Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whispering Pines Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with COPD and chronic respiratory failure was on continuous O2 via nasal cannula and was found with uncovered tubs of VapoRub on the overbed table. The resident said the ointment had been brought in by family and had been self-applied inside the nose for months while the O2 was running. An LPN knew the ointment was present and being used, but there was no order or self-administration assessment, and staff did not act on the posted warning about petroleum products with oxygen.
Failure to Notify APRN of Missed D-Mannose Doses: The facility did not notify the APRN when an ordered D-Mannose supplement was unavailable and missed for multiple residents with UTI-related conditions. MARs and nursing notes showed repeated missed doses for residents with Foley use, BPH, incontinence, and dementia, while progress notes did not reflect the missed medication. Staff interviews confirmed the APRN was not informed until later, despite the medication being unavailable and not administered.
A resident with diabetes did not receive ordered fingerstick glucose monitoring when symptoms developed, and a later lab showed critically high glucose with transfer to the ED. Two residents with UTI concerns missed multiple doses of D-Mannose because the OTC medication was unavailable, not properly tracked, and substitute cranberry orders were not consistently documented in the MAR. Another resident’s non-pressure wound worsened and merged into a larger coccyx wound before the change was identified and documented by nursing staff.
A resident with dysphagia, weak hand grip strength, and poor nutritional intake was observed eating without ordered adaptive equipment despite OT recommendations, a physician order, and care card instructions for a sippy cup and foam built-up utensils with all meals. Staff interviews and record review showed the NA did not check the beverage cart list or care card before serving meals, and the resident was repeatedly seen using regular utensils and cups instead of the ordered adaptive devices.
PASRR redeterminations were not submitted for two residents after short-term approvals expired. One resident with schizophrenia, depression, and intellectual disabilities had a 60-day approval that lapsed without a redetermination, and another resident with catatonic schizophrenia and major depressive disorder remained beyond a 30-day approval without the required updated PASSR Level I screen and LOC form being submitted.
The facility failed to keep accurate MAR documentation for D-Mannose, a UTI-prevention supplement, for three residents with UTI risk factors including dementia, chronic Foley use, BPH, incontinence, and prior sepsis. The MARs showed missed doses, conflicting entries marking the medication as both unavailable and given on the same or surrounding shifts, and staff reported the medication was not in the building or on the med cart. An LPN and central supply staff also reported delays and confusion with ordering and availability of the OTC medication.
A dependent resident with hemiplegia, aphasia, and severely impaired cognition, who required staff assistance for bed mobility and transfers, was found by an LPN with multiple unexplained injuries, including a lip laceration, forehead abrasion with swelling, and bruising to the right hand and wrist. Earlier in the shift, the NA assigned to the resident had been upset, stated she should not be working, and left early. Another NA later found the resident incontinent of stool with stool on the floor and confirmed the resident required two-person assistance for care. The DON reported the resident could not get up independently and there were no wandering or aggressive residents on the unit. In a subsequent interview, the resident, using limited verbal communication and gestures, indicated that the NA had struck him, while also acknowledging a fall but without details, leaving the injuries as an injury of unknown origin that met the facility’s criteria for potential abuse.
A resident with a seizure disorder received both 100 mg and 125 mg doses of Lamotrigine on two days due to a failure to discontinue the previous order when a new dosage was prescribed. The error occurred because the previous order was not properly discontinued in the MAR, resulting in the resident receiving an excessive dose.
A resident with a history of dementia, depression, and behavioral symptoms was not permitted to return to the facility after hospitalization, even though hospital psychiatric staff determined the resident was not a risk to self or others. The facility refused re-admission following repeated incidents of inappropriate touching, did not consult with the hospital, and lacked a specific emergency discharge policy.
A resident with severe cognitive impairment and osteoporosis developed a bruised and discolored right pinky finger and hand, which was first identified by staff during the night shift. The nurse supervisor assessed the injury but did not promptly notify the physician, becoming distracted by other duties. The injury was only reported to the provider several hours later after further assessment revealed swelling and abnormal positioning, leading to the discovery of a fracture and transfer to the emergency department.
A resident with severe cognitive impairment and mobility deficits, who required total assistance for transfers, was found with a significant bruise on the chest. Investigation determined the injury likely resulted from contact with the Hoyer lift bar during a transfer, indicating a failure to ensure the area was free from accident hazards and to provide adequate supervision to prevent accidents.
A resident with diabetes and mobility issues did not receive necessary podiatry services for nearly nine months, resulting in excessively long and uncomfortable toenails. Despite a physician's order for podiatry services as needed, the facility's staff failed to identify and address the issue during routine care and audits. The deficiency was discovered during a surveyor inquiry.
A resident with heart failure, hypertension, and COPD was not weighed for four consecutive days due to a broken scale, and the physician was not notified as required by the care plan. Despite the availability of another scale, the facility failed to adhere to the physician's order for daily weight monitoring, which was crucial for assessing the resident's nutritional status.
A facility failed to develop a comprehensive care plan for a resident with major depressive disorder and alcohol dependence, who exhibited behaviors such as agitation, cursing, sexual inappropriateness, and refusal of care. Despite these behaviors being documented in nurse's notes, the Resident Care Plan did not address these issues. Staff interviews revealed that the behaviors were discussed but not formally documented or planned for, leading to a deficiency in care.
Two residents experienced a decline in bowel and bladder function due to the facility's failure to assess and implement continence care. One resident, admitted with various diagnoses, was not assessed for continence and was not provided with preferred toileting options, leading to frequent incontinence. Another resident, with a history of urinary issues, was identified as a candidate for retraining but did not receive appropriate programs, resulting in frequent incontinence. Staff interviews revealed a lack of communication and understanding of continence care policies.
The facility failed to monitor and address significant weight changes for two residents. One resident experienced a significant weight loss over two months without timely identification or intervention, while another was not weighed for four days due to a broken scale, despite physician orders. The facility's weight policy was not followed, and staff failed to utilize alternative weighing options.
A resident with COPD and other conditions was observed receiving oxygen at 3.0 LPM, contrary to the physician's order of 2.0 LPM. An LPN, unfamiliar with the unit, had not checked the oxygen settings, leading to a failure in following the facility's Oxygen Therapy policy.
A facility failed to monitor and document targeted behaviors for a resident receiving psychotropic medications, as required by a physician's order. The resident, diagnosed with major depressive disorder and alcohol dependence, was not monitored for increased anxiety, yelling, or agitation due to an incorrect entry by a previous APRN. This lack of monitoring from November 2023 through May 2024 was confirmed by facility staff, resulting in a deficiency.
The facility failed to maintain proper temperature controls for medications in one of its medication rooms. The refrigerator used for storing medications such as lispro, Levemir, and lorazepam had recorded out-of-range temperatures on multiple occasions, with no corrective actions taken. The Infection Preventionist and an LPN were unable to explain the lack of rechecking or reporting of these temperatures, which violated the facility's Medication Storage policy.
The facility failed to ensure a clean environment in the laundry room's drying and folding areas. Observations revealed lint on fan blades blowing onto clean laundry and debris on dryer tops. Interviews indicated that laundry staff were responsible for cleaning, but no cleaning schedule or checklist was in place, contrary to the facility's policy.
A facility failed to refer a resident for a level II PASRR evaluation after a new diagnosis of schizoaffective disorder. Initially admitted with other diagnoses, the resident's care plan included psychotropic medications and mood disorders. Despite a progress note identifying the new psychiatric condition, no level II PASRR was conducted, as confirmed by a social worker.
Resident Used Petroleum-Based Ointment While on Continuous Oxygen
Penalty
Summary
The facility failed to ensure a safe environment for a resident receiving continuous oxygen by allowing the resident to self-administer a petroleum-based ointment inside the nose without a physician order, a self-administration assessment, or staff intervention. Resident #37 had COPD, acute and chronic respiratory failure with hypercapnia, and mild persistent asthma, and was ordered oxygen at 2 liters per minute via nasal cannula continuously. The resident’s care plan identified altered respiratory status and difficulty breathing related to oxygen dependence and COPD. During observation, Resident #37 was found in bed on continuous oxygen with two uncovered tubs of VapoRub ointment on the overbed table. The resident stated a family member had brought in the ointment and that the resident had been applying it inside the nose several times a day for months when the nose felt dry or congested. The resident also stated nursing staff were aware of the ointment in the room and of the self-administration, and that no one had told the resident not to use a petroleum-based ointment while on oxygen. Staff interviews and record review showed an LPN knew the ointment was in the room and knew the resident was using it in the nose while on oxygen, but did not recognize the significance of the oxygen warning sign posted at the doorway. The resident did not have a current order for VapoRub and had not had a self-administration of medication assessment completed. The DNS later stated the resident should not have had or been using VapoRub while on continuous oxygen, that staff should have ensured it was not in the room, and that the resident should have been educated not to use it.
Failure to Notify APRN of Missed D-Mannose Doses
Penalty
Summary
The facility failed to ensure the APRN was notified when D-Mannose, an ordered supplement for UTI prevention, was unavailable and not administered to residents with urinary tract-related diagnoses. For Resident #7, who had dementia, chronic urinary retention with a Foley catheter, and a history of UTIs, the February 2026 MAR showed 5 missed doses of D-Mannose because it was coded as unavailable. Nursing notes from 2/3/26 through 2/26/26 did not document that the APRN was notified of the missed doses, and the APRN progress note on 2/24/26 did not reflect the missed medication. The APRN stated she was not made aware of the unavailable medication until 2/27/26. For Resident #14, who had dementia, diabetes, BPH, urinary incontinence, and a history of urinary complications, the February 2026 MAR showed D-Mannose was not administered 26 out of 51 opportunities and was repeatedly coded as unavailable. Review of the MAR and nursing notes showed that 19 notes documented the medication was unavailable and/or on order, but the notes did not identify that the physician or APRN was notified of the missed doses. APRN and physician progress notes dated 2/20/26, 2/23/26, and 2/25/26 addressed other issues, including rash, a regulatory visit, and UTI symptoms, but did not reflect the missed D-Mannose doses. An LPN stated the medication had not been available since about 2/20/26 and that the APRN was not notified. For Resident #20, who had dementia with behaviors, sepsis, type 2 diabetes, incontinence, and limited mobility, the February 2026 MAR showed 19 missed doses of D-Mannose because it was unavailable. Nursing notes from 2/3/26 through 2/26/26 did not document that the APRN was notified of the missed doses. Interviews with central supply, the pharmacy manager, the ADNS, and an LPN showed confusion about ordering and availability of the medication, including that the pharmacy had called back multiple times without getting a response and that the ADNS did not notify the APRN, believing she already knew the medication was unavailable. The APRN stated she was not made aware until 2/27/26 and that she should have been notified when the medication was not given due to unavailability.
Missed Glucose Monitoring, Medication Administration Errors, and Delayed Wound Change Recognition
Penalty
Summary
The facility failed to provide ordered treatment and monitoring for a resident with type 2 diabetes when fingerstick blood glucose checks were not performed as indicated in an APRN progress note. The resident had diagnoses including diabetic neuropathy, chronic kidney disease, morbid obesity, and a history of sepsis related to UTIs. Although the APRN documented that finger-stick glucose levels, A1C, B12, and weights should be monitored, there were no corresponding physician orders for routine fingerstick glucose monitoring, and nursing staff did not complete routine checks. When the resident later developed lethargy, cough, nausea, and a positive COVID-19 test, the record did not show that a fingerstick glucose was obtained at that time, despite facility policy directing fingerstick checks for diabetic residents on oral hypoglycemics who show symptoms such as lethargy or mental status changes. A lab glucose later returned critically high at 709 mg/dL, and the resident was transferred to the emergency department for higher-level care. The facility also failed to administer medications per physician orders for residents with urinary tract infection concerns. One resident with dementia, chronic foley use, and UTI history had an order for D-Mannose twice daily, but the MAR showed multiple missed doses coded as unavailable, and nursing notes did not document that the APRN was notified of the missed doses. Another resident with dementia, diabetes, BPH, and urinary issues had an order for D-Mannose twice daily and shift-by-shift UTI monitoring, but the MAR showed 22 missed doses out of 51 opportunities because the medication was unavailable. Nursing notes repeatedly documented the medication as unavailable and/or on order, and staff interviews showed confusion about who was responsible for ordering the OTC medication and whether the pharmacy or central supply should obtain it. The record also showed that a cranberry tablet was later ordered as an alternative, but the MAR did not reflect that the substitute medication was properly signed out when D-Mannose was unavailable. A third resident with dementia, anxiety, and hypertension had a non-pressure wound to the bilateral buttocks/coccyx that changed in appearance without timely identification in the record. Earlier wound documentation described two smaller open areas with granulation tissue and drainage, but during observation the wound appeared larger, with the two areas merged into one wound over the coccyx and with greater slough tissue than previously documented. The LPN performing the dressing change stated the wound had looked different the previous day but had not reported the change to the ADNS or MD/APRN because wound rounds were scheduled later. When the wound nurse/ADNS reviewed the wound, she measured it as larger and documented that the wound had merged and worsened, with a new treatment order then written. Facility policy required changes in skin condition to be recognized, documented, and reported when indicated, including significant changes in wound appearance.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils for a resident with dysphagia and weak hand grip strength despite documented orders and care instructions. The resident’s diagnoses included type 2 diabetes mellitus, dysphagia, and gastro-esophageal reflux disease. An OT requisition form dated 11/11/25 directed that the resident have a sippy cup, foam built-up utensils, and an updated beverage cart list, and a physician’s order dated 2/2/26 directed a sippy cup and foam handle built-up utensils for all meals. The quarterly MDS identified the resident as moderately cognitively impaired, dependent for transfers, toileting, and bed mobility, and needing setup or clean-up assistance with eating while on a mechanically altered and therapeutic diet. The resident care plan identified the resident required assistance with eating, had poor nutritional intake, and had a potential for nutritional deficit. The NA care card also directed the use of a sippy cup and adaptive equipment with all meals. However, observations on 2/25/26 and 2/26/26 showed the resident eating in bed with regular utensils and drinking from a large clear cup without a handle, rather than using the ordered foam handle utensils and sippy cup. During a later observation, the resident was again seen eating mashed potatoes with regular utensils and drinking from a Kennedy cup instead of the ordered adaptive equipment. Interviews and record review showed the beverage cart list identified the resident’s need for a sippy cup and foam handle utensils for breakfast, lunch, and dinner, but the NA had not reviewed the list or the care card before serving the meal. The Director of Dietary and the NA confirmed the resident should have had the adaptive equipment and that it was available on the beverage cart. OT stated the equipment was needed because of bilateral weak hand grip strength and was intended to promote independence and increase meal intake, and that without it the resident could be unable to feed him/herself and have decreased nutritional intake. The facility policy directed that residents be served prescribed diets, adaptive self-help devices be provided to support independence in eating, and the diet card be checked before serving the meal.
PASRR redeterminations were not submitted when short-term approvals expired
Penalty
Summary
The facility failed to ensure that PASRR redeterminations were submitted to the appropriate state agency when short-term approvals expired for 2 of 5 residents reviewed. One resident was admitted with diagnoses including schizophrenia, major depression, and moderate intellectual disabilities, and had a hospital Level of Care Screening Assessment that approved a short-term 60-day stay. The resident’s 5-day admission MDS identified schizophrenia and depression, and the care plan documented psychotropic medication use related to those diagnoses. The social worker stated that the redetermination was not submitted when the 60-day approval expired and that this was an oversight. A second resident was admitted with catatonic schizophrenia, major depressive disorder with recurrent severe psychotic symptoms, and obsessive-compulsive disorder. The admission MDS showed severe cognitive impairment, dependence for transfers, and use of antianxiety, antidepressant, and anticonvulsant medications. A Notice of PASSR Level I Screen Outcome approved the resident to remain in the facility for up to 30 days without a Level II screen and stated that if the stay extended beyond 30 days, an updated screen and Level of Care form had to be submitted on or before the 30th day. The social worker acknowledged that the resident remained beyond the initial 30-day period and that the required updated PASSR Level I and Level of Care screen had not been completed by the contracted state agency.
Inaccurate MAR Documentation for UTI Prevention Medication
Penalty
Summary
The facility failed to ensure the Medication Administration Record (MAR) contained accurate documentation for medications related to urinary tract infection (UTI) prevention for 3 residents. For Resident #7, who had dementia, chronic Foley use, and a history of UTIs, physician orders directed D-Mannose twice daily, but the February 2026 MAR showed multiple missed doses and entries documenting the medication as unavailable, along with documentation of administration on some shifts when it was also recorded as unavailable on other shifts. An APRN note identified the resident as high risk for UTIs due to the chronic urinary Foley and poor fluid and food intake. For Resident #14, who had dementia, diabetes, BPH, urinary incontinence, and risk for urinary complications, a physician order directed D-Mannose twice daily for UTI prevention. The February 2026 MAR showed the medication was not administered 22 out of 51 opportunities and was coded as unavailable. The MAR also contained conflicting documentation, with several times when D-Mannose was documented as given even though it was recorded as unavailable on the same day or surrounding shifts. An LPN stated the medication was not on the medication cart and had been unavailable since about 2/20/26. For Resident #20, who had dementia with behaviors, sepsis, and type 2 diabetes, the care plan and APRN note identified UTI risk and the physician ordered D-Mannose twice daily and UTI monitoring every shift. The February 2026 MAR showed conflicting entries in which D-Mannose was documented as unavailable on some shifts and given on others, despite staff stating the medication was not in the facility. The central supply clerk stated she did not place an order for D-Mannose when the physician order was initiated, and later an order was placed for a case of the medication, but it had not yet arrived by the end of the review period.
Failure to Protect Dependent Resident From Possible Physical Abuse and Unexplained Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent resident from physical abuse and to ensure the resident remained free from injuries of unknown origin. The resident had hemiplegia and hemiparesis affecting the left side, aphasia, depression, and anxiety, with a BIMS score of 3 indicating severely impaired cognition. The care plan documented that the resident was dependent on staff for bed mobility and transfers and required assistance of one staff member for activities of daily living and transfers in and out of bed and chair. The resident was also identified as at risk for falls due to decreased functional mobility and hemiplegia/hemiparesis. On the evening in question, an LPN reported that the NA assigned to the resident approached him in an upset and erratic manner, stating she should not be working because it was her mother’s birthday, and then left the shift early. When the LPN entered the resident’s room to administer medications, he discovered the resident with multiple injuries, including a swollen right lip with a laceration, an abrasion and quarter-sized bump on the forehead, and bruises on the back of the right wrist and thumb area. The resident, who communicated primarily through yes/no responses due to aphasia, initially nodded no when asked if he had fallen or bumped his head and was unable to explain how the injuries occurred. The facility documented this as an injury of unknown origin. Subsequent interviews and observations further highlighted the unexplained nature of the injuries and the possibility of abuse. Another NA who came on after the first NA left reported that the resident was incontinent of stool, required assistance of two staff for personal care, and that stool was found on the floor near the bed when she later provided care and observed the injuries. The DON stated the resident would not have had the ability to get up independently and would likely require two staff to assist if a fall had occurred, and there were no residents on the unit who wandered or had a history of aggression. In a later interview, the resident, with a family member present, verbally identified that the NA who had left the shift early had struck him, and demonstrated this by forming a fist and touching his forehead, while also acknowledging a fall but without being able to provide details. The facility’s own abuse policy required that injuries of unknown origin be investigated as potential abuse when the source is not observed or cannot be explained, or when the injury is suspicious due to its extent, location, or number, conditions that were present in this case.
Medication Order Transcription Error Led to Overdose
Penalty
Summary
A deficiency occurred when a resident with a seizure disorder received incorrect dosages of Lamotrigine due to a failure in accurately transcribing medication orders. The resident had physician orders for Lamotrigine that required a dosage adjustment, with the previous 100 mg dose to be discontinued and a new 125 mg dose to be started. However, the previous order for 100 mg was not discontinued in the medication administration record, resulting in the resident receiving both the 100 mg and 125 mg doses on two consecutive days. This error was identified through clinical record review, facility documentation, and interviews with facility staff. The resident's care plan included interventions to medicate as ordered and monitor for effectiveness, and the facility's medication orders policy required discontinuation of previous entries when a dosage change occurred. Despite this, the transcription error led to the administration of an excessive dose of Lamotrigine. The facility did not have a specific medication order transcription policy, and the error was attributed to the failure to discontinue the previous order when entering the new one.
Failure to Re-Admit Hospitalized Resident After Psychiatric Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite the hospital psychiatric team determining the resident was not a risk to self or others. The resident, who had diagnoses including alcohol abuse with alcohol-induced Korsakoff's psychosis, depression, and dementia, had previously exhibited inappropriate behavioral symptoms, including inappropriately touching staff. After a second incident of inappropriate touching, the resident was placed on one-to-one observation and transferred to the emergency department for psychiatric evaluation. The hospital records indicated the facility required psychiatric clearance for the resident's return, and after clearance was provided, the facility refused to re-admit the resident. Interviews and documentation revealed that the facility informed the resident's conservator and the hospital that the resident would not be allowed to return, citing repeated behavioral incidents. The facility did not initiate a consultative process with the hospital and did not have a specific policy for emergency discharges. The facility's own policy stated that involuntary transfer or discharge is permitted when the health and safety of individuals in the facility is endangered, but there was no evidence of a formal process or documentation supporting the emergency discharge in this case.
Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to timely notify a physician of a resident's change in condition. The resident, who had Alzheimer's Disease, anxiety disorder, and osteoporosis, was found to have a bruise and discoloration on the right pinky finger and hand during the night shift. The nurse supervisor assessed the resident but did not immediately report the change to the physician, intending to review previous notes first. The nurse became distracted by a re-admission and routine duties, ultimately forgetting to notify the physician until the morning shift, when another nurse aide reported the injury again. Further assessment in the morning revealed swelling and abnormal positioning of the resident's right pinky finger, prompting immediate notification to the next nurse on duty, who then contacted the APRN. An x-ray confirmed a displaced fracture, and the resident was sent to the emergency department. Facility policy required prompt notification of the physician and responsible party for any significant change in condition or injury, which was not followed in this instance, as the injury was identified several hours before the physician was notified.
Failure to Prevent Injury During Hoyer Lift Transfer
Penalty
Summary
A resident with Alzheimer's disease and severe cognitive impairment, who was dependent on staff for activities of daily living including transfers, was found to have a large bruise on the left chest during morning care. The resident's care plan required the use of a Hoyer lift for transfers due to impaired mobility and cognition. Clinical documentation indicated that the bruise measured 6.5 cm in length and 10.5 cm in width, and an X-ray of the left ribs was negative for fracture. The bruise was determined to be of unknown origin at the time of discovery. Facility investigation revealed that the bruise aligned with the Hoyer lift bar, suggesting that the bar may have swung and struck the resident's chest during a transfer. Staff interviews conducted for the 24 hours prior to the incident did not identify any specific event or issue that could have caused the injury. The facility's policy required safe handling and transfers to minimize risk of injury, but the incident indicated a failure to ensure the resident remained free from injury during a Hoyer lift transfer.
Failure to Provide Podiatry Services to Diabetic Resident
Penalty
Summary
The facility failed to provide necessary podiatry services to a long-term resident with type II diabetes mellitus, muscle weakness, difficulty in walking, and repeated falls. The resident, who was admitted in August 2023, had a physician's order for podiatry services as needed. Despite this, observations in May 2024 revealed that the resident had excessively long toenails, which were uncomfortable and jagged, causing them to get caught on sheets. The resident reported that their toenails had not been cut since before their admission to the facility, nearly nine months prior, despite having complained to nursing assistants multiple times. Interviews and record reviews indicated that the facility's policy required diabetic residents to be seen by a podiatrist. However, there was no record of podiatry consent or services for the resident. Nursing staff, including an RN and an LPN, failed to identify the issue during weekly body audits, and the social worker, who was the podiatry liaison, was unaware of the resident's need for podiatry services. The deficiency was identified when surveyors inquired about the resident's toenail care, leading to the discovery of the oversight.
Failure to Notify Physician of Missed Weights
Penalty
Summary
The facility failed to notify the physician when weights were not obtained for a resident as per the physician's order. Resident #62, who had diagnoses including heart failure, hypertension, and COPD, was identified as being at risk for nutritional deficit. The care plan required monitoring of weights and notifying the physician of any significant weight changes. A physician's order specified that the resident should be weighed every night shift, with notification to the physician if there was an increase of 2-3 pounds per day or 5 pounds per week. However, the clinical record revealed that Resident #62 was not weighed for four consecutive days due to a broken scale, and there was no documentation indicating that the physician was informed of this lapse. Interviews with RN #6 and an Advanced Practice Registered Nurse confirmed that the physician was not notified, despite the availability of another scale in the facility. This oversight was contrary to the facility's policy, which emphasized the importance of regular weight monitoring as an indicator of the resident's nutritional status and medical condition.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #67, who was diagnosed with major depressive disorder and alcohol dependence. The resident exhibited behaviors such as agitation, cursing, sexual inappropriateness, and refusal of care, which were documented in nurse's notes over several months. Despite these documented behaviors, the Resident Care Plan (RCP) did not include a plan addressing these issues. Interviews with staff, including an LPN and the Director of Nursing Services (DNS), revealed that although the behaviors were discussed in morning reports, there was no formal documentation or care plan in place to address the resident's noncompliance and behaviors. The facility's Comprehensive Care Plan policy requires documentation of refusals and behaviors in the resident's clinical records, which was not adhered to in this case. The DNS acknowledged awareness of the resident's behaviors but was unaware that a care plan had not been developed. The MDS nurse, responsible for the noncompliance care plan, also did not ensure that a care plan was created. This lack of documentation and formal planning led to the deficiency in addressing Resident #67's needs and behaviors effectively.
Failure to Implement Bowel and Bladder Continence Care
Penalty
Summary
The facility failed to assess and implement a plan for bowel and bladder continence for two residents. Resident #53 was admitted with diagnoses including fall, aspiration pneumonia, and acute kidney injury. Despite being cognitively intact and using a walker, the nursing admission assessment did not address bowel and bladder continence. The resident was incontinent of bladder and bowel multiple times and expressed a preference for using a toilet, which was not accommodated. The DNS acknowledged the lack of a bowel and bladder assessment and the oversight during the facility's weekly Standards of Care meeting. Resident #67, with a history of urinary tract infections and urogenital implants, was frequently incontinent of urine and bowel. Despite being identified as a candidate for retraining and toileting schedules, no such programs were implemented. The resident experienced incontinence due to delayed assistance and was unaware of the urge to use the bathroom. Interviews with staff revealed a lack of communication and understanding of the facility's bowel and bladder retraining policies, with no clear process for initiating or documenting toileting programs. The facility's policies directed the completion of bowel and bladder assessments and retraining programs, but these were not followed. The DNS and staff interviews highlighted a lack of documentation, communication, and follow-up on residents' bowel and bladder functioning. The facility's failure to implement appropriate continence care and retraining programs contributed to the residents' decline in bowel and bladder function.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure timely identification and response to significant weight changes for two residents. Resident #14, who was admitted with diagnoses including dementia, congestive heart failure, and diabetes, experienced a significant weight loss of 23.2 pounds over two months. Despite physician orders for daily weights, there were no recorded weights from December 21, 2023, to February 16, 2024. The dietician, responsible for monitoring weight changes, was unavailable for part of this period and was not informed by staff about the weight loss. It was only on her third visit, 24 days after the weight loss, that the dietician recognized the issue. Resident #62, with diagnoses including heart failure and COPD, was not weighed for four consecutive days due to a broken scale, despite physician orders to weigh the resident nightly and report any significant weight changes. The facility's weight policy requires re-weighing within 24 hours for any weight gain or loss of 5 pounds or more. However, the resident was not weighed during this period, and RN #6 could not provide an explanation, although alternative weighing options were available.
Failure to Follow Physician's Oxygen Order
Penalty
Summary
The facility failed to follow the physician's order for oxygen administration for a resident diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), anxiety disorder, and dementia. The resident was severely cognitively impaired and dependent on staff for various activities of daily living. Observations on two separate occasions revealed that the resident was receiving oxygen at a rate of 3.0 liters per minute (LPM) via nasal cannula, despite the physician's order specifying 2.0 LPM. This discrepancy was noted during an observation on 5/10/24 and again on 5/13/24. An interview with an LPN revealed that she was unaware of the mismatch between the oxygen concentrator settings and the physician's order, as she did not typically work on the resident's unit and had not yet checked the oxygen settings during her shift. The facility's Oxygen Therapy policy requires that oxygen administration follow a physician's order and that the flow meter be set to the prescribed rate, which was not adhered to in this case.
Failure to Monitor and Document Targeted Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors for a resident receiving psychotropic medications, as per the physician's order. The resident, who was diagnosed with major depressive disorder and alcohol dependence, was cognitively intact and required assistance with personal hygiene and mobility. The care plan required monitoring and documentation of signs and symptoms of depression, but the facility did not comply with these requirements. A physician's order specifically directed monitoring for increased anxiety, yelling, agitation, or unusual behaviors, but the Medication Administration Record and Treatment Administration Record from December 2023 through May 2024 did not include documentation of such monitoring. Interviews with facility staff revealed that behavior monitoring was not conducted due to an incorrect entry by a previous APRN. The RN responsible for the resident's care was unable to locate behavior monitoring documentation in the clinical record, and the ADNS confirmed that the orders for behavior monitoring had been incorrectly entered, leading to a lack of monitoring from November 2023 through May 2024. The facility's policy on psychotropic medications required behavioral monitoring to record specified target behaviors, but this was not adhered to, resulting in a deficiency.
Improper Temperature Control for Medication Storage
Penalty
Summary
The facility failed to maintain proper temperature controls for drugs and biologicals in one of the two medication rooms reviewed. During an observation and interview with the Infection Preventionist, it was identified that the Windsor Court medication refrigerator had recorded out-of-range temperatures on 13 out of 16 days in May 2024, with temperatures ranging from 49 F to 60 F, and on 3 out of 30 days in April 2024, with temperatures between 47 F and 54 F. The medications stored in this refrigerator included carboxymethyl cellulose sodium, lispro, Levemir, Trulicity, Aranesp syringes, and lorazepam oral concentrate. The Infection Preventionist was unable to explain why the temperatures were not rechecked or how long the medications had been exposed to these unacceptable temperatures. An interview with an LPN revealed that the responsibility for checking the refrigerator temperature fell to the 11:00 PM to 7:00 AM nurse, who should report any out-of-range temperatures to maintenance. The facility's Medication Storage policy, aligned with the United States Pharmacopeia and the Centers for Disease Control, mandates that refrigerated medications be kept between 35 F to 46 F. However, the facility did not adhere to this policy, leading to the deficiency in maintaining proper storage conditions for medications.
Failure to Maintain Clean Laundry Environment
Penalty
Summary
The facility failed to maintain a clean environment in the laundry room's drying and folding areas. During an observation with the Infection Preventionist, a moderate coating of white/gray debris, identified as lint, was found on the protective covering over the blades of two wall-mounted fans. These fans were blowing directly onto clean, uncovered laundry on the clean linen cart. Additionally, a moderate amount of similar debris was observed on the tops of the dryers. Interviews with the Maintenance worker and the Laundry Attendant revealed that the dryer tops and fans required cleaning, and it was the responsibility of the laundry staff to clean them as needed. However, there was no cleaning schedule implemented for the fans. The Director of Environmental Services confirmed that the laundry staff were responsible for cleaning the laundry area but was unable to locate a cleaning schedule or a checklist for cleaning the fans or dryer tops. The facility's Laundry Service policy, dated 8/19/22, directed that the cleaning schedule must be posted and up to date.
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a level II PASRR evaluation following a new psychiatric diagnosis. The resident, admitted in June 2020, had diagnoses including chronic obstructive pulmonary disease, anxiety, and lung neoplasm. Initially, a negative PASRR level I was recorded with no diagnosis of Alzheimer's dementia or mental illness. However, a progress note dated September 29, 2022, identified a new diagnosis of schizoaffective disorder. Despite this, the clinical record did not show that a PASRR level II was conducted. The resident's care plan noted the use of psychotropic medications and mood and behavior disorders, with interventions to assist in expressing feelings and de-escalation. During an interview, a social worker confirmed that the state agency should have been notified for a level II PASRR assessment following the new diagnosis.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 571 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near East Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ark Healthcare & Rehabilitation At Branford Hills | 0.9 mi | ★★★★★ | 24 | 0 |
| Apple Rehab Laurel Woods | 2 mi | ★★★★★ | 11 | 0 |
| New Haven Center For Nursing & Rehabilitation Llc | 3.3 mi | ★★★★★ | 46 | 1 |
| Mary Wade Home, The Incorporated | 3.7 mi | ★★★★★ | 4 | 0 |
| Apple Rehab West Haven | 4.5 mi | ★★★★★ | 37 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.