during the COVID period, competencies were limited to hand hygiene and PPE donning and doffing. The facility had been fined in 2022 for similar issues, and there was an upcoming skills fair planned to address the deficiencies. The DNS acknowledged the lack of completed competencies and mentioned that a competency in-service was scheduled but was delayed due to the surveyors' visit. The facility assessment outlined specific areas where licensed staff and CNAs should receive yearly competencies, but these were not completed as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Wade Home, The Incorporated | 1 mi | ★★★★★ | 4 | 0 |
| New Haven Center For Nursing & Rehabilitation Llc | 1.5 mi | ★★★★★ | 46 | 1 |
| Whitney Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Montowese Center For Health & Rehabilitation | 2.3 mi | ★★★★★ | 1 | 0 |
| Grimes Center | 2.5 mi | ★★★★★ | 13 | 0 |
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