Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint John Paul Ii Center during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with severe cognitive impairment and high fall risk was found on the floor by a nurse aide, who moved the resident back to bed without notifying the charge nurse or RN supervisor and without an RN assessment. The resident later reported pain and was diagnosed with a displaced humerus fracture. Facility policy required immediate reporting and RN assessment after a fall, which was not followed.
A resident with severe cognitive impairment and dependent transfer status was found on the floor and was manually lifted back into bed by a nurse aide, contrary to the care plan requiring two staff and a mechanical lift. The aide did not check the transfer status or report the fall, and the resident was later diagnosed with a displaced humerus fracture.
A resident who required two-person assistance for mechanical lift transfers was moved by a single nurse aide, contrary to facility policy. During the transfer, the sling shifted and struck the resident's nose, causing a minor nosebleed. The aide did not request help from another aide present in the room, despite being trained on the two-person transfer requirement. The resident's care plan and facility policy both specified the need for two staff during such transfers.
A resident with multiple medical conditions was subjected to inappropriate physical contact when a nurse aide, following a verbal altercation with an LPN, grabbed the resident's wrist in the hallway after the resident intervened. The incident was witnessed by staff and reported, and the facility's zero-tolerance abuse policy was not followed.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
The facility did not ensure that a licensed pharmacist consistently performed required monthly drug regimen reviews for several residents with complex medical conditions, resulting in missing documentation for multiple months. Interviews indicated that changes in pharmacy providers and facility ownership contributed to the lack of pharmacy consultant services and incomplete medication reviews, contrary to facility policy.
Surveyors identified that medication refrigerators were found unlocked, expired medications were not discarded, and refrigerator temperature logs were incomplete in two medication rooms. Staff interviews confirmed lapses in daily checks and documentation, as well as a broken lock on a refrigerator used for medication storage, contrary to facility policy.
Staff failed to serve meals at appropriate temperatures, with food items significantly cooling between leaving the kitchen and being served to a resident. Despite food leaving the kitchen at high temperatures, by the time the last resident was served, items were well below the acceptable minimum for hot foods, contrary to facility policy and staff expectations.
A resident with a history of mental health disorders received a new diagnosis of schizoaffective disorder, but the facility did not refer this new diagnosis to the state mental health authority for a required Level II evaluation. The social worker was unaware that a new referral was needed for a long-term care resident with a previous Level II, resulting in the omission.
A resident with neuromuscular disease and limited mobility, requiring assistance with ADLs, did not consistently receive scheduled showers as documented in their care plan. Staff interviews and medical record review confirmed missed showers, with staff citing insufficient availability and lack of follow-up on the resident's complaints. Facility policy required real-time documentation of ADL care, but records did not reflect that showers were provided as scheduled.
Two residents experienced deficiencies: one did not have a written physician order entered for a diagnostic x-ray after a fall, leading to confusion about the intended imaging, and another had a cervical collar that was repeatedly positioned incorrectly by staff who were not fully trained on proper application, despite a physician's order and facility policy requiring correct placement.
A resident with severe cognitive impairment and a stage 3 pressure ulcer was found using a specialty air mattress without a physician's order or documented instructions for mattress settings, contrary to facility policy. Licensed staff could not locate the required order or evidence of regular monitoring, resulting in a deficiency related to pressure ulcer care.
A resident with obesity, dysphagia, and aphasia experienced significant unplanned weight loss, but staff failed to obtain timely reweights and did not document or notify the physician as required by facility policy. The resident's weight was not checked within the required timeframe after hospital readmission, and the responsible RN was unaware of the missed weights and did not update the care plan or notify the physician.
Licensed staff, including an LPN hired in 2023, did not have required clinical competency validations completed for 2024. Review of employee files and facility documentation showed these validations were missing for all licensed staff, and the DON confirmed that none had been completed due to the departure of the responsible staff member. The facility could not provide a policy for clinical competency validations.
Two residents with severe cognitive impairment and court-appointed conservators did not have proper consent or refusal obtained from their responsible parties for influenza vaccination for the current season. Although the facility attempted to contact conservators and power of attorneys, the process was incomplete, and immunization records did not indicate whether the vaccine was offered or administered.
A resident with diabetes was discharged without receiving necessary education on insulin administration, diabetes management, or use of a glucometer, and was also sent home without prescribed medications and supplies due to a lack of medication reconciliation and communication among staff.
A resident with multiple diagnoses, including seizure disorder and anxiety, repeatedly refused prescribed morning doses of Primidone and Hydroxyzine over a month. Despite facility policy requiring physician notification for medication refusals, nursing staff did not inform the physician or document the refusals beyond the MAR. The unit manager, APRN, and DON were unaware of the refusals, resulting in a deficiency due to lack of required communication.
A resident with multiple diagnoses, including seizures and anxiety, repeatedly refused prescribed medications, but the facility did not develop or implement a comprehensive care plan to address these refusals. Despite documentation of frequent medication refusals and facility policy requiring individualized care planning for such situations, staff interviews confirmed that no specific interventions or care plan were in place.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Notify RN and Assess Resident After Fall
Penalty
Summary
A resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility, who required maximum assistance for bed mobility and was dependent for transfers, experienced an unwitnessed fall during the night. The resident, who had severely impaired cognition, was found on the floor by a nurse aide who, without notifying the charge nurse or RN supervisor, picked the resident up and placed them back in bed. The resident later complained of pain and was found to have a displaced fracture of the left humerus. The nurse aide admitted to not reporting the fall to nursing staff and to moving the resident without an RN assessment, despite knowing facility policy required notification and assessment before moving a resident after a fall. The RN supervisor on duty was unaware of the fall until informed later by management, and confirmed that the nurse aide should have reported the incident so an RN assessment could be completed. Facility documentation and interviews confirmed that the resident required two staff and a mechanical lift for transfers, and that the nurse aide acted alone and failed to follow protocol. The facility's falls management policy defined a fall as any instance of a patient found on the floor and required immediate reporting and assessment, which was not followed in this case.
Failure to Follow Care Plan for Dependent Transfer After Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility was not transferred in accordance with their care plan. The resident, who had severely impaired cognition and was dependent for transfers, was found on the floor by a nurse aide during the night. The care plan required two staff and a mechanical lift for all transfers due to the resident's high fall risk and physical limitations. However, the nurse aide, without checking the resident's transfer status, lifted the resident alone and placed them back in bed without using the required mechanical lift or seeking assistance. The nurse aide did not report the fall to the charge nurse as required. The resident subsequently complained of pain and was found to have a displaced fracture of the left humerus, confirmed by hospital evaluation. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the resident's care plan specified the use of a mechanical lift with two staff for all transfers, and that the nurse aide's actions were not in accordance with facility policy or the resident's care plan.
Failure to Follow Two-Person Mechanical Lift Transfer Policy Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to morbid obesity, osteoarthritis, gait abnormalities, and generalized muscle weakness, was transferred using a mechanical lift by only one nurse aide, contrary to the facility's policy requiring two staff members for such transfers. The resident's care plan and care card both specified the need for two-person assistance during mechanical lift transfers. On the day of the incident, the assigned nurse aide performed the transfer alone because other aides were occupied, and did not request assistance from another aide who was present in the room but separated by a curtain. During the solo transfer, the sling of the mechanical lift shifted and the resident's nose was struck by the end of the sling straps, resulting in a minor nosebleed. The resident was alert and oriented, reported the incident, and denied hitting any metal part of the lift, attributing the injury to the sling straps. A subsequent assessment found no other injuries, and x-rays were normal. The resident later expressed reluctance to get out of bed, which was noted as potentially related to the incident. Interviews with staff confirmed that the nurse aide was aware of the policy requiring two staff for mechanical lift transfers and had received training on this procedure. The facility's policy explicitly stated that two trained staff are required for all mechanical lift transfers, regardless of manufacturer instructions. The nurse aide admitted to not following this policy and did not seek help from the other aide present in the room.
Failure to Protect Resident from Inappropriate Physical Contact by Staff
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical diagnoses including surgical aftercare, dysthymic disorder, and hypertensive heart disease, was subjected to inappropriate physical contact by a nurse aide. The resident, who was alert and oriented, reported that the nurse aide grabbed their wrist too hard during an altercation that began with a verbal argument between the nurse aide and an LPN in the hallway. The resident intervened by asking the nurse aide to calm down, at which point the nurse aide approached and grabbed the resident's wrist. The resident immediately objected to being touched and pulled away, stating, 'don't touch me.' Multiple staff statements corroborated that the nurse aide engaged in a loud verbal altercation and then physically grabbed the resident's wrist in the hallway. The incident was witnessed by other staff and reported to the nursing supervisor. The facility's policy mandates zero tolerance for abuse and requires staff to prevent any form of abuse or neglect. The nurse aide's actions were in direct violation of this policy, as the physical contact was not warranted and occurred in the context of a heated exchange.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Consistently Complete Monthly Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist consistently performed monthly drug regimen reviews, including review of the medical chart, for several residents as required by policy. For four of five residents reviewed for unnecessary medication use, documentation showed that monthly pharmacy reviews were missing for specific months. In some cases, such as with residents diagnosed with end stage renal failure, anxiety, major depression, dementia, schizophrenia, diabetes, and other serious conditions, the required monthly reviews were not completed or could not be located in the clinical records. Care plans for these residents indicated they were at risk for complications related to psychotropic and other high-risk medications, and interventions included monitoring for side effects and consulting with a pharmacist as needed. Interviews with the Director of Nursing Services (DNS) revealed that a change in pharmacy providers and a change in facility ownership led to lapses in pharmacy consultant services, resulting in missed monthly medication regimen reviews. The DNS was unable to provide documentation for the missing months and could not explain the absence of pharmacy consultations for other periods. Facility policy required monthly review and documentation of medication administration records, but these were not consistently completed or available for review for the affected residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication storage and labeling in two medication rooms. In one instance, a medication refrigerator containing medications was found unlocked, and a registered nurse acknowledged forgetting to secure it. In another medication room, an expired ear wax removal medication, which should have been discarded after the resident's departure, was found stored. Nursing staff are responsible for weekly checks for expired medications, but the expired item had been missed. Additionally, temperature logs for medication refrigerators were incomplete, with numerous days across several months lacking documentation of temperature checks and signatures. Staff interviewed confirmed that temperature logs are required to be completed daily during the overnight shift but could not explain the lapses. Furthermore, a refrigerator storing medications was found unlocked due to a broken lock, and staff were unsure how long the lock had been inoperable. Facility policy requires daily temperature checks and removal of expired medications from storage areas.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, as required by policy. Observations showed that food trucks left the kitchen with hot food items at high temperatures (pureed eggs at 200°F, pureed hash browns at 198°F, and pureed bread at 182°F). However, by the time the last resident on Unit 2 North was served, the temperatures of these items had dropped significantly (pureed hash browns at 110.1°F, pureed bread at 106°F, and pureed eggs at 106.3°F). The time between the food leaving the kitchen and being served to the last resident was approximately 46 minutes. Staff from various departments were observed passing out dietary trays, and the last resident served was dining in their room. Interviews with the Food Service Director and the DNS confirmed that the expectation is for meals to be served warm, with 135°F identified as the acceptable minimum temperature for hot foods. Both acknowledged that the temperatures measured at the time of service were not warm enough for consumption. The DNS also noted that food trays should be distributed immediately upon arrival to the unit and suggested that better organization of trays and delivery could improve efficiency. The facility's policy requires that each resident receive food and drink that is palatable and at a safe and appetizing temperature, which was not met in this instance.
Failure to Refer New Mental Health Diagnosis for Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to refer a newly identified mental health diagnosis to the appropriate state-designated mental health authority for a Level II evaluation, as required by policy. The clinical record review for one resident revealed that although a previous Level II evaluation had been completed for a diagnosis of delusional disorder, a new diagnosis of schizoaffective disorder was identified several months later without evidence of a subsequent referral for reassessment. The facility's policy mandates prompt notification to the state mental health authority after a significant change in mental or physical condition for residents with mental disorders. The resident involved had a history of schizoaffective disorder, mild cognitive impairment, and delusional disorder, and was assessed as severely cognitively impaired but independent in certain activities of daily living. The care plan noted ongoing psychosocial distress and the use of antipsychotic medication, with interventions including evaluation for psychiatric or behavioral health consults. During interviews, the social worker indicated she was unaware that a new referral was required for a new mental health diagnosis in a long-term care resident with a prior Level II evaluation, leading to the failure to initiate the necessary referral process.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A deficiency occurred when a resident with Guillain-Barre Syndrome and muscle weakness, who required assistance with activities of daily living (ADLs) such as bathing and grooming, did not consistently receive scheduled showers. The resident's care plan specified the need for assistance with bathing, and the Minimum Data Set (MDS) assessment confirmed the resident required partial to moderate assistance for bathing and transfers. Despite being cognitively intact, the resident reported missing two scheduled showers and stated that staff told them the day staff were too busy to provide the shower. Documentation in the medical record confirmed the absence of showers on the scheduled dates, and only one shower was documented during the review period, with bed baths provided on other dates. Multiple staff interviews corroborated the resident's complaint, with nurse aides and the unit manager acknowledging the missed showers and the resident's requests. Staff indicated that the resident sometimes requested showers at times when adequate staff were not available to assist, and there was confusion or lack of follow-up regarding the resident's complaints. Review of nursing progress notes and behavior monitoring did not identify any care refusal or behaviors that would have prevented the resident from receiving showers. Facility policy required real-time documentation of ADL care, but the medical record did not reflect that showers were provided as scheduled.
Failure to Obtain Written Physician Order and Improper Cervical Collar Positioning
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of repeated falls experienced a fall after dinner and complained of right thigh pain. The Advanced Practice Registered Nurse (APRN) was notified and verbally ordered an x-ray, and the responsible party was informed that an x-ray would be completed. However, there was inconsistency in the documentation regarding whether a hip or femur x-ray was ordered, and no written physician order was entered into the electronic order management system as required by facility policy. The radiology report later indicated a femur x-ray was performed, but the lack of a written order created confusion about the intended diagnostic procedure. Another deficiency was identified involving a resident admitted with a cervical spine fracture and a physician's order to maintain a cervical collar at all times, except for care. Observations revealed that the resident's cervical collar was not appropriately positioned, with the chin piece on the resident's chin and the front piece floating above the chest. Nursing staff believed this was the correct placement, and one LPN stated she had not received the in-service training provided by physical therapy. The Director of Physical Therapy later confirmed the collar was not properly positioned and adjusted it accordingly. Documentation showed that staff education on collar alignment had been provided only to those present at the initial in-service. Review of the resident's care plan and nursing notes did not indicate prior issues with the resident moving the collar or behaviors affecting its alignment. Only after surveyor inquiry was the care plan updated to address resistance to care related to the cervical collar. Facility policy specified correct collar placement, but this was not consistently followed, resulting in improper positioning of the cervical collar for the resident.
Failure to Obtain Physician Order and Monitor Specialty Mattress Settings for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a stage 3 pressure ulcer, not present on admission, was found to be using a specialty air mattress without a physician's order specifying the mattress settings. The resident's care plan included interventions such as the use of a pressure redistribution surface and regular repositioning, but there was no documentation of a physician's order for the mattress or instructions regarding its settings and monitoring. During observations and staff interviews, it was revealed that licensed staff were unable to locate any physician order or guidance for the air mattress settings, despite facility policy requiring such an order and regular monitoring by nursing staff. The facility's policy also stipulated that the mattress settings should be adjusted according to manufacturer recommendations and checked by a licensed nurse, which was not documented as being done for this resident.
Failure to Obtain and Document Weights per Policy for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document resident weights according to its own policy for a resident with a history of weight loss and multiple risk factors, including obesity, dysphagia, and aphasia. The resident experienced significant weight loss over a period of weeks, with electronic records showing a drop from 155.0 pounds to 147.6 pounds, and later to 140.0 pounds. Despite these changes, no reweight was obtained within 24 hours to verify the weight loss, as required by facility policy. Additionally, a readmission weight was not obtained within 48 hours after the resident returned from the hospital, and the first weight post-readmission was documented six days later, two days after the dietician requested it. The facility's policy required prompt reweighing and documentation in cases of unplanned weight loss or gain of 5 pounds or more, as well as timely notification to the physician and updates to the care plan. However, interviews and record reviews revealed that the responsible RN was unaware of the missed weights and did not monitor weights after hospital readmissions. There was also no documentation that the physician was notified of the significant weight loss, nor evidence that the care plan was adjusted in response to these changes.
Failure to Complete Clinical Competency Validations for Licensed Staff
Penalty
Summary
Licensed staff, including an LPN hired in May 2023, did not have documented clinical competency validations completed for the year 2024. Review of employee files and facility documentation revealed that these required validations were missing for all licensed staff. The facility assessment emphasized the importance of employee competency assessment and education as essential for proper resident care, and staff are expected to understand their scope of practice and daily responsibilities. During an interview, the Director of Nursing Services confirmed that no licensed staff had received clinical competency validations for 2024, attributing this lapse to the departure of the staff member responsible for conducting the validations. Additionally, the facility was unable to provide a policy for clinical competency validations for licensed staff.
Failure to Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain proper consent or refusal for influenza vaccination from the responsible parties of two residents with severe cognitive impairment and court-appointed conservators. In the first case, a resident with severe cognitive impairment and a conservator had previously received consent for the influenza vaccine from the conservator, but the conservator changed, and no new consent or refusal was obtained from the new conservator for the current vaccination season. The immunization record did not indicate whether the resident had received or been offered the influenza vaccine for the current season. In the second case, another resident with severe cognitive impairment was initially self-responsible and gave consent for the influenza vaccine, but later had a conservator appointed. For the current vaccination season, neither consent nor refusal was obtained from the new conservator. Although the facility attempted to contact conservators and power of attorneys via email to obtain consent, the process was incomplete, and the immunization record did not reflect whether the vaccine was offered or administered for the current season.
Failure to Provide Discharge Education and Medication Reconciliation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, among other diagnoses, was discharged from the facility without receiving necessary education on diabetes management, specifically regarding the use of newly prescribed Insulin Lispro, insulin sliding scale, and self-injection techniques. The clinical record and facility documentation showed that the resident did not receive teaching or training on diabetes care, use of a glucometer, or insulin administration during their stay, despite care plans and physician orders indicating these needs. Nursing notes failed to document any education provided on these critical aspects of diabetes self-management prior to discharge. Additionally, the facility failed to perform proper medication reconciliation before the resident's discharge. The discharge summary and medication list indicated that the resident was to continue with Insulin Lispro and gabapentin, but these medications and necessary supplies were not provided to the resident upon discharge. Communication breakdowns between nursing staff and the prescribing provider led to the assumption that the resident had all required medications, resulting in the omission of new prescriptions and supplies needed for safe transition home. Interviews with facility staff confirmed that the resident was discharged without the prescribed medications and without the required education on their use. The facility's own discharge planning policy required reconciliation of all pre- and post-discharge medications and provision of education, but these steps were not completed. The deficiency was identified after the home care nurse reported the missing medications and lack of discharge teaching, prompting an internal investigation that confirmed the failures in discharge planning and education.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident repeatedly refused prescribed medications, as required by facility policy. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was care planned for medication administration and monitoring for side effects and effectiveness. Despite physician orders for Primidone and Hydroxyzine, the resident refused the morning doses of Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during a one-month period. Documentation review confirmed these refusals were recorded in the Medication Administration Record (MAR). Interviews with nursing staff revealed that the charge nurse was aware of the refusals but could not recall notifying the physician or documenting the refusals in a nurse's note. The unit manager and APRN were not aware of the medication refusals and stated that their expectation was to be notified in such cases. The Director of Nursing confirmed there was no documentation of physician notification regarding the refusals, and facility policy required such notification. This lack of communication and documentation led to the deficiency.
Failure to Develop and Implement Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's repeated refusals of prescribed medications. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was prescribed Primidone for seizures and Hydroxyzine for anxiety. Despite a care plan that addressed behavioral concerns and medication monitoring, there was no specific care plan or interventions in place to address the resident's frequent medication refusals. The Medication Administration Record showed that the resident refused Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during the review period, with only one nurse's note documenting a refusal. Interviews with facility staff, including the unit manager and Director of Nursing Services (DNS), confirmed that a care plan should have been implemented for medication refusals, but none was found in the clinical record. The facility's own policy required a person-centered care plan that addresses services not provided due to a resident's exercise of rights, such as refusing treatment. The DNS was unable to provide documentation or an explanation for the lack of a comprehensive care plan addressing the resident's medication refusals.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Danbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Havencare At Hancock Hall | 1.1 mi | ★★★★★ | 0 | 0 |
| Havencare At Filosa | 1.3 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Danbury | 1.4 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Glen Hill | 2.1 mi | ★★★★★ | 0 | 0 |
| Bethel Health Care Center | 4 mi | ★★★★★ | 0 | 0 |
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