Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Abbey Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Cold lunch items were not consistently held at safe temperatures during meal service observation, with a turkey croissant and puree turkey measuring above the required 41 degrees F while the DM confirmed the items were ready for resident consumption. In separate observations, kitchen staff handling food did not perform proper hand hygiene: one staff member touched exposed food and her chin without washing, and another touched food and then self-contacted clothing and skin without washing. The DM confirmed staff had been trained on hand hygiene and glove use, but the observed practices did not follow those standards.
A facility failed to maintain resident dignity during room care, communication, and meal service. One resident was left lying in tobacco saliva and debris with the call light out of reach, an LPN repeatedly told another resident to speak English, and a resident was briefly tapped on the buttocks in the dining room. Other residents were seated away from tables, served last, or assisted with meals while staff stood over them, and staff said residents needing feeding help often waited until last because of limited staffing.
Homelike Environment Not Maintained on Secured Unit: Surveyors observed 15 resident rooms on the secured unit with bare walls, minimal decor, no personal touches, and sparse common areas with non-inviting seating. A family representative said the unit was not very home like, and the NHA and DON acknowledged the area needed more items to make it feel more homelike, with the DON noting they were waiting for budget approval.
The facility failed to provide enough nursing staff to meet resident needs and to ensure a licensed nurse was in charge on each shift. Two cognitively intact residents reported that evening meds were late because one nurse was covering about 40 residents, and MAR review confirmed delayed administration of scheduled meds and repeat oxycodone doses. Resident council members reported call lights could take 1 to 2 hours to answer and that residents had waited up to 2 hours for bathroom help and incontinence care. An LPN on the 100 hallway and another LPN on the 200 hallway described heavy workloads, late starts, and limited support, while the staffing coordinator stated the facility needed more staff.
Staff failed to follow infection control practices during meal service and contact precautions. Residents on the secure unit were served meals without being offered hand hygiene, an RN and CNA passed trays without hand hygiene, and one CNA handled food with bare hands. In a room under contact precautions, a CNA removed gloves without hand hygiene and entered without a gown, despite staff stating that hand hygiene and gown/glove use were required.
Surveyors found that the facility failed to follow care plan interventions for two residents: one who used a scoop plate for eating and another who required a call light within reach. A resident with CVA-related hemiparesis, dysphagia, and dementia was repeatedly served meals with the high side of the scoop plate positioned away from him, causing food to be scraped off the plate, while staff did not adjust the plate and the meal ticket lacked instructions on proper positioning. Another cognitively intact resident with multiple neuropsychiatric diagnoses and an ADL self-care deficit was observed several times in bed with her call light on the floor or clipped to the back or top of her pillow, out of reach, despite a care plan requiring the call bell and call light to be kept within reach in her room and bathroom.
A resident with cognitive impairment and psychiatric diagnoses alleged that a CNA slapped him while he was being taken to the shower room after vomiting. Staff heard a loud smack and elevated voices, but the resident was then left alone in the shower room with the CNA, and no nurse assessed him for possible marks or skin changes after the allegation. The AD reported the resident was being handled roughly, while the CNA denied abuse and said the resident had a history of accusing staff of hitting him.
PASARR screening was not completed correctly for three residents with qualifying mental health diagnoses. One resident had no Level I PASARR before admission and no Level II request after diagnoses including schizoaffective disorder, bipolar disorder, and anxiety. Two other residents had Level I PASARRs showing mental illness and, in one case, intellectual disability/serious mental illness, but no Level II PASARR evaluations were submitted. The SSD stated the Level I screens were incorrect and that Level II requests were delayed pending completion of Level I screens and psychiatry notes.
Delayed care plan revision for resident behaviors. A resident with cognitive impairment, schizophrenia, psychosis, anxiety, and a history of TBI repeatedly yelled, accused staff and residents of hitting him, and engaged in self-injurious behaviors such as biting himself and picking at scabs. During one incident, staff heard a loud smack and the resident alleged he had been slapped, but he was not assessed for marks or skin changes, and staff later confirmed the behavior care plan had not been initiated until much later despite the behaviors being known to multiple staff members.
Two residents did not receive meal assistance despite documented needs for help with eating. One resident with severe cognitive impairment, hemiplegia, dementia, and malnutrition was observed trying to scoop food and dropping it on the table, while another resident with severe cognitive impairment and dependence for eating was observed feeding herself without assistance. Care plans identified assisted dining or dependent assist for eating, and CNAs and the DON acknowledged that residents who need help with meals should be assisted.
A resident with severe cognitive impairment and a BIMS score of 0 had change-in-condition documentation listing the resident as the responsible party or notifying the resident’s own RP, despite records showing family contacts and staff confirming the resident could not make decisions for himself. The DON and SSD acknowledged the resident’s impaired cognition and that family communication was expected for updates, labs, and condition changes, but the documentation did not reflect proper notification of the resident representative.
Failure to monitor and report abnormal catheter urine. A resident with a nephrostomy catheter and diagnoses including anoxic brain damage and obstructive/reflux uropathy had dark red, cloudy, red, and amber urine observed in the catheter bag. The care plan required staff to observe, document, and report signs of UTI and catheter complications, but a CNA did not report the red urine because it was believed to be normal, an LPN was unaware of the change, and the EMR showed no physician follow-up or documentation of the abnormal urine color.
Oxygen therapy was not provided per physician order for a resident with anoxic brain damage and chronic respiratory failure who received oxygen via trach. An observation showed the oxygen concentrator set at 9 LPM instead of the ordered 7 LPM, and staff stated the nurse was responsible for setting and maintaining the concentrator according to the order. The ADON acknowledged the incorrect setting and said nurses should check oxygen settings during care and med passes.
Inadequate behavioral documentation, supervision, and staffing on the secured unit. A resident with TBI, schizophrenia, depression, anxiety, and psychosis was observed yelling that a CNA hit him, but the nurse did not assess him for marks and the resident was left alone with the CNA in the shower room. His chart showed repeated behaviors such as yelling, accusations, agitation, and self-injury, yet the behavior task documented no behaviors observed. Two other residents were observed with limited supervision during meals, including one resident who was dependent for eating but was seen feeding herself, while staff reported the unit was short an aide and lunch care was challenging.
Pharmacy recommendations to stop unnecessary lithium level labs were not fully carried out for a resident whose lithium had been discontinued. The consulting pharmacist noted the resident was still getting monthly lithium labs despite no active order for the medication, and repeated the recommendation after the lab continued. The DON said there was confusion because two lithium lab orders existed, one monthly and one every 3 months, and both were later discontinued.
A resident with a suprapubic catheter missed outside ophthalmology and urology appointments. The resident said he needed eye care for his vision and monthly urology follow-up, but the transportation log and appointment binder had no entries for him, and records noted a missed urology visit due to transport issues. Staff interviews showed the facility relied on nursing, medical records, and MAR-based coordination, but the process did not result in the resident’s appointments being arranged and completed as expected.
A facility failed to inform a physician of critical lab values for a resident receiving Vancomycin, leading to ICU admission for renal dialysis due to Vancomycin toxicity. Nursing staff did not follow protocol to notify the physician or DON, and lab results were not reviewed or communicated properly. Additionally, another resident with a history of substance abuse and elopement left the facility unnoticed, highlighting inadequate supervision and risk assessment.
The facility failed to ensure staff donned appropriate PPE while caring for residents under Enhanced Barrier and Transmission Based Precautions. A CNA did not wear a gown while providing care to a resident with a gastrostomy tube, and failed to perform proper hand hygiene. The CNA was unaware of the specific precautions required and did not see the necessary signage. Additionally, the CNA had long artificial fingernails, against facility policy. The facility's policies on isolation precautions and personal hygiene were not adhered to, leading to the deficiency.
Cold Food Temperature Control and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure planned cold lunch items were held at or below the required temperature during meal service observation on 4/1/2026. The posted lunch menu included turkey croissant, macaroni salad, relish salad, pudding, and an alternate of beef stew. The Dietary Manager confirmed the primary lunch items were to be served cold and should be below 41 degrees F, and staff stated the items had been prepared and were ready for resident consumption. During temperature demonstrations, the turkey croissant with cheese reached 47.9 degrees F and later 46.9 degrees F, and the puree consistency turkey reached 44.4 degrees F and later 44.6 degrees F. The macaroni salad and mechanical soft sandwich reached 40 degrees F, and the turkey croissant later reached 40.6 degrees F, but the puree turkey did not meet the required holding temperature. The Dietary Manager stated the cold items were normally prepared and placed in the walk-in refrigerator for about an hour before meal service and then set in ice to maintain temperature, with temperatures documented on a food temperature log. On the day of observation, he confirmed the process had been completed, but some items did not get below 41 degrees F. Because two food items did not meet the minimum holding requirement, the Dietary Manager stated the items would be taken off the service table and placed in the walk-in freezer longer, and he confirmed the lunch meal would be served late due to the delay. The facility also failed to promote good hand hygiene during food handling. On 4/1/2026, Staff A conducted a food temperature demonstration while wearing one glove on the left hand and no glove on the right hand, and was observed touching exposed food items and the side of her chin with her right hand without washing her hands afterward. On 4/2/2026, Staff C was observed at the steam table without washing her hands before the demonstration, touching food items with her bare right hand, and then touching her pants, left hand, and arm without washing during the observation. The Dietary Manager later confirmed staff had been trained on hand hygiene and should wash hands after touching self, food items, or potentially contaminated surfaces, and that hands must be washed before wearing gloves and between changing gloves.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to promote and maintain dignity for residents during activities, meal services, and while residents were in their rooms. One resident was observed lying in bed with the call light cord/button out of reach and with dark saliva and brown matter from chewing tobacco on the resident’s mouth, bedding, mattress, bed frame, and nearby trash can. The resident stated the tobacco spit had been on the bed since the day before and that the call light was out of reach when the resident wanted staff to clean it up. The resident’s record showed diagnoses including encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood disorder, and anxiety, and the DON acknowledged staff should have cleaned the area and that the resident should not have remained in it for long periods of time. During another observation, a resident was heard speaking in a language of choice in the hallway, and an LPN repeatedly redirected the resident to speak English, stating, "Speak English." In the dining room, another resident was observed standing between tables and chairs while an LPN briefly tapped the resident on the buttocks. A different resident was observed seated alone away from other residents near a sink without a table while waiting for a meal and was served last; on another day, that resident remained in bed while other residents were served and assisted, then was brought to the dining room after others had already eaten. On a later observation, the same resident was moved away from a table to a chair without a table and was assisted with the meal after the other residents had been served. Additional observations showed residents needing feeding assistance were handled in ways that did not maintain dignity. One resident was assisted with a meal while staff stood next to the resident, and another resident was overheard being described by staff as "a feeder" who needed help eating. Staff interviews reflected that residents needing meal assistance often had to wait until last because there were only two aides and a nurse on the floor. The facility policy stated that each resident has a dignified existence and the right to be free of interference, coercion, discrimination, and reprisal, and the NHA stated dignity should always be held, residents should be knocked on for, covered, and addressed by preferred names.
Homelike Environment Not Maintained on Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment in 15 resident rooms (#1 through #15) on the secured unit (300 Hall). During multiple tours of the unit from 03/30/3026 through 04/02/2026, surveyors observed plain hallways with minimal decor, no personal touches or affects throughout the physical environment, bare resident rooms with no personal effects, and common areas that were sparse with little decoration and non-inviting seating. The overall atmosphere was described as lacking warmth, comfort, and familiar features. Residents on the secured unit could not be interviewed because of severe cognitive impairments. A family representative stated that the place could use some personal touches and was not very home like. The NHA confirmed the secured unit could use more items to make it feel more homelike and stated the walls were bare. The DON stated the facility was working on getting items that were more interactive and could not be removed from the walls, but said they had to wait for budget approval. Review of the facility policy titled Physical Environment, effective August 2024, stated that a safe, clean, comfortable, and home life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible.
Insufficient Nursing Staffing Caused Late Medications and Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. During the evening medication pass, Resident #100, who was cognitively intact with diagnoses including major depressive disorder, opioid dependence, chronic pain syndrome, chronic systolic heart failure, and hypertension, reported that staffing was low and that only two nurses were covering the 100 hallway instead of the usual three. The resident stated the nurse was rushing and had close to 40 residents to medicate. Record review showed scheduled medications, including pregabalin and oxycodone, were administered late on 3/29/2026, with the 5:00 p.m. doses given at 7:06 p.m. and another oxycodone dose given at 8:30 p.m. Resident #94, who was cognitively intact and had diagnoses including COPD with exacerbation, hypertension, major depressive disorder, generalized anxiety disorder, and dislocation of an internal left hip prosthesis, also reported that evening medications were late because the nurse assigned to the hallway had 40 residents to administer medications to. Her medication record showed that scheduled 5:00 p.m. doses of baclofen, ipratropium-albuterol, buspirone, and oxycodone-acetaminophen were administered at 7:40 p.m., and the next oxycodone dose was given at 8:38 p.m. Staff Y, an LPN assigned to the 100 hallway, stated he and one other nurse covered the entire hallway, that he did not get a bathroom break or a break in general on Friday, and that the same situation occurred on Sunday when normally there are three nurses on the hallway. He stated he knew residents were unhappy with their care and questioned whether a good nurse could realistically get the work done. Resident council members reported that the 7 a.m.-3 p.m. and midnight shifts needed extra help and that call lights could take one to two hours to be answered. They also reported residents had been left in the bathroom waiting for assistance for up to two hours and had waited up to two hours for incontinence care. Staff O, an LPN on the 200 hallway, stated she had 18 residents, including 4 with tracheostomies, 6 with gastrostomy tubes, and 3 wound dressings, and that she had a late start because the night shift nurse was still providing care and overwhelmed by workload. The staffing coordinator stated she was new to the position, used PPD and census to determine staffing, had not used the facility assessment to staff the building, and said, "We need more staff."
Infection Control Failures During Meal Service and Contact Precautions
Penalty
Summary
The facility failed to follow infection prevention and control practices related to hand hygiene during meal service and transmission-based precautions. On the secure unit (300 hall), residents were observed sitting in the dining room while staff began passing meal trays without offering hand hygiene before meals on three separate observations. During one meal service, an RN moved glasses from the top of her head to her face, lifted lids off the food on the meal cart, and passed trays without performing hand hygiene. A CNA also passed meal trays to multiple residents without hand hygiene in between and, while assisting a resident with a meal, grabbed a food item with bare hands and began cutting it up. Staff interviews stated that hand hygiene should be used in between residents and that residents should be offered hand hygiene before meals, but paper towel dispensers had been removed from rooms on the 300 unit, making hand hygiene difficult for staff to perform and dry properly. The facility also failed to follow contact precautions in room [ROOM NUMBER]. A CNA was observed exiting the room with gloves, removing and disposing of the gloves at the nurse’s station without hand hygiene, then later entering the room without a gown and reaching outside the room with a gloved hand to obtain a gown. The CNA stated that residents in the 200 unit were under contact precautions and that hand hygiene should be performed before and after care, along with gown and glove use before entering the room. An LPN stated that contact precautions required hand hygiene before entering and upon exit, along with gloves, gown, and mask. The facility policy on hand washing and glove use stated that hands must be washed before wearing gloves and dried using disposable paper towels, and the isolation precautions guidance stated that contact precautions require hand hygiene and gown use when caring for residents under contact precautions.
Failure to Implement Care Plan Interventions for Adaptive Eating Equipment and Call Light Access
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions related to adaptive eating equipment for one resident. During multiple lunch observations in the main dining room, a resident with a history of cerebral infarction, seizures, dementia, dysphagia, lack of coordination, muscle wasting, and hemiparesis with left-side neglect was served meals using a scoop plate. On at least two observed occasions, the high side of the scoop plate was positioned away from the resident, even though he scooped food inward toward himself. As a result, food was scraped off the plate onto the table and his lap. Staff present in the dining room did not adjust the plate to accommodate his scooping pattern, and the meal ticket only indicated “use of scoop plate” without specifying how it should be positioned, despite the resident’s care plan and therapy input indicating the need for adaptive equipment to support nutrition and functional limitations. The deficiency also includes the facility’s failure to ensure that a resident’s call light was within reach, as required by her care plan. Over several observations, the resident was repeatedly found in bed with the call light cord either on the floor behind the bed or clipped to the back or top of her pillow, out of her reach. On one occasion, she was lying in bed with dark-colored saliva and brown matter on her upper buttocks, mattress surface, bed frame, and nearby trash can, and she could not reach the call light. On subsequent days, the call light remained positioned where she could not access it, and she reported that staff routinely clipped it to the top of her pillow and that this happened all the time. The resident with the inaccessible call light had diagnoses including encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood disorder, and anxiety, but her most recent MDS showed she was cognitively intact with a BIMS score of 15 and required setup/cleanup assistance for personal hygiene, toileting, and toilet transfer. Her care plan included interventions specifying that the call bell should be within reach in her room, bathroom, and shower room, and that environmental adaptations should include keeping the call light within reach due to her risk for falls or fall-related injuries. Despite these documented interventions, staff practices resulted in the call light being placed out of her reach on multiple observed occasions.
Failure to Separate Resident After Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its abuse policy after an allegation of physical abuse involving one resident. On 3/30/26, while the Activities Director was approaching the closed shower room door on the secured 300 unit, she heard elevated voices, a loud smack, and the resident state, "He slapped me." When the door was opened, the resident was observed in a wheelchair with a pink substance on his shirt and pants, and he said the CNA slapped him. The CNA denied hitting the resident and said the resident slapped himself. The resident was then escorted into the shower room with the CNA, and the nurse walked away; the resident was left alone with the CNA in the shower room after the allegation was made. The resident involved had an admission date of 7/17/25 and diagnoses including traumatic brain injury, schizophrenia, psychotic disorder, mood disorder, anxiety, depression, and cerebral infarction. His record also showed a BIMS score of 8/15, indicating moderate cognitive impairment. The resident’s care plan included that he accuses others of hitting him when there is no one around, and the facility’s behavior task showed daily documentation of no behaviors observed. However, staff interviews described the resident as frequently yelling and accusing staff or residents of hitting him, while the Activities Director stated she had not previously observed that type of interaction between the resident and the CNA. The Activities Director reported that she heard the resident yelling that he was hit and saw the CNA pushing him in a rough and aggressive manner. She said she tried to get the resident away from the CNA because the situation felt hostile, and she reported the allegation to the NHA/Risk Manager. The NHA and DON later confirmed that, for an allegation of abuse between a staff member and a resident, the resident should have been separated from the staff member and made safe, and they confirmed the resident should not have gone back into the shower room with the CNA. The resident was not assessed by a nurse for markings or skin changes after the allegation, and the shower room door was closed with the CNA and resident inside without other staff present.
PASARR Screening Not Completed for Residents With Mental Illness and Related Conditions
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for three residents with qualifying psychiatric and related diagnoses. Resident #10 was admitted with diagnoses including schizoaffective disorder, bipolar type, depressive disorder, mood disorder, psychoactive substance abuse, antisocial personality disorder, generalized anxiety disorder, epilepsy, and alcohol use, but the record showed no Level I PASARR completed prior to admission and no Level II PASARR submitted after the qualifying diagnoses were identified. Resident #34 was admitted with diagnoses including dementia with behavioral disturbance, mood disorder due to a known physiological condition with mixed features, other psychotic disorder, major depressive disorder, generalized anxiety disorder, anxiety disorder, insomnia, and alcohol abuse. The Level I PASARR dated 1/30/26 identified multiple mental illnesses and showed yes responses in Section II, with Section IV indicating serious mental illness and intellectual disability, yet no request for a Level II PASARR evaluation was submitted. Resident #62 was admitted with diagnoses including unspecified dementia with anxiety and agitation, mood disorder due to a known physiological condition, major depressive disorder, other persistent mood disorders, pseudobulbar affect, cannabis use, bipolar disorder, anxiety disorder, and insomnia. The Level I PASARR dated 1/30/26 identified mental illness and Section IV indicated serious mental illness, but no Level II PASARR evaluation was requested. During interview, the SSD stated the Level I PASARRs were incorrect, that she completed the Level I screens for multiple halls, and that Level II PASARRs would be worked on after the Level I screens; she also stated she could not submit Level II evaluations without the DON and that Level II is requested when there are related conditions.
Delayed Care Plan Revision for Resident Behaviors
Penalty
Summary
The facility failed to revise Resident #80’s care plan in a timely manner related to behaviors. Resident #80 was admitted on 7/17/25 with diagnoses including traumatic brain injury, recurrent depressive disorders, schizophrenia, persistent mood disorder, psychotic disorder with delusions due to a known physiological condition, generalized anxiety disorder, unspecified psychosis, and cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and the behavior section marked that physical, verbal, and other behavioral symptoms were not exhibited. On 3/30/26, staff observed an incident in the shower room on the secured unit in which elevated voices were heard, followed by a loud smack and the resident stating, “Ow, he slapped me.” The resident was observed in a wheelchair with a pink substance on his shirt and pants. Staff F, CNA denied slapping the resident and stated the resident slapped himself. The Activities Director asked if the resident wanted assistance from an LPN, and Staff J, LPN responded that she had a care plan for vomiting on himself. The resident said he wanted the Activities Director to stay with him, but Staff J, LPN turned him around in the wheelchair, escorted him into the shower room, and left him with Staff F, CNA. The resident was not assessed by the nurse for markings or skin changes after the allegation, and the shower room door was closed with only the CNA and resident inside. Record review and staff interviews showed the resident had a pattern of yelling, accusing staff and residents of hitting him, and engaging in self-injurious behaviors such as biting himself, scratching himself, picking at scabs, and scraping his hands against the wheelchair. Staff members stated these behaviors were known and occurred repeatedly, but Staff J, LPN confirmed the care plan for the behavior of accusing staff and residents of hitting him was not initiated until the day before the interview. The DON stated nursing staff should have documented the behavior and the care plan needed to be updated when the behavior occurred. The facility policy required the interdisciplinary care plan to address resident needs, including behavioral management, and to be updated based on current diagnoses, interventions, and changes in condition.
Failure to Assist Residents With Meals
Penalty
Summary
The facility failed to provide assistance with meals for two residents who had documented needs for help with eating. Resident #34, admitted with diagnoses including cerebral infarction sequelae, left-sided hemiplegia and hemiparesis, protein-calorie malnutrition, dementia, muscle wasting, generalized weakness, anxiety, mood disorder, and psychotic disorder, was observed in the secure unit dining room attempting to scoop food from his plate and dropping it onto the table. On a later observation, the resident was again seen scooping food from his plate and feeding himself. His admission record showed severe cognitive impairment with a BIMS score of 02 out of 15, and his care plan identified a nutritional problem with an intervention for assisted dining and documentation of the amount of assistance needed with meals. Resident #61, admitted with diagnoses including metabolic encephalopathy, dementia, major depressive disorder, altered mental status, and convulsions, was observed in the secure unit dining room feeding herself without assistance. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 0 out of 15, and Section GG indicated she was dependent for eating, meaning the helper does all of the effort or two or more helpers are required. Her care plan also identified an ADL self-care performance deficit and listed eating as dependent assist of 1. During interviews, CNAs stated they would assist residents with meals if they saw they needed help, and one CNA stated Resident #61 needed assistance with meals and that she had helped her that day. The DON stated staff should be helping all residents who need assistance with their meals.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to ensure a notification of change was completed for a resident with severe cognitive impairment. Resident #129 had an admission record showing diagnoses including unspecified intracranial injury with loss of consciousness, unspecified sequelae of cerebrovascular disease, acute and chronic respiratory failure with hypoxia, encephalopathy, and tracheostomy status. The resident’s MDS and BIMS evaluations showed a BIMS score of 0, indicating severe cognitive impairment, yet the admission record listed the resident as the responsible party and identified two family members as emergency contacts. Record review showed change in condition evaluations documenting notifications to “SELF” or the resident’s own responsible party, including a 3/11/26 change in condition evaluation and a 3/28/26 change in condition evaluation. Progress notes also documented communication with the MD, ARNP, pharmacy, and “Resident own RP.” During interviews, the SSD and DON confirmed the resident had a BIMS of zero and could not make decisions for himself due to cognition, and the DON stated the expectation would be to call the family member for lab results, changes in condition, and updates. The facility policy required notification of the resident, resident representative, or legal representative when there was a significant change in condition, but the documentation reflected the resident as his own responsible party despite severe cognitive impairment.
Failure to Monitor and Report Abnormal Catheter Urine
Penalty
Summary
The facility did not ensure ongoing monitoring for changes in condition related to catheter use for one resident with a nephrostomy catheter. Resident #126 was admitted with diagnoses including anoxic brain damage and obstructive and reflux uropathy, and had an active order for a nephrostomy catheter with drainage every shift and as needed. The care plan identified the resident as having a urinary catheter with risk for infection and/or complications and directed staff to observe, document, and report signs and symptoms of UTI, including blood-tinged urine, cloudiness, no output, deepening urine color, fever, chills, altered mental status, and changes in behavior or eating patterns. Observations showed the resident’s catheter bag contained dark red and cloudy urine, and later red and amber urine. Staff O, an LPN, stated the physician should be notified if changes were observed in the resident’s output or color, but the EMR contained no documentation or follow-up with the physician regarding the observed urine changes. Staff P, a CNA, stated she observed red urine while providing morning care and draining the nephrostomy bag but did not report it because she believed it was normal. The ADON stated abnormal urine output would include a change in color and that the CNA should notify the nurse, who should assess the resident and notify the physician and family, but no documentation of abnormal urine output was provided.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility did not ensure oxygen therapy was provided per physician orders for Resident #126. The resident was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and had a care plan focus for oxygen therapy related to oxygen via tracheostomy and oxygen dependence. The physician order active as of 04/02/2026 directed humidified oxygen per trach continuously, 7 liters every shift for shortness of breath, effective 03/26/2026. On 03/30/2026 at 2:21 PM, observation showed Resident #126's oxygen concentrator was set at 9 liters per minute instead of the ordered 7 liters. Staff O, an LPN, stated the nurse is responsible for setting and maintaining the oxygen concentrator according to the resident's orders. The ADON stated nurses should follow the orders in the electronic medical record and check the oxygen concentrator settings every time they provide care or pass medications, and acknowledged the photographic evidence showing the concentrator set at 9 liters per minute. The facility policy on Oxygen Therapy stated oxygen is provided based on physician's orders and requires applying the device with the appropriate liter flow.
Inadequate behavioral documentation, supervision, and staffing on secured unit
Penalty
Summary
The facility failed to ensure nursing staff were competent to meet the behavioral health needs of residents on the secured unit. During observation, Resident #80 was heard yelling from a closed shower room after Staff F, CNA, was observed behind him in a wheelchair with a pink substance on his clothing. Resident #80 stated that Staff F slapped him, while Staff F denied hitting him and said the resident had slapped himself. The Activities Director observed the resident being pushed in a rough manner and aggressively by Staff F, and the resident was not assessed by the nurse for markings or skin changes that could indicate a slap or hit. Staff J, LPN briefly came to the shower room, but the resident and CNA were left together in the shower room without other staff present. The resident continued yelling that he had been hit. Resident #80 had diagnoses including traumatic brain injury, schizophrenia, psychotic disorder, major depressive disorder, generalized anxiety disorder, and cerebral infarction. His record showed an order for side effect monitoring every shift, and his care plan included behavioral interventions such as documenting episodes of behavior and reviewing their effectiveness. However, the behavior task for the last 30 days showed daily documentation of no behaviors observed. The record also showed multiple notes describing yelling, accusations, agitation, and impulsive verbalizations, and staff interviews confirmed that he frequently accused staff and residents of hitting him, yelled, picked at and ate his scabs, and bit himself. The DON stated that behaviors such as agitation, hitting, kicking, or biting could be documented in behavior monitoring or progress notes, and that documentation was important for psychiatry to know when evaluating medications and side effects. The deficiency also involved supervision and staffing on the secured unit. During observations, Resident #62 was seen in a room with the door closed, moving around slowly and opening drawers, while staff were observed in the dining room and at the nurse’s station. Resident #34 was observed in the dining room scooping food off his plate and dropping it on the table, and Resident #61 was observed feeding herself even though her MDS showed she was dependent for eating and her care plan indicated she required assistance. Staff interviews stated that the unit normally had three aides and one nurse, but on the day of observation there were only two aides and a nurse because one aide had been sent home, making lunch time challenging because residents needing assistance had to wait while trays were passed. Staff also stated that behaviors were not documented if they were considered usual for the resident, and that only certain behaviors such as resident-to-resident or sexual behaviors were documented.
Pharmacy Lab Monitoring Recommendations Not Completed
Penalty
Summary
The facility did not ensure pharmacy recommendations related to lab monitoring were completed for one resident. Resident #13 had a history that included other persistent mood disorders, undifferentiated schizophrenia, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. The resident had been prescribed Lithium Carbonate 300 mg daily for mood disorder, which was ordered on 6/14/2025 and discontinued on 12/12/2025. Psychiatric progress notes on 12/12/2025 stated the resident should continue lithium 300 mg daily because the last lithium level was very low and the resident had been stable, with consideration of restarting if mood destabilized. The consulting pharmacist completed monthly medication regimen reviews and documented that the resident was still receiving monthly lithium level labs even though the medication had been discontinued or was not reordered. On 01/08/2026, the pharmacist recommended discontinuing the lithium level lab order, and the recommendation was marked "Done" in the follow-through column. A later medication regimen review again noted that the resident no longer received drug therapy requiring lab monitoring and recommended discontinuing lithium levels, with the pharmacist stating she repeated the recommendation because the lab continued. Lab results for lithium remained low on multiple dates, and the DON acknowledged there had been confusion because two lithium lab orders existed, one monthly and one every three months. Psychiatric progress notes on 3/13/2026 documented that the resident remained stable and cooperative with care, with no behavioral disturbances, anxiety, or agitation reported.
Missed Outside Appointments Due to Scheduling and Transportation Failures
Penalty
Summary
The facility did not ensure outside physician appointments were arranged and scheduled in a timely manner for one resident who had a suprapubic catheter and reported needing monthly urology follow-up, as well as an ophthalmology appointment for vision concerns. During interview, the resident stated he had missed an outpatient ophthalmology appointment and also missed his monthly urologist appointment for March. An appointment card showed an ophthalmology visit scheduled for 01/16/2026, and the resident stated he needed to be seen by his eye doctor for his vision. Record review showed the resident declined the scheduled ophthalmology appointment on 01/16/2026, after which a new appointment was arranged for 02/02/2026. Progress notes also showed the resident returned from a urology appointment on 01/12/2026 with a follow-up scheduled for 02/02/2026, and later a nurse practitioner note stated the resident missed a recent urology appointment due to transport issues. Interviews with the RN/UM, ADON, and DON showed the facility used a transportation binder, nursing staff, medical records staff, and MAR entries to coordinate appointments and transportation, but the transportation log for January, February, and March had no entries for the resident and the March binder had no appointment entry for him.
Neglect in Lab Result Communication and Resident Supervision
Penalty
Summary
The facility failed to protect a resident from neglect by not informing the attending physician of critical lab values in a timely manner and continuing to administer Vancomycin despite these critical results. The resident, who had a history of chronic kidney disease and other serious health conditions, was receiving Vancomycin for an infection. Critical lab results indicating Vancomycin toxicity and elevated potassium levels were acknowledged by nursing staff but not communicated to the physician or acted upon appropriately. This led to the resident being admitted to the Intensive Care Unit for renal dialysis due to acute kidney injury and Vancomycin toxicity. The report details a breakdown in communication and protocol adherence among the nursing staff. Despite receiving critical lab results, the responsible nurses did not notify the physician or the Director of Nursing as required by the facility's policy. The Unit Manager and other staff members failed to review the lab results properly, and the results were not communicated to the pharmacy for appropriate dosing adjustments. The attending physician was not informed of the critical lab values, which could have prompted immediate medical intervention. Additionally, the facility failed to provide adequate supervision and a secure environment for another resident with a history of substance abuse and leaving medical facilities against medical advice. This resident was able to leave the facility unnoticed, despite having an intravenous site, and was later found in a hospital. The facility's failure to assess the resident's risk for elopement and provide necessary supervision contributed to this incident.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to implement an effective Infection Control and Prevention program, as evidenced by staff not donning appropriate personal protective equipment (PPE) while caring for residents under Enhanced Barrier Precautions and Transmission Based Precautions. Specifically, a Certified Nursing Assistant (CNA) did not wear a gown while providing care to a resident with a gastrostomy tube, who was under Enhanced Barrier Precautions. The CNA also failed to perform proper hand hygiene after exiting the resident's room and before interacting with another resident. The report highlights that Resident #5, who had a gastrostomy tube and was on Enhanced Barrier Precautions, did not receive care in accordance with the required infection control measures. The CNA entered the room without a gown, only wearing gloves, and did not follow the protocol of donning a gown and gloves before providing care. Additionally, the CNA was unaware of the specific precautions required for residents with certain medical devices, such as a g-tube, and did not see the necessary signage indicating the precautions. Furthermore, the facility's Infection Control Preventionist and Assistant Director of Nursing (ICP/ADON) confirmed that staff should be aware of the PPE requirements based on door signage and information received during reports. The report also noted that the CNA had long artificial fingernails, which is against the facility's policy due to infection control concerns. The facility's policies on isolation precautions and personal hygiene were not adhered to, contributing to the deficiency.
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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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare St Petersburg | 0.4 mi | ★★★★★ | 0 | 0 |
| Aventura At The Bay | 2 mi | — | 47 | 0 |
| Laurellwood Post- Acute And Rehabilitation Center | 2 mi | ★★★★★ | 9 | 0 |
| Brighton Bay Center For Rehabilitation And Healing | 2.1 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Gateway | 2.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.