Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Noble Horizons during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and dependence for ADLs, including transfers, was care planned as a fall risk requiring contact guard assist of two and close monitoring. While seated in a wheelchair near the nurse’s station due to fidgeting and repeatedly leaning forward, the resident fell to the floor when a NA attempted to reposition the resident alone without calling for help, despite feeling the resident was too large to manage alone. According to facility documentation and staff interviews, an RN heard the NA tell the resident that if the resident kept leaning forward she would let the resident fall, then heard a loud noise and found the resident on the floor while the NA was reclined with feet elevated. Multiple staff reported that the NA laughed after the fall and made comments such as hoping the resident had learned a lesson, and other NAs told her the situation was not funny. These actions conflicted with the facility’s Resident Rights policy requiring residents be treated with respect and dignity.
Staff failed to immediately report an allegation of verbal mistreatment involving a resident with dementia, severe cognitive impairment, and dependence for ADLs who required assist for transfers and had an indwelling catheter. One NA told the resident that if the resident kept leaning forward the NA would let the resident fall, after which a loud noise was heard and the resident was found on the floor while the NA laughed. Other NAs observed the NA laughing and informed the RN supervisor, who did not promptly notify the DON and instead sent an email that was not seen until many hours later, contrary to the facility’s abuse policy requiring immediate reporting of alleged abuse.
A resident with dementia, severe cognitive impairment, dependence in ADLs, and a Foley catheter was care planned as needing two-person assistance for transfers and repositioning when leaning forward in a wheelchair. While the resident was seated at the nurse’s station and repeatedly leaning and sliding forward, a NA attempted to verbally redirect the resident but then tried to reposition the resident alone from behind without requesting help, despite the resident’s size and assessed need for two staff. The resident fell forward from the wheelchair, striking their head on a door, while an RN and other NAs reported hearing the NA make comments about letting the resident fall and observed the NA laughing and sitting in a reclined position with feet elevated after the fall, demonstrating a failure to provide safe repositioning and adequate supervision.
A resident with dementia, severe cognitive impairment, and dependence for ADLs, who required two-person assistance for transfers, was seated at the nurse’s station with an NA due to fidgeting and repeatedly sliding forward in a wheelchair. The NA stated, “If you keep leaning forward, I am going to let you fall,” then attempted to reposition the resident alone, contrary to the required two-person assist, and the resident fell forward, striking a door. An RN reportedly assessed the resident after the fall and found no injuries, but the assessment was not documented in the clinical record, resulting in an incomplete and inaccurate medical record in violation of facility documentation policy.
Failure to develop and implement a water management plan led to positive Legionella findings in multiple water samples, including Legionella pneumophila serogroups 1-14, with facility leadership not recognizing the results as significant or notifying the IP or MD. The DOPP stated the facility had no water management plan and took no action after the abnormal lab reports, while the Administrator was unaware the results were abnormal. The IP was unaware of the positive samples, and the MD was unaware of the Legionella findings or the absence of a water management plan.
Failure to Follow Two-Person Transfer Assistance Plan: A resident with stroke-related deficits, dementia, and impaired mobility was care planned for 2-person assist with transfers using a walker, but an NA attempted a transfer alone during morning care. The resident lost balance, fell into a wall, and later was found to have a right clavicle fracture. Interviews confirmed the resident required 2 staff for transfers and that the NA did not follow the plan of care.
Failure to provide bed hold notices and monthly ombudsman discharge notifications. A resident with heart failure, dementia, and pneumonia was transferred to the hospital twice with severe respiratory decline, but the record did not show that the resident or representative received the bed hold policy at either transfer. Staff gave conflicting accounts about who was responsible for the notice. In addition, SW acknowledged ombudsman discharge reports were not sent monthly and were instead submitted in batches every few months.
The facility failed to complete required MDS assessments on time for multiple residents, including admission and annual assessments. Residents with diagnoses such as dementia, HF, CKD, arthritis, cancer, chronic pain, diabetes, and cognitive decline had MDSs that were late, still in process, or not signed as completed. An LPN MDS coordinator acknowledged that most of the identified MDS assessments had not been completed or submitted, despite the facility policy requiring timely comprehensive, quarterly, and annual assessments.
Delayed Quarterly MDS Assessments: Multiple residents with diagnoses including stroke, COPD, DM, CKD, HF, dysphagia, and fractures had overdue or incomplete quarterly MDS assessments. The MDS coordinator stated she was responsible for CMS-required submissions and acknowledged that most of the identified residents' MDS assessments had not been completed or submitted, despite the facility policy requiring timely quarterly and annual resident assessments.
Late and Incomplete MDS Assessments: The facility failed to complete and transmit MDS assessments timely for multiple residents. Several discharge and death-in-facility MDSs remained in process or incomplete long after the residents had discharged or died, one MDS was completed and submitted 143 days late, and an LPN/MDS coordinator acknowledged that most of the identified assessments had not been completed or submitted.
Failure to Reconcile Controlled Substances: The facility failed to consistently and accurately reconcile controlled substances for 2 medication carts. Monthly or bi-monthly audits could not be produced, and the DNS stated she had not completed any controlled substance reconciliations or audits since starting at the facility. The DNS said the process involved counting controlled substances and comparing them to the CSDR, but the facility could not verify the accuracy of its controlled substance inventory and did not provide a Controlled Substance Reconciliation and Audit policy.
Unlabeled, undated, and expired food items were found in multiple dietary and nourishment refrigerators, along with dirty refrigerator and freezer surfaces containing dried spills and food crumbs. Surveyors observed cups, pitchers, fruit containers, bread, soda, milk, and other partially used items that lacked required labels, dates, or expiration information. The dietary staff member and DOD stated food must be labeled and dated and that opened items are discarded after 3 days, but the items remained stored in the refrigerators without proper identification or sanitation.
A nurse aide did not have documentation showing completion of the required annual 12 hours of in-service education. The staff development nurse could not locate education records for the nurse aide for two years and stated the file lacked documentation, while the DON said she was unaware the requirement had not been met. Facility policy required annual training in topics including infection control, abuse prevention, dementia care, and other resident care areas.
Advance Directive Education and Code Status Wishes Not Documented: The facility failed to document advance directive education and resident wishes for two residents with impaired cognition. One resident with stroke-related deficits and dementia had a DNR order, but the code status form was not signed by the resident or representative and notes did not show representative education. Another resident with dementia, HF, and depression had verbal consent noted, but the form was unsigned and the record did not show that the representative was contacted, educated, or that code status wishes were identified.
Failure to notify the physician and resident representative of missed medications. A resident with Parkinson’s disease, stroke, depression, and cancer had multiple ordered meds omitted because they were not available, including Amlodipine, Droxidopa, and Sertraline. eMAR review showed repeated missed doses, but nursing notes did not document timely notification to the pharmacy, MD, or resident representative. An LPN said she had told the supervisor about unavailable Droxidopa, while the DON stated she was unaware the resident had missed multiple doses and the MD said he was not notified.
Failure to Report an Injury of Unknown Origin: A resident with dementia, COPD, lupus, peripheral vascular disease, and fragile skin developed an unexplained 3 cm by 3 cm facial bruise during care. Staff documented that the resident did not know how it happened, but the cause remained unknown and the incident file lacked additional investigative documents. Interviews showed the APRN was not recalled as being informed, an RN was unaware the bruise met the abuse policy definition for injury of unknown origin, and the DNS confirmed the investigation lacked staff interviews and that the bruise was of unknown origin.
Failure to thoroughly investigate an unexplained facial bruise: A resident with dementia, lupus, COPD, peripheral vascular disease, and fragile skin developed a 3 cm by 3 cm bruise on the face during care, and the resident could not explain how it occurred. Staff noted the injury, notified the APRN and family, but the incident file lacked additional investigative documents, and interviews confirmed the bruise was unusual, potentially suspicious, and not fully investigated as an injury of unknown origin.
Failure to care plan for dementia: A resident admitted with dementia and moderately impaired cognition had an RCP that addressed depression and facility orientation, but it did not include the dementia diagnosis or dementia-related interventions. Later psychiatric evaluation found significant cognitive problems consistent with unspecified dementia, and the DON stated she expected specific dementia interventions in the care plan but could not explain why they were not included.
Medication Omission and Failure to Notify for Unavailable Ordered Medications: A resident with Parkinson’s disease, stroke, depression, and cancer missed multiple scheduled doses of ordered meds, including Droxidopa, Amlodipine, and Sertraline, because they were not available. MAR review showed repeated omissions, and progress notes did not document timely notification of the pharmacy, MD/APRN, or the resident’s representative when the meds were unavailable. During observation, an LPN stated some meds were not available, and the DON later identified the omissions as medication errors.
Failure to complete annual performance reviews for three nurse aides was identified. Personnel file review and HR interview showed the aides lacked documentation of annual evaluations for 2024 and 2025, despite being active on the nursing staff contact list. The DON was responsible for ensuring reviews were completed, and the facility policy required formal evaluations within 60 working days and at least annually.
Administrative Oversight and Infection Control Failures: Facility administration failed to effectively oversee staff and resident care, with survey findings showing missing water management planning, failure to prevent and mitigate Legionella in the water, delayed reporting of reportable events, incomplete injury investigations, medication timing and narcotic audit failures, missing Nurse Aide training and evaluations, delayed care plan review, unsanitary kitchen conditions, an incomplete infection control program including antibiotic stewardship, missed immunization education/offers, and late MDS completion/transmission. Immediate jeopardy was identified in infection prevention and control, and the Administrator acknowledged the facility lacked a water management plan and was unaware of abnormal annual water testing results.
Failure to Track Antibiotic Use and Infection Trends: The facility failed to maintain a facility-wide system to monitor antibiotic use, infection trends, or outcomes. The IP stated there was no current or complete tracking of antibiotic use, no active line list, no infection logs, and no statistical reports, even though the facility had 28 pneumonia cases during the review period. The APRN reviewed culture and sensitivity reports and used McGeer's criteria for prescribing, but the information was not tracked, and the only line list provided was a master list for Flu/COVID testing.
Failure to Offer and Document Vaccination Consent/Declination: A resident with intact cognition and another resident with chronic pain, arthritis, and insomnia had pneumococcal vaccine history documented, but the chart did not show they were offered the vaccine on admission, which pneumococcal product was given, or that consent or declination was obtained. A third resident with progressive lung disease, lung cancer, and HTN also lacked documentation that pneumococcal and influenza vaccines were offered or declined on admission. The IP RN stated she was responsible for ensuring residents were offered these vaccines on admission.
Nurses were found to lack up-to-date competencies in IV therapy, with the last review conducted several months ago. The Staff Educator, who is responsible for annual IV competency assessments, was unaware of the outdated status until mid-year and had not received the necessary training. The DON acknowledged the issue.
The facility failed to discard expired food in the kitchen, including cans of beets, corn, and boxes of chickpea rotini. The Director of Dining Services, responsible for monthly checks, could not explain the oversight, despite facility policy requiring proper dating and rotation of food.
The facility failed to ensure that therapeutic and resident pets were up to date with vaccinations and veterinary visits as per facility policy. One of the facility cats had outdated vaccinations and wellness exams, and a resident's pet cat lacked evidence of a distemper vaccine. The facility's policies on pets and support animals were inconsistent with actual practices, leading to deficiencies in pet care and documentation.
The facility failed to ensure a dignified dining experience for eight residents by serving meals on dietary trays instead of placing food and drink items on the dining table. A nurse aide cited mess containment as the reason, while the ADNS confirmed this practice was against facility policy.
A facility failed to ensure an updated code status form was signed by both a resident and physician, reflecting a change from full code to DNR. The resident's consent was not documented, violating the facility's policy and the resident's rights.
A resident with type II diabetes mellitus and heart failure refused the prescribed dose of insulin, opting for a lower dose without notifying the physician. The incident was not reported to the evening/night shift supervisor or the physician, leading to delayed medical intervention and fluctuating blood sugar levels.
The facility failed to assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. The resident, who had cognitive impairments and was readmitted after hip surgery, had siderails in place at night per family request. The facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use.
The facility failed to complete timely comprehensive assessments for two residents who experienced significant changes in condition, including the development of pressure ulcers and substantial weight loss. The MDS Coordinator did not perform the required significant change MDS assessments, leading to a deficiency in care.
The facility failed to complete quarterly MDS assessments for four residents in a timely manner. The MDS Coordinator, an LPN, cited being the sole staff member in the MDS office as the reason for the delays, which ranged from 28 to 57 days past due.
The facility failed to submit MDS assessments timely for four residents. An LPN responsible for the assessments was unable to meet the required timeframes due to being the only staff member in the MDS office.
The facility failed to ensure a comprehensive and individualized care plan for a resident with type II diabetes and heart failure. Despite the care plan indicating the use of alarms for fall risk, observations and staff interviews confirmed that no alarms were ever in place.
The facility failed to revise care plans for two residents after multiple falls and for another resident who frequently refused a daily treatment. Despite several incidents and refusals, the care plans were not updated with new interventions to prevent further falls or address treatment refusals. Interviews with staff confirmed that the care plans should have been updated but were not.
A resident with a history of falls experienced multiple unwitnessed falls, and the facility failed to complete the required neurological checks as per policy. The DNS confirmed that staff did not document any refusals for the missed checks, indicating a lapse in adherence to the neuro-check policy.
The facility failed to document the turning and repositioning of a resident at risk for pressure ulcers, leading to the development and progression of multiple pressure ulcers. The resident's care plan included interventions for pressure ulcer prevention, but the clinical record lacked documentation of these actions. Interviews confirmed the absence of documentation and identified issues with the facility's software.
The facility failed to ensure safety checks for a resident's alarm and did not complete fall assessments after multiple falls for another resident, contrary to their policies. This led to unaddressed safety risks and potential harm.
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. The resident, diagnosed with anxiety disorder and depression, was prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended a 'stop' date, but there was no documented provider response until after surveyor inquiry, contrary to facility policy.
A resident's medications were administered 30 minutes late, exceeding the facility's allowed time frame. The LPN responsible cited the difficulty of safely administering medications to 30 residents within the given time.
A resident with type II diabetes mellitus refused the prescribed dose of insulin and was administered a reduced dose by an LPN without notifying the supervisor or physician, leading to a significant medication error. Subsequent elevated blood sugar readings were recorded, and the facility's policy on reporting medication errors was not followed.
The facility failed to ensure clinical records were complete and accurate for a resident with dementia, anxiety, and depressive episodes. A pharmacy review recommendation was missing, and there was no evidence it had been addressed by the physician, contrary to the facility's policy.
The facility failed to ensure the Medical Director attended QAPI meetings quarterly. Despite being listed as a required member, there was no evidence of the Medical Director's attendance at any QAPI meetings from January 2023 through March 2024. The DNS acknowledged the requirement but noted the Medical Director might not have been able to attend. Attempts to contact the Medical Director were unsuccessful.
The facility failed to ensure infection control policies and procedures were reviewed annually. A review of the Infection Control Program revealed no documented evidence of an annual review, and the DON confirmed that such a review was never required. The facility was also unable to provide a policy for the review of policies and procedures when requested.
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby. Observations noted the missing census, and interviews revealed confusion between the receptionist and the scheduler regarding responsibility for filling in the census. The DNS and the scheduler were working on revising the procedure.
Failure to Treat a Resident With Dignity Following a Fall
Penalty
Summary
A resident with dementia, severe cognitive impairment (BIMS score of 4), dependence for personal hygiene, bed mobility, and transfers, and an indwelling urinary catheter was care planned as being at risk for falls and requiring contact guard assist of two for transfers, with staff directed to anticipate the resident’s needs. On the evening in question, the resident was seated in a wheelchair near the nurse’s station due to fidgeting and repeatedly leaning forward. Nursing assistant (NA) #1, who was assigned to the resident, reported that the resident continued to lean forward despite her directions. NA #1 stated she went behind the resident to attempt to reposition the resident in the wheelchair without calling for assistance, even though she felt the resident was too big for her to reposition alone. The resident then leaned too far forward and fell from the wheelchair onto the floor. Multiple staff accounts and facility documentation indicated that NA #1 made disrespectful comments and laughed in connection with the fall. According to a reportable event and the DON’s interview, RN #1 heard NA #1 say to the resident, "If you keep leaning forward, I'm going to let you fall," followed by a loud noise, after which RN #1 observed the resident on the floor and NA #1 in a reclined position with her feet elevated, not appearing to have attempted to prevent the fall. RN #1 further reported that NA #1 laughed after the incident and told the resident, "I hope you learned your lesson," while another NA responded that it was not funny. NA #2 and NA #3 each reported observing the resident on the floor and NA #1 laughing, and both stated they told NA #1 that laughing or making fun of the situation did not help. The DON stated that the comments and laughing at the resident after the fall were disrespectful and not an appropriate way to respond, in contrast to the facility’s Resident Rights policy, which states that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Timely Report Allegation of Verbal Mistreatment After Resident Fall
Penalty
Summary
Staff failed to timely report an allegation of mistreatment involving a cognitively impaired resident with dementia who was dependent for ADLs, including personal hygiene, bed mobility, transfers, and had an indwelling urinary catheter. The resident’s care plan identified a risk for falls and the need for contact guard assist of two for transfers, with interventions to anticipate the resident’s needs. On the evening in question, the 3–11 PM RN supervisor heard a nursing assistant tell the resident, "If you keep leaning forward, I am going to let you fall," followed by a loud noise. The RN then observed the resident on the floor and the nursing assistant laughing. Other nursing assistants also observed the same nursing assistant laughing at the resident after the fall and reported their concerns to the RN supervisor. The resident later had no recollection of the events leading up to the fall or the interaction with staff after the fall. The deficiency centers on the failure to immediately report this allegation of verbal mistreatment and potential abuse to facility leadership as required by policy. The RN supervisor did not notify the DON at the time of the incident and instead sent an email that was not received by the DON until approximately 11.5 hours later the following morning. The facility’s abuse policy required that reports of alleged abuse be immediately reported to the DON, ADON, Administrator, and/or supervisor, and defined verbal abuse as oral, written, or gestured language that willfully includes disparaging or derogatory terms, including threats of harm or statements intended to frighten a resident. The DON confirmed that the allegation should have been reported immediately and that she did not know why the RN supervisor failed to do so.
Failure to Provide Safe Two-Person Repositioning and Supervision Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe repositioning and adequate supervision to prevent a fall for a resident with dementia and severe cognitive impairment. The resident’s care plan identified a risk for falls, dependence in ADLs, and the need for contact guard assist of two staff for transfers. A subsequent MDS confirmed the resident was dependent for bed mobility, transfers, and personal hygiene, and had a Foley catheter in place. The resident was of substantial size and required two staff for safe repositioning when leaning forward in a wheelchair. On the evening of the incident, the resident was seated in a wheelchair at the nurse’s station due to fidgeting and repeated leaning forward and sliding in the chair, reportedly focusing on the Foley catheter. NA #1, who was assigned to the resident, was seated next to the resident and repeatedly attempted verbal redirection, instructing the resident to sit back and sit up. Despite knowing the resident required two-person assistance for repositioning when leaning too far forward and not responding to directions, NA #1 did not request help from other staff before attempting to reposition the resident alone. NA #1 moved behind the resident and tried to pull the resident back in the wheelchair while attempting to hold the resident up, but the resident was too heavy to manage alone and fell forward and to the left, striking their head on a door. RN #1, who was nearby, reported hearing NA #1 say to the resident, "If you keep leaning forward, I'm going to let you fall," followed by a loud noise and then observing the resident on the floor. RN #1 and other NAs reported that NA #1 laughed after the fall and made a comment to the resident, and that NA #1 had been in a reclined position with feet elevated after the fall. Facility staff interviews and documentation confirmed that NA #1 did not seek assistance prior to attempting to reposition the resident, despite the resident’s assessed need for two-person assistance and the facility’s fall prevention policy to provide a safe environment by addressing fall risk factors.
Failure to Document RN Assessment Following Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and accurate clinical record by not documenting an RN assessment after a resident fall. The resident had dementia and was care planned as being at risk for falls, requiring assistance with ADLs and contact guard assist of two staff for transfers. A significant change MDS showed severe cognitive impairment (BIMS score of 4), dependence for personal hygiene, bed mobility, transfers, and the presence of a Foley catheter, with a height of 67 inches and weight of 199 pounds. On the date of the incident, the resident was seated at the nurse’s station with a nursing assistant (NA) due to fidgeting behaviors and was observed sliding forward and leaning in the wheelchair. According to the facility’s reportable event documentation and interviews, the NA told the resident, “If you keep leaning forward, I am going to let you fall,” and then attempted to reposition the resident without obtaining the required additional staff assistance, during which the resident fell forward and to the left, striking a door headfirst. The RN heard the NA’s comment, then a loud noise, and found the resident on the floor. Facility documentation indicated that an RN assessment was completed and no injuries were identified, but the Director of Nursing confirmed that although the RN performed the assessment, it was not documented in the medical record. This failure to document occurred despite a facility nursing documentation policy directing that nursing documentation must reflect the resident’s assessment.
Failure to Develop and Implement Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to develop and implement a water management plan to prevent, identify, and mitigate Legionella contamination in the water system. During survey review, the facility did not provide a water management plan, and the Director of Physical Plant stated the facility did not have one and was not aware that one was required. He also stated he was responsible for reviewing water sample results, but when June 2024 and June 2025 laboratory reports showed positive Legionella findings, he believed the results were not significant and took no action. Water sampling reports showed positive Legionella findings in multiple locations. The June 2024 report identified Legionella non-pneumophila in the Exam Room at 2 CFU/mL and Legionella pneumophila serogroups 1-14 in the Chapel at 96 CFU/mL. The June 2025 report identified Legionella non-pneumophila in the Dining Room at 62.5 CFU/mL and Legionella pneumophila serogroups 1-14 in the Chapel at 148.5 CFU/mL. The Administrator stated he was not aware the annual water testing results were abnormal, and the Director of Physical Plant stated he assumed the laboratory would notify him if Legionella was present. The Infection Preventionist stated she was not aware of the positive water samples, and the Medical Director stated he was not aware the facility water samples were positive for Legionella or that the facility lacked a water management plan. The Medical Director also stated he would have expected the facility to have a water management plan in place. Review of facility documentation showed 26 residents had pneumonia from 6/1/26 through 2/26/26, and the Medical Director later stated any resident with respiratory symptoms would be tested for Legionella using a urine antigen test.
Failure to Follow Two-Person Transfer Assistance Plan
Penalty
Summary
The facility failed to ensure Resident #27 received the level of assistance identified in the care plan to prevent accidents when staff provided only one-person assistance during a transfer despite the resident's assessed need for two-person assistance. Resident #27 had diagnoses including a stroke with memory, speech, and language deficits, dementia, and abnormalities of gait and mobility. The quarterly MDS identified moderately impaired cognition, dependence for toileting and showering, and maximum assistance needed for personal hygiene, dressing, and transfers. The resident's care plan and caregiver training record both directed that two staff assist with transfers using a rolling walker, and therapy staff had educated nursing staff on that transfer status. On the morning of the incident, NA #1 assisted Resident #27 to stand from the bed and pull up pants without another staff member present. While the aide was reaching for the wheelchair and handling the resident, the resident lost balance, tilted to the right, and fell into the wall near the doorway, striking the right side of the forehead and appearing to land on the right shoulder. The nurse who responded documented that the resident did not lose consciousness and initially denied head or shoulder pain, with range of motion and strength noted as intact. The aide's written statement described the same sequence of events, including that the resident fell to the right after the aide stepped behind the resident to get the wheelchair. After the fall, the resident developed right shoulder pain and later had swelling and firmness to the right shoulder. An X-ray was ordered and the radiology report identified a right clavicle fracture. The resident was then documented as non-weight bearing with a sling and requiring two staff for ADLs and transfers using a mechanical lift. Interviews with therapy and nursing leadership confirmed that, before the fall, the resident required two staff for transfers and standing, that therapy had educated nursing staff on the transfer status, and that NA #1 did not follow the plan of care during the transfer.
Failure to Provide Bed Hold Notices and Monthly Ombudsman Discharge Notifications
Penalty
Summary
The facility failed to ensure that Resident #97, a long-term care resident with diagnoses including heart failure, dementia, and pneumonia and with severely impaired cognition, was provided written bed hold information at the time of hospital transfer. On 2/2/25, the resident had a fever, oxygen saturation of 73% on room air, pale skin, and rhonchi in the left lung, was placed on oxygen, and was transferred by ambulance to the hospital. Review of the nurse's notes and social work notes from that transfer period did not show documentation that the resident or the resident's representative received the Bed Hold Policy. The resident was readmitted on 2/5/25. The same issue occurred again when Resident #97 was transferred to the hospital on 6/10/25 for evaluation and treatment after a physician ordered transfer to the emergency room. The nurse's notes identified the resident was admitted to the hospital with pneumonia, but review of the nursing and social work documentation from that transfer period again failed to show that the resident or representative was given the Bed Hold Policy. During interviews, RN #1 stated she did not provide the bed hold notice at transfer and believed social work was responsible, while the DNS stated the supervisor was responsible for completing the paperwork and providing the notice but could not explain why it was not done. The facility also failed to notify the ombudsman of resident discharges at least monthly. SW #1 stated she was responsible for sending the monthly report through the portal but acknowledged she had not been updating the ombudsman's office monthly and had been doing it every few months. The Ombudsman Monthly Notification Report showed resident discharge information was transmitted in batches covering multiple months rather than monthly. The facility's policy stated that the charge nurse or shift supervisor would complete the emergency transfer and bed hold forms and provide the original to the resident or family member, but the ombudsman notification of discharges policy was not provided.
Late and Incomplete MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive resident assessments within 14 days after admission and at least annually for five residents reviewed for assessment compliance. Resident #4, admitted with diagnoses including a right artificial knee joint, age-related cognitive decline, diabetes mellitus, and hypertension, had a 5-day MDS assessment with an ARD of 9/9/2025 that was not completed and submitted until 2/2/2026, 185 days late. Resident #47, admitted with dementia and heart failure, had an admission 5-day MDS with an ARD of 12/8/2025 that was documented completed on 2/19/2026 and submitted on 2/20/2026, 123 days late. Resident #58, admitted with cancer of the digestive system and chronic pain, had an admission MDS with an ARD of 9/18/2025 that was still in process and not yet completed as of 2/26/2026, 55 days late. Resident #68, admitted with heart failure, chronic kidney disease, and arthritis, had an annual MDS with an ARD of 9/12/2025 that was completed and submitted on 11/14/2025, 59 days late. Resident #79, admitted with dementia, heart failure, and arthritis, had an admission MDS with an ARD of 10/31/2025 that was identified as finalized, but the medical record showed it was not signed as completed and remained 112 days late as of 2/26/2026. The MDS coordinator stated she was responsible for coordinating MDS submissions according to CMS requirements and acknowledged that most of the identified residents' MDS assessments had not been completed or submitted. The facility policy directed that a comprehensive, accurate assessment be completed within 14 days for admission and that quarterly and annual assessments be completed on schedule.
Delayed Quarterly MDS Assessments
Penalty
Summary
Quarterly MDS assessments were not completed timely for six of fifteen residents reviewed for resident assessment. Resident #3 had diagnoses including stroke and COPD, and the quarterly MDS with an ARD of 12/23/2025 was still in process and had not been completed as of 2/26/2026; the last submitted quarterly MDS had an ARD of 9/24/2025. Resident #4, with diagnoses including a right artificial knee joint, age-related cognitive decline, diabetes mellitus, and hypertension, had a quarterly MDS with an ARD of 11/26/2025 that was still in process and had been completed as of 2/26/2026, with the last submitted quarterly MDS dated 9/9/2025. Resident #27, diagnosed with displaced fracture of the left femur, dysphagia, and stroke, had a quarterly MDS with an ARD of 11/28/2025 that was still in process and not completed as of 2/26/2026, and the last submitted quarterly MDS had an ARD of 9/25/2025. Resident #32, with diagnoses including displaced fracture of the left femur and stroke, had a quarterly MDS with an ARD of 11/03/2025 that was still in process and not completed as of 2/26/2026; the last submitted comprehensive 5-day MDS had an ARD of 10/22/2025. Resident #68, diagnosed with heart failure, chronic kidney disease, and arthritis, had a quarterly MDS with an ARD of 12/11/2025 that was still in process and not completed as of 2/26/2026, with the last submitted annual MDS dated 9/12/2025. Resident #75, with diagnoses including diabetes mellitus, surgical aftercare following mouth surgery, and hypertension, had one quarterly MDS with an ARD of 8/29/2025 completed on 11/14/2025 and another quarterly MDS with an ARD of 11/28/2025 that was still in process and not completed as of 2/26/2026; the last submitted quarterly MDS had an ARD of 8/29/2025. The MDS coordinator stated she was responsible for coordinating MDS submissions according to CMS requirements and acknowledged that most of the identified residents' MDS assessments had not been completed or submitted. The facility policy directed that a comprehensive, accurate assessment be completed for each resident within 14 days for admission, quarterly, and comprehensive assessments, and that quarterly updates be completed every 92 days from admission and annual updates every 365 days from the comprehensive.
Late and Incomplete MDS Assessments
Penalty
Summary
The facility failed to complete and transmit MDS assessments timely for six residents reviewed for resident assessment. Resident #21, admitted with heart failure and atrial fibrillation, had a discharge MDS with an ARD of 9/20/2025 that remained in process and incomplete during the survey on 2/26/2026, even though the resident had been discharged on 9/25/2025 and had not resided in the facility for over five months. Resident #24, admitted with rhabdomyolysis and dysphagia, also had a discharge MDS with an ARD of 9/20/2025 that was still in process and incomplete during the survey, despite discharge on 9/20/2025. Resident #36, admitted with endocarditis and heart failure, had an MDS with an ARD of 9/16/2025 that was completed on 2/19/2026 and submitted on 2/20/2026, 143 days late. Resident #73, admitted with joint replacement surgery and bipolar disorder, had a discharge MDS with an ARD of 11/23/2025 that was still in process and incomplete during the survey. Resident #79, admitted with dementia, heart failure, and arthritis, had a death-in-facility MDS with an ARD of 1/2/2026 that was marked finalized on the status report, but the medical record review on 2/26/2026 showed it had not yet been signed as completed. Resident #87, admitted with diabetes mellitus, asthma, and hypertension, had a discharge MDS with an ARD of 9/24/2025 that remained in process and not completed as of the survey date. The MDS coordinator stated she was responsible for coordinating submissions according to CMS requirements and acknowledged that most of the identified residents' MDS assessments had not been completed or submitted.
Failure to Reconcile Controlled Substances
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to implement a system to consistently and accurately reconcile controlled substances for 2 of 2 medication carts. The facility was unable to provide monthly or bi-monthly controlled substance audits for January 2026 or February 2026 and stated that any prior audits could not be located at the time of survey. The DNS, interviewed on 2/27/2026 at 10:15 AM, stated she had not reconciled any controlled substances or conducted audits since starting 3 1/2 months earlier and could not locate any bi-monthly audits from the past year. She described the process as counting controlled substances in the two medication carts and comparing the count to the controlled substance disposition record (CSDR), and stated the pharmacy had emailed audit tools for reconciliation and auditing. The DNS also stated that without these audits, the facility could not verify the accuracy of its controlled substances inventory, and she could not explain why the audits had not been completed. A facility Controlled Substance Reconciliation and Audit policy was not provided.
Unlabeled, Undated, and Expired Food Found in Dietary and Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure stored food was labeled and dated when opened, expired food was discarded, and nourishment refrigerators were maintained in a clean sanitary manner. During a tour of the Dietary Department, surveyors observed multiple items in Refrigerator #1 that were not labeled or dated, including a hard plastic cup with a lid that was dated but not labeled and was expired, a large pitcher of brown liquid covered with saran wrap that was not labeled or dated, and another large pitcher of brown liquid that was not covered, labeled, or dated. Refrigerator #2 contained two cups of yellow liquid and one cup of red liquid that were not labeled or dated. Refrigerator #3 contained two large gallon-sized containers with what appeared to be peaches and pears that were covered with saran wrap but were not labeled or dated and were expired. The dietary staff member interviewed stated all food items are required to be labeled and dated, opened food must be discarded after 3 days, and dietary staff are responsible for discarding items that exceed the 3-day limit. A subsequent tour of the nourishment rooms with the DOD identified additional unlabeled, undated, and partially used food and drink items in nourishment refrigerator #1 and nourishment refrigerator #2. These included a partially eaten yogurt container, an opened partially eaten chocolate pudding container, three partially used loaves of bread, an opened can of soda, a half-full glass bottle of coconut milk, cut cantaloupe, a bag of dried cranberries or raisins, mixed fruit, an English muffin, a candy bar, and a paper cup with frozen yellow liquid. The bottoms of the nourishment refrigerator drawers and freezer shelves contained dried spilled liquids, food crumbs, and dried brown liquid. The DOD stated she was responsible daily for cleaning and maintaining the nourishment refrigerators and checking that items are labeled and dated, but she had been off for the last 3 days and could not explain why the items were not covered, labeled, or dated. Facility policy stated food storage areas shall always be clean, all food must be dated when opened and stored, and outdated items are to be removed.
Failure to Provide Required Annual Nurse Aide In-Service Education
Penalty
Summary
The facility failed to ensure that nurse aide #1 received the required annual in-service education. Review of facility documentation and interview with the infection control/staff development nurse identified that all nurse aides were required to receive a minimum of 12 hours of in-service education each year, but no in-service education documentation could be located for nurse aide #1 for 2024 or 2025. The nurse aide’s education file lacked documentation of education, and the only educational documents located for the nurse aide were from 2016. During interview, the infection control/staff development nurse stated she should have ensured that all nurse aides received the minimum 12 hours annually and reported that she had emailed the DNS that nurse aide #1 had not completed the 12-hour requirement each year. The DNS stated she was unaware that nurse aide #1 had not completed the required education, although the expectation was that all nurse aides should have a minimum of 12 hours of education annually. The facility policy required annual in-service credit and included mandatory topics such as infection control, abuse and neglect prevention, dementia care, and other resident care subjects, and the facility assessment also directed that required in-service education include dementia training, resident abuse prevention training, cultural competence, identification of changes in condition, and services to residents with cognitive impairments.
Advance Directive Education and Code Status Wishes Not Documented
Penalty
Summary
The facility failed to ensure that residents or their resident representatives were educated about advance directives and that their wishes were identified and documented for 2 of 2 sampled residents reviewed for advance directives. Resident #27 had diagnoses including stroke with memory, speech, and language deficits and dementia. The record showed the resident was admitted and later re-admitted with confusion, and the resident’s representative was present at the bedside. However, the nurse’s notes and social worker notes did not document that the representative was provided education on advance directives, and the code status form was not signed by the resident or the representative to identify their wishes. For Resident #27, a physician note directed DNR, and an Advance Directives Consent Form showed the DNR box checked and signed by RN #10 and MD #1, with verbal consent noted from the representative. The form was not signed by Resident #27 or the representative. The record also showed a physician order that the DNR must be renewed annually, an APRN note stating the resident was DNR per chart documentation, and a significant change MDS identifying moderately impaired cognition. The RCP directed staff to review code status and advance directives, but the nurse’s notes and social worker notes still did not show documentation that the representative received advance directive education or that the code status form was signed by the resident or representative. Resident #104 was admitted with diagnoses including dementia, heart failure, and depression, and the quarterly MDS identified severely impaired cognition. The RCP failed to identify a code status or wishes for code status. The Advance Directives Consent Form documented verbal consent from the representative, but the form was not signed, and the physician’s and APRN notes did not show that the representative was contacted and educated about code status or that the resident’s wishes were identified. A physician order later directed DNR, DNI, and RN pronouncement. During interview, staff stated the code status and advance directive form must be signed within 24 hours of admission or re-admission, that the APRN or physician is responsible for educating the resident or representative about CPR versus DNR, and that the resident’s representative should sign the form; however, the record for Resident #104 did not reflect that process was completed.
Failure to Notify Physician and Resident Representative of Missed Medications
Penalty
Summary
The facility failed to ensure the physician and the resident’s representative were notified when ordered medications were omitted for a resident with diagnoses including stroke, Parkinson’s disease, depression, and cancer. The resident’s care plan identified Parkinson’s disease and directed staff to monitor for related symptoms and notify the physician if changes occurred. The physician’s orders included multiple scheduled medications, including Amlodipine, Droxidopa, and Sertraline, and the quarterly MDS indicated the resident had intact cognition and required maximum assistance with toileting, dressing, and personal hygiene. Review of the eMAR showed multiple omitted doses between 2/17/26 and 2/26/26, including Amlodipine documented as not available and not administered, Droxidopa documented as not available and not administered on several scheduled doses, and Sertraline documented as not available and not administered. Nursing progress notes did not show documentation that the pharmacy, physician, or resident’s representative were notified when the medications were unavailable and not given in accordance with orders. During observation of medication administration, an LPN stated that some of the resident’s Droxidopa was not available and that she had notified the supervisor a couple of days earlier. The RN later documented that the pharmacy was contacted and that the physician was notified the resident had missed 12 doses of Droxidopa, 2 doses of Amlodipine, and 1 dose of Sertraline, and that the resident’s representative was notified. The DNS stated she was not aware the resident had not received Parkinson’s medication since 2/22/26 and had missed 12 doses, and stated the nurse or supervisor should have notified the pharmacy, physician, and resident’s representative when the medications were unavailable. The physician stated he was not aware the medications were not administered and would have expected to be notified.
Failure to Report an Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin after a bruise was found on Resident #10’s right face near the chin line. Resident #10 had diagnoses including dementia, COPD, lupus, and peripheral vascular disease, and the record identified fragile skin related to long-term steroid use. The resident’s significant change MDS showed moderately impaired cognition, substantial assistance needed for transfers, and dependence on staff for wheelchair mobility. During care, staff observed a 3 cm by 3 cm facial bruise, and Resident #10 stated that he/she did not know how it happened. The incident record identified the bruise as occurring without a known cause, and the APRN was notified. The investigation form completed by RN #4 listed Eliquis as a causative factor, but the actual cause remained unknown. Additional investigative documents were not included in the incident file. Nursing notes later described the bruise as stable and resolving, with intact skin and no swelling, and the resident reported no pain. Interviews showed that the APRN could not recall being informed of the facial bruise and stated that a bruise on the face or one measuring 3 cm by 3 cm would be unusual and potentially suspicious. RN #1 stated she was unaware that a bruise of unknown origin was defined in the facility abuse policy, and the DNS stated the investigation lacked staff interviews and that the bruise was of unknown origin. The facility abuse policy defined suspicious or unexplained bruising as abuse-related and included injury of unknown origin when the source could not be observed or explained by the resident, with a state report initiated based on the investigation results.
Failure to Thoroughly Investigate an Unexplained Facial Bruise
Penalty
Summary
The facility failed to complete a thorough investigation for Resident #10’s injury of unknown origin when a bruise was found on the right side of the face near the chin line. Resident #10 had diagnoses including dementia, COPD, lupus, and peripheral vascular disease, and was identified as having fragile skin related to long-term steroid use. The resident’s cognitive status was moderately impaired, with a BIMS score of 11, and the resident required substantial assistance for transfers and was dependent on staff for wheelchair mobility. During care, staff observed the facial bruise, which measured 3 cm by 3 cm, and Resident #10 stated that he/she did not know how it happened. The incident report identified Eliquis as a causative factor, but the actual cause remained unknown. The APRN was notified, and the family was notified later that morning, but no additional investigative documents were included in the incident file. Interviews with the APRN, RN #1, the DNS, and RN #4 showed that the bruise was considered unusual and potentially suspicious, yet the facility did not complete a thorough investigation. The DNS stated the investigation lacked staff interviews and that the injury was determined to be of unknown origin. Facility abuse policy defined suspicious or unexplained bruising as a sign of abuse and included injuries of unknown origin when the source could not be explained by the resident.
Failure to Care Plan for Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with dementia. The resident was admitted with diagnoses that included dementia, age-related cognitive decline, diabetes mellitus, hypertension, and a right artificial knee joint. The admission orders and nursing admission note identified dementia, and the admission MDS with an ARD of 8/28/25 showed a BIMS score of 8, indicating moderately impaired cognition, along with an active diagnosis of non-Alzheimer's dementia. The resident's RCP dated 9/3/25 addressed the resident as newly admitted with depression and included interventions to orient the resident to the facility and provide psychiatric services as needed, but it did not include the diagnosis of dementia or interventions related to dementia needs. APRN #2 later evaluated the resident for depression and cognitive decline and found significant cognitive problems consistent with unspecified dementia without behavioral disturbances. The DON stated that when a resident has a diagnosis of dementia, the care plan should include specific interventions to address those needs, but she could not explain why a comprehensive care plan was not implemented for the resident's dementia.
Medication Omission and Failure to Notify for Unavailable Ordered Medications
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for a resident with diagnoses including stroke, Parkinson’s disease, depression, and cancer. The resident’s care plan identified Parkinson’s disease and directed staff to monitor for signs and symptoms such as shuffling gait, tremors, lip smacking, loss of voluntary movements, blank facial expressions, drooling, difficulty swallowing, weakness, fatigue, and stiffness, with notification to the physician if changes occurred. The physician’s orders included multiple scheduled medications, including Amlodipine, Droxidopa, and Sertraline. Review of the electronic MAR showed multiple omitted doses. Amlodipine was documented as not available and not administered on 2 occasions, Droxidopa was documented as not available and not administered for multiple scheduled doses over several days, and Sertraline was documented as not available and not administered on one occasion. Nursing progress notes did not provide documentation that the pharmacy, physician, or the resident’s representative were notified when the medications were unavailable and not given in accordance with orders. During observation of medication administration, an LPN stated that Sertraline and Droxidopa were not available and that she had notified the supervisor a couple of days earlier that Droxidopa was unavailable. RN #1 later documented that the pharmacy was contacted, medications were ordered, and the physician and resident’s representative were notified after surveyor inquiry. The DNS stated she was not aware the resident had missed multiple doses of Droxidopa and other medications, and identified the omission of a medication as a medication error. The facility’s medication error and medication administration policies required ordered medications to be administered and required notification of the supervisor, physician/APRN, resident’s representative, and DNS when medications were unavailable.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three nurse aides, NA #1, NA #2, and NA #3, as required by facility policy. Review of personnel files showed NA #1 had a hire date of 11/14/2008, NA #2 had a hire date of 7/6/1992, and NA #3 had a hire date of 7/17/2001, and all three were listed on the current nursing staff contact list. The Administrator stated the Director of Nursing was responsible for ensuring annual performance reviews were completed and was not surprised the three nurse aides had not received recent reviews because of a recent transition in the DNS position. The Human Resources Director confirmed that NA #1, NA #2, and NA #3 lacked documentation of annual evaluations for 2024 and 2025. The facility Performance Appraisals policy required the employee's supervisor to formally evaluate job performance before the end of sixty working days and then at least annually.
Administrative Oversight and Infection Control Failures
Penalty
Summary
The facility administration failed to administer its resources effectively and to provide effective administrative oversight of staff and resident care in a timely manner. Survey findings identified multiple failures, including not developing and implementing a water management plan, not preventing and mitigating Legionella growth in the facility's water, not ensuring timely notification to the State Agency of reportable events, not investigating injuries of unknown origin timely and thoroughly, not ensuring medications were administered timely and according to professional standards, not completing bimonthly narcotic audits, not completing required Nurse Aide in-service training and evaluations, not reviewing and updating care plans in a timely manner, not maintaining the kitchen in a sanitary condition, not maintaining a comprehensive infection control program that included an antibiotic stewardship program, not ensuring residents were educated and offered Influenza and Pneumococcal immunizations, and not completing and transmitting MDS comprehensive assessments as required by CMS. The report states that immediate jeopardy was identified in infection prevention and control. During interview, the Administrator stated he had been employed at the facility since 2018 and acknowledged the facility did not have a water management plan because he was not aware one was required. He also stated that although the Director of Physical Plant shared the last annual water testing results, he was not aware the results were abnormal. The Administrator job description identified responsibility for planning, organizing, developing, directing, controlling, and supervising the general operations of the facility in accordance with applicable laws, regulations, standards, and guidelines, and for ensuring the highest degree of quality resident life is maintained.
Failure to Track Antibiotic Use and Infection Trends
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program included a process for tracking antibiotic use, protocols, trends, and outcomes, and failed to develop, promote, and implement a facility-wide system to monitor antibiotic use. During interviews, the Infection Preventionist stated the facility did not maintain current or complete tracking of antibiotic use, had not implemented antibiotic stewardship principles to reduce adverse events from unnecessary or inappropriate antibiotic use, and did not have a facility-wide system to monitor antibiotic use. She also stated that the facility used a 3-day urine protocol, but no other tracking logs existed for that protocol, and that no additional tracking of antibiotic use occurred. The Infection Preventionist further stated that the APRN reviewed culture and sensitivity reports to confirm prescribed antibiotics targeted identified bacteria, but she did not maintain an active line list, infection log, statistical reports, or other records to track infections, monitor antibiotic use, assess appropriateness, or evaluate outcomes. She reported the facility had 28 cases of pneumonia from 6/1/25 through 2/26/26, but no logs or statistical reports were kept to identify infection trends or monitor antibiotic use. She also stated that one APRN used McGeer's criteria for antibiotic prescribing but did not track the information. The DON later provided only a master line list dated 12/28/25 listing 6 residents tested for Flu and Covid-19 in December 2025, and no other line lists or infection tracking were provided.
Failure to Offer and Document Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated and given the opportunity to consent to or decline pneumococcal vaccination for 3 of 5 residents reviewed for pneumococcal immunizations. Resident #9 was admitted with diagnoses including hypertension, stroke, and arthritis, and the quarterly MDS identified intact cognition and that the resident had received a pneumococcal vaccine. Although the immunization record showed a pneumococcal vaccine on 1/1/2018, the clinical record and consent records did not identify that the resident was offered the vaccine on admission, that the specific pneumococcal vaccine administered was documented, or that consent or declination was obtained. Resident #100 was admitted with chronic pain, arthritis, and insomnia, and the quarterly MDS identified intact cognition and no vaccine history listed; the immunization record showed a pneumococcal vaccine on 1/1/2018, but the clinical record and consent records did not identify that the resident was offered the vaccine on admission, which pneumococcal vaccine had been administered, or that consent or declination was obtained. Resident #26 was admitted with progressive lung disease, lung cancer, and hypertension, and the quarterly MDS identified intact cognition, that the pneumococcal vaccine was offered, and that the resident declined. However, the clinical record and consent records did not identify that the pneumococcal vaccine was offered or that a declination was obtained upon admission, and also did not identify that the influenza vaccine was offered or that a declination was obtained upon admission. A nurse note documented that the CT wiz immunization system was active for the resident and that no immunization history was documented. The Infection Preventionist stated she was responsible for ensuring residents were offered pneumococcal and influenza vaccines on admission and could not explain why these residents had not been educated and given an opportunity to consent or decline the vaccines.
Outdated IV Competencies Identified Among Nursing Staff
Penalty
Summary
The facility failed to ensure nurses were competent in intravenous (IV) therapy, as evidenced by outdated IV competencies last reviewed on 12/23/22. The Staff Educator, responsible for annual IV competency assessments, only became aware of the outdated competencies after July 2023 and had not received the necessary training herself. The Director of Nursing Services acknowledged the need for addressing the issue.
Expired Food Not Discarded
Penalty
Summary
The facility failed to ensure that expired food was discarded, as identified during a tour of the kitchen. In the dry storage room and the overflow dry storage room, 12 cans of beets, several cans of corn, and 3 boxes of chickpea rotini were found to be expired. The Director of Dining Services, who is responsible for checking food storage monthly for expiration dates, could not explain why the expired foods were not discarded. The facility's Dietary Services policy mandates that all food must be dated when opened and stored, with the most recent dates utilized first to prevent expiration.
Deficiency in Pet Care and Documentation
Penalty
Summary
The facility failed to ensure that the facility assessment included therapeutic facility pets and individualized resident pets to meet the needs of the residents. Specifically, the facility did not ensure that therapy pets were up to date with vaccinations and veterinary visits as per facility policy. During an interview and document review with the Director of Recreation, it was found that one of the two facility cats had outdated vaccinations and wellness exams. Cat #2 was overdue for its rabies vaccine and had not had a wellness exam since 2019. Additionally, there was no evidence of a distemper vaccine for Cat #2. The Director of Recreation indicated that an appointment had been scheduled for Cat #2 with the veterinarian on the day of the interview. Furthermore, Resident #58 had a pet cat (Cat #3) whose veterinary care was managed by the resident's family. Upon request, documentation for Cat #3 was provided, showing up-to-date rabies vaccination and wellness exam but no evidence of a distemper vaccine. The facility's policies on pets and support animals were reviewed and found to be inconsistent with the actual practices observed during the survey. The facility's Pet Policy and Agreement required that pet cats have current veterinary health records, including distemper and rabies shots. However, the facility's Service and Support Animal Policy indicated that support animals are not subject to the Pet Policy and Agreement but must have an annual clean bill of health and be immunized against common diseases. The Recreation policy indicated that the Recreation Director was responsible for the wellbeing, shots, and licenses of resident cats. The facility assessment did not mention services and care offered based on resident needs concerning support animals, despite providing care for residents with psychiatric/mood disorders. This lack of documentation and adherence to policies led to the identified deficiencies in the care and management of therapeutic and resident pets.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for eight residents during the noon meal service. Observations on 3/13/24 at 12:15 PM revealed that these residents were served their meals on dietary trays, with food and drink items remaining on the trays rather than being placed on the dining table. An interview with a nurse aide indicated that the trays were used to contain messes caused by residents spilling their food and drinks. However, the Assistant Director of Nursing Services (ADNS) confirmed that the facility's policy required food and drink items to be removed from the trays and set in front of the residents. The ADNS was unsure why the policy was not followed and planned to investigate the issue. The Dietary Services Policy dated 7/28/21 emphasized the importance of resident rights, choice, and quality of life in meal service.
Failure to Update Code Status Form with Required Signatures
Penalty
Summary
The facility failed to ensure that an updated code status form was signed by both the resident and the physician to reflect the resident's wishes and the physician's orders. Resident #57, who was admitted with diagnoses including venous insufficiency, urinary tract infection, and anxiety, had a signed Advanced Directive form indicating full code status. However, a subsequent physician's order directed Do Not Resuscitate (DNR) without evidence of the resident's consent to this change. The clinical record did not provide documentation that the resident agreed to the DNR status, which is a violation of the resident's rights to participate in their care decisions. During an interview, both a Registered Nurse and a Licensed Practical Nurse confirmed that the updated code status form was not signed by the resident or the physician to reflect the change from full code to DNR. The facility's policy requires that such decisions be consensually reached between the resident and the attending physician, and the nurse managers are responsible for ensuring the accuracy of these forms. The deficiency was identified when the surveyor inquired about the documentation, leading to the discovery that the required signatures were missing.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure the physician was notified of a medication refusal by Resident #52, who has diagnoses including type II diabetes mellitus and heart failure. The resident, who is cognitively intact and requires supervision for certain activities, refused the prescribed 6 units of Humalog insulin and insisted on receiving only 4 units. Despite patient teaching and encouragement to take the full dose, the resident's request was honored without notifying the physician or the evening/night shift supervisor. The incident was only reported to the day shift nurse manager the following morning, and no immediate action was taken to inform the physician or adjust the care plan accordingly. Interviews with the involved staff, including the LPN, RN, and APRN, revealed that the proper protocol for medication refusal was not followed. The Director of Nursing was unaware of the incident until the survey, and the facility's policy clearly states that changes in a resident's condition or medication should be reported timely to the physician or nurse practitioner. The failure to notify the physician of the medication refusal led to a delay in appropriate medical intervention, as evidenced by the resident's fluctuating blood sugar levels and the eventual administration of a higher insulin dose without prior notification to the on-call provider.
Failure to Assess and Obtain Consent for Use of Siderails as Restraints
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. Resident #40, who was readmitted after hip surgery and had cognitive impairments, was found to have full siderails in place at night per family request. However, the facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use. The care plan indicated the use of siderails but did not classify them as a restraint, and there was no evidence of ongoing monitoring or evaluation of the siderails' use. Interviews with staff revealed that the resident was unable to remove or adjust the siderails independently, confirming their status as a restraint. The facility's policy required a specific consent form for the use of restraints, but this form was not provided. Additionally, the facility's Side Rail Policy was requested but not supplied. The lack of proper assessment, consent, and documentation led to the deficiency identified by the surveyors.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to ensure a comprehensive resident assessment was completed timely after a significant change in condition was identified for two residents. Resident #47, who had a diagnosis including a fracture of the right femur and pressure ulcers, was found to have developed multiple new pressure ulcers and experienced a decline in the condition of an existing ulcer. Despite these significant changes, the MDS Coordinator did not complete a significant change MDS assessment as required by the Resident Assessment Instrument guidelines. The resident's condition, including the development of three pressure ulcers and likely weight loss, was not adequately monitored or reassessed in a timely manner. Similarly, Resident #38, who had diagnoses including dysphagia, dementia, and nutritional deficiency, experienced a significant weight loss over a short period. Despite a care plan that included monitoring weights and dietary interventions, the resident's weight continued to decline significantly. The MDS Coordinator acknowledged that a significant change MDS assessment should have been completed due to the resident's substantial weight loss, but it was not done. The facility's failure to complete these assessments in a timely manner represents a deficiency in their care processes.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments for four residents were completed in a timely manner. Resident #12's quarterly MDS assessment was 33 days late, Resident #32's was 57 days late, Resident #53's was 28 days late, and Resident #56's was 33 days late. The MDS Coordinator, an LPN, acknowledged the delays and attributed them to being the only staff member in the MDS office, which hindered their ability to keep up with the workload. The facility's policy requires quarterly assessments to be completed every 92 days from admission to allow for necessary revisions to the care plan.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for four residents. Resident #12's quarterly MDS with an Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. Similarly, Resident #32's quarterly MDS with an ARD of 1/8/24 was due on 1/22/24 and required submission by 2/5/24, but it was not submitted as of 3/19/24, making it 43 days late. Resident #53's quarterly MDS with an ARD of 2/6/24 was due on 2/20/24 and required submission by 3/5/24, but it was not submitted as of 3/19/24, making it 14 days late. Lastly, Resident #56's annual MDS with an ARD of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. An interview with the LPN responsible for completing and submitting the MDS assessments revealed that she was the only one in the MDS office and was unable to keep up with the required timeframes. The LPN acknowledged the delays and attributed them to her being the sole person handling the MDS assessments. The Resident Assessment Instrument 3.0 user manual from October 2023 specifies that quarterly assessments must be completed within 14 days of the ARD and submitted within 14 days after completion, which was not adhered to in these cases.
Failure to Ensure Comprehensive and Individualized Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for Resident #52 was comprehensive and individualized. Resident #52, who has diagnoses including type II diabetes mellitus and heart failure, was identified as cognitively intact and requiring partial assistance with transfers and ambulation. The care plan dated 8/25/23 indicated that the resident was at risk for falls and included interventions such as the use of alarms to notify staff of the resident's needs. However, observations on 3/18/24 revealed that no safety devices were in use in the resident's room, and interviews with staff confirmed that the resident never had any alarms in place. LPN #7 acknowledged that nursing staff were responsible for initial care planning and that she should have removed the incorrect information regarding the use of alarms during her review. RN #1 admitted to placing interventions regarding alarms in the care plan as a precaution, even though the resident never had any motion detection alarms and would require an order and consent for their use. The Director of Nursing confirmed that the care plan should accurately reflect the individualized needs of the resident. The facility's policy mandates that the Resident Care Plan should ensure high-quality, individualized care and be developed within 21 days of admission.
Failure to Revise Care Plans After Falls and Treatment Refusals
Penalty
Summary
The facility failed to revise the care plan for Resident #11 after multiple falls. Despite several incidents where the resident was found on the floor, the care plan was not updated with new interventions to prevent further falls. The resident's care plan was last reviewed on 6/28/23, and subsequent falls on 8/13/23, 9/24/23, 9/26/23, 10/1/23, 10/16/23, 11/1/23, 12/8/23, 1/12/24, 1/18/24, 2/1/24, 2/26/24, 3/5/24, and 3/13/24 did not result in any new interventions being added to the care plan. Interviews with the DNS and MDS Coordinator revealed that the care plan should have been updated with each fall and personalized to the resident's needs, but this was not done. Resident #38 also experienced multiple falls without appropriate updates to the care plan. Despite being identified as at risk for falls due to moderate dementia, behaviors, and poor safety awareness, the care plan was not revised after falls on 2/11/24, 2/13/24, and 2/21/24. Although some revisions were made on 2/27/24, 3/6/24, and 3/8/24, these did not directly address the falls. The DNS indicated that the care plan is only updated if there is a change to be made, and interventions are not always added to the care plan. Resident #57 frequently refused a daily treatment of ACE wraps for bilateral lower extremities edema, but the care plan was not revised to reflect this. Observations on 3/13/24 and 3/18/24 showed the resident out of bed without the ACE wraps, and the MAR indicated refusals on 33 occasions. Interviews with LPN #2 and the DNS confirmed that the staff was aware of the refusals, but the care plan was not updated to include interventions to address this issue. The facility policy directed that the care plan should be reviewed and revised as needed, but this was not followed in the case of Resident #57.
Failure to Complete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed to professional standards after Resident #11 experienced multiple unwitnessed falls. Resident #11, who was admitted with diagnoses including heart failure, generalized muscle weakness, and repeated falls, had a care plan identifying them as at risk for falls. Despite this, the facility did not consistently complete the required neurological checks following the resident's falls. Specifically, on five separate occasions, the neurological checks were either partially completed or not done at all, and there was no documentation of the resident refusing these checks as per facility policy. The DNS confirmed that staff should have attempted the checks and documented any refusals, but this was not done in the cases reviewed. The incidents occurred on 8/13/23, 9/24/23, 9/26/23, 1/18/24, and 2/26/24, with the resident found on the floor each time. The facility's policy required neurological assessments to be documented on a 24-hour flowsheet, with specific intervals for checks. However, the flowsheets for these dates showed missing entries, and in one instance, the flowsheet was not completed at all. The DNS could not provide an explanation for these lapses, indicating a failure to adhere to the facility's neuro-check policy designed to monitor residents following a head injury or suspected head injury.
Failure to Document Turning and Repositioning
Penalty
Summary
The facility failed to consistently document the turning and repositioning of Resident #47, who was at risk for pressure ulcers. The resident's diagnoses included a fracture of the right femur, pressure ulcer of the sacrum, and deep tissue damage of the left hip and right heel. The care plan dated 3/8/2024 indicated that the resident was at risk for pressure ulcers due to poor nutrition, immobility, and incontinence, and included interventions such as stage-appropriate wound care, pain management, and pressure reduction measures. However, a review of the clinical record from 2/27/24 through 3/7/24 showed no documentation of turning and repositioning per facility practice. Interviews with the DNS and MDS Coordinator confirmed the lack of documentation and identified that the facility software did not include a section for Nurse Aides to document these actions. The resident's condition deteriorated over time, with the development of new pressure ulcers and the progression of existing ones. On 3/1/2024, the resident was found to have a right heel deep tissue injury, and by 3/8/2024, new deep tissue injuries on the left hip and a stage 1 pressure ulcer on the coccyx were noted. By 3/15/2024, the coccyx wound had progressed to a stage 2 pressure ulcer. The MDS Coordinator indicated that the resident likely experienced weight loss, contributing to the development of the pressure ulcers. The facility's failure to document turning and repositioning as per their practice contributed to the resident's declining condition and the development of multiple pressure ulcers.
Failure to Conduct Safety Checks and Fall Assessments
Penalty
Summary
The facility failed to ensure that staff conducted safety checks as directed by the manufacturer to ensure the alarm was functional for Resident #10. The resident, who had diagnoses including dementia, abnormalities of gait, and rheumatoid arthritis, was found lying on the floor with a complaint of right hip pain. The Tab alarm, which was supposed to be used for safety, did not sound at the time of the fall. Interviews with staff revealed that safety checks were not logged, and there was uncertainty about whether the checks were completed the night of the fall. The facility's policy required safety checks every shift, but documentation of these checks was inconsistent or missing. For Resident #11, the facility failed to ensure fall assessments were completed after each fall as per facility policy. The resident, who had a history of multiple falls and was identified as at risk for falls, experienced several unwitnessed falls. Despite the facility's policy requiring a new fall risk assessment after each fall, reviews of clinical records and facility documentation showed that these assessments were not completed. Interviews with the DNS revealed a misunderstanding of the policy, with the DNS indicating that fall risk assessments were not necessary after every fall, contrary to the written policy. The facility's current Fall Prevention Policy, revised in 2019, indicated that a fall risk assessment should be completed quarterly, annually, and whenever a resident experiences a fall. However, this policy was not followed, leading to multiple instances where Resident #11 did not receive the required assessments after falls. This failure to adhere to the policy potentially compromised the resident's safety and well-being.
Failure to Respond to Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. Resident #38, who had diagnoses including anxiety disorder and depression, was identified as moderately cognitively impaired and dependent with ADL assistance. The resident's care plan included the use of psychotropic drugs and directed attempts for gradual dose reductions and psychiatric consults. A physician's order prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended including a 'stop' date for the PRN use of Trazadone, but there was no documented provider response until after surveyor inquiry. The facility policy required monthly pharmacy consults to be reviewed by the practitioner, but this was not adhered to in this case.
Medication Administration Timeliness Deficiency
Penalty
Summary
The facility failed to ensure medications were administered timely and that medication errors did not exceed 5% for one of the residents reviewed. Resident #57, who had diagnoses including localized swelling and edema, vitamin deficiency, and left knee effusion, had specific physician orders for the administration of Vitamin C, Vitamin D3, and Hydrochlorothiazide at 8:00 AM daily. However, during an observation on 3/19/2024 at 9:30 AM, it was noted that these medications were administered 30 minutes late by an LPN. The facility policy allows for medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. An interview with the Director of Nursing Services (DNS) and a review of the medication administration history confirmed the late administration. The DNS acknowledged that the medications were administered outside the allotted time frame and indicated that an interview with the LPN would be necessary to determine the reason. The LPN explained that the delay was due to the challenge of safely administering medications to 30 residents within the given time. The DNS mentioned the possibility of adjusting medication administration times to make them more manageable for the nursing staff.
Failure to Administer Prescribed Insulin Dose
Penalty
Summary
The facility failed to ensure that Resident #52 was free from significant medication errors following the administration of an unprescribed reduced dose of insulin. Resident #52, who had diagnoses including type II diabetes mellitus and heart failure, was cognitively intact and had specific physician orders for Humalog insulin to be administered based on a sliding scale. On 3/11/24, the resident's blood sugar was 300 mg/dl, requiring 6 units of insulin. However, the resident refused the prescribed dose and requested only 4 units, which was administered by LPN #4 without notifying the supervisor or the physician. This deviation from the prescribed dosage was not reported to the evening/night shift supervisor or the physician, contrary to the facility's policy on medication errors. The incident was only reported to the day shift nurse manager the following morning, who also did not notify the physician immediately. The Director of Nursing Services and the Advanced Practice Registered Nurse (APRN) were unaware of the medication error until later interviews. Subsequent blood sugar readings for Resident #52 showed elevated levels, including a reading of 432 mg/dl early the next morning, which required 12 units of insulin per APRN orders. The facility's policy mandates that all medication errors, including wrong doses, be reported to the supervisor, Director of Nursing, and the attending physician. However, this protocol was not followed, leading to a significant medication error. Interviews with the involved staff confirmed the failure to adhere to the policy and the lack of timely communication with the medical provider regarding the resident's refusal and the administration of a reduced insulin dose.
Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for a resident diagnosed with dementia with psychotic disturbance, anxiety, and depressive episodes. The quarterly Minimum Data Set (MDS) indicated the resident was cognitively impaired and received antipsychotic and antidepressant medications. The care plan included interventions such as monitoring mood and response to medications, consulting with the psychiatric APRN, conducting an Abnormal Involuntary Movement Scale (AIMS) assessment every six months, and assessing and recording the effectiveness and side effects of the medication. However, during an interview and record review with the Director of Nursing Services (DNS), it was revealed that a monthly pharmacy review recommendation made on 12/4/2024 could not be found, nor was there evidence that the recommendation had been addressed by the physician. The facility's policy on Medication Regimen, dated 1/2024, required that within 24 hours of the medication regimen review, the consultant pharmacist provides a written report to the physicians for each resident reviewed, including the resident's name, the name of the medication, the identified irregularity, and the pharmacist's recommendation. The policy further indicated that copies of medication regimen review reports, including the physicians' responses, are to be maintained as part of the permanent medical record. The failure to adhere to this policy resulted in incomplete and inaccurate clinical records for the resident in question.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director attended Quality Assurance Performance Improvement (QAPI) meetings quarterly. A review of facility documentation and interviews revealed that although the Medical Director was listed as a required member of the QAPI committee, there was no evidence of their attendance at any QAPI meetings from January 2023 through March 2024. The Director of Nursing Services (DNS) acknowledged that the Medical Director was aware of the requirement but may not have been able to attend the meetings. The Medical Director was reportedly updated during medical staff meetings, but no evidence of these meetings was provided. Attempts to contact the Medical Director for further clarification were unsuccessful.
Failure to Review Infection Control Policies Annually
Penalty
Summary
The facility failed to ensure infection control policies and procedures were reviewed annually. During the survey, a review of the facility's Infection Control Program and policies revealed no documented evidence of an annual review. An interview with the Director of Nursing Services confirmed that the facility had never required a documented review of current policies and procedures. Additionally, the facility was unable to provide a policy for the review of policies and procedures when requested.
Failure to Post Daily Census on Nurse Staffing Sheet
Penalty
Summary
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby for the view of the residents and the public. Observations on two separate occasions noted that the resident census was missing from the designated space on the form. Interviews with the receptionist and the scheduler revealed confusion and miscommunication regarding the responsibility for filling in the census. The receptionist believed it was the scheduler's responsibility, while the scheduler initially indicated it was the receptionist's duty before acknowledging it was their own responsibility. The Director of Nursing Services (DNS) and the scheduler were working on revising the procedure for completion and posting of the 24-hour nurse staffing sheet.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Geer Nursing And Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
| Sharon Center For Health & Rehabilitation | 8.3 mi | ★★★★★ | 11 | 1 |
| Timberlyn Heights Nursing And Rehabilitation | 13.4 mi | ★★★★★ | 1 | 0 |
| Fairview Commons Nursing & Rehabilitation Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Berkshire Rehabilitation & Skilled Care Center | 17.1 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.