Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alexander "sandy" Nininger State Veterans Nursing during CMS and state inspections, most recent first.
Food was not stored, prepared, distributed, and served according to professional standards in the Main Kitchen. Surveyors observed spoiled-looking raw mushrooms in the walk-in refrigerator, heavy food residue in the convection oven, dirty knives and a food processor with food particles on the blade, a bug zapper without a collection tray above a prep table, buildup in the dish area, broken floor tiles with standing water, and dirty plates in the plate-warmer. A water bottle and Bluetooth speaker were also found on a prep table near food items, and during tray-line service Staff I used bare hands with portion scoops that sank into pureed foods down to the handle and release mechanism.
Menu items and portion sizes were not followed during meal service. A regular-texture lunch chicken portion was observed smaller than the approved 4 oz serving, a resident’s breakfast tray was missing oatmeal listed on the ticket, another resident’s lunch tray was missing parslied potatoes from the approved alternate meal, and bite-sized fish portions were served using an underfilled 3 oz scoop.
Pureed diets were not served in the required consistency for multiple residents with puree orders. Observations showed pureed foods were thin, runny, and puddled on plates instead of holding shape as described by the facility's IDDSI-based standards and recipes. Residents with dementia, anxiety, seizures, depression, diabetes, and CVA were among those affected, and the Dietary Manager and SLP stated the facility followed IDDSI guidelines for puree consistency.
A resident reviewed for dementia care had psychoactive meds ordered for hallucinations and depression, including quetiapine and duloxetine. The record contained informed consent only for one duloxetine order, with no informed consent found for the other psychoactive meds ordered by the MD/NP/PA.
PASARR screenings were not accurately completed for 3 residents with mental health diagnoses. One resident’s PASARR listed dementia as the primary diagnosis despite hospital and psych eval records showing CHF, major depressive disorder, PTSD, and insomnia. Another resident’s PASARR had no mental illness diagnoses checked even though admission records listed psychotic disorder and depression. A third resident had multiple psychiatric diagnoses documented across the chart, including bipolar disorder, depression, PTSD, dementia, and psychosis, while staff described inconsistent PASARR review and completion practices.
A resident with PTSD, depression, bipolar disorder, and anxiety had no care plan with measurable goals or interventions for PTSD triggers and behaviors, despite reporting that touching and male caregivers were triggers and describing feeling uneasy and unsafe. Another resident with severe cognitive impairment and a history of falls had a toileting-based fall prevention plan, but staff did not follow the documented schedule and offered toileting far less often than planned.
Failure to update fall interventions after repeated falls. A resident with dementia, severe cognitive impairment, and dependence with toileting had falls while coming from the bathroom and while urinating. The care plan included basic fall precautions, but no new approaches were added after the first fall beyond short-term neuro checks and monitoring, and the RM agreed no new interventions were added to address the fall.
Failure to provide trauma-informed care for two residents with PTSD. Staff gave inconsistent answers about PTSD training, and the staff development coordinator said training was limited to watching a video and signing a sheet with no assessment of understanding. One resident’s trauma history and triggers were not reflected in the admission screening, while the resident later described childhood abuse-related trauma and a trigger of being touched. Another resident with PTSD related to combat had a care plan listing loud noises and fireworks as triggers, but staff responses showed limited understanding of the resident’s trauma history and behavior triggers.
A resident with dementia had orders for Quetiapine for hallucinations and Duloxetine for depression, but the MAR showed behavior monitoring only for the antipsychotic and not for the antidepressant. Progress notes also lacked documentation of mood or behavior changes related to depression or Duloxetine. An LPN and an RN stated that behavior and mood monitoring was expected for these psychotropic meds and should be documented on the MAR or in progress notes.
A resident with a history of adrenalectomy, bipolar disorder, dementia, and hypertension experienced significant weight loss, which the facility failed to address in a timely manner. The dietitian did not attend risk meetings consistently or communicate the weight loss to the resident's practitioner or nursing staff. Despite monitoring the resident's weight, the facility did not implement effective nutritional interventions, leading to a deficiency in maintaining the resident's nutritional health.
The facility did not provide fresh fruit to residents as per the menu, affecting eight residents who reported receiving fresh fruit only once or twice a week instead of daily. The diet technician confirmed the availability of bananas and other fruits but could not explain the discrepancy. Residents involved had various medical conditions and were mostly cognitively intact.
The facility failed to provide palatable and appetizing meals to several residents, as evidenced by consistent complaints about the food's taste and appearance. Despite varying cognitive impairments, residents reported that meals were bland, unappetizing, and inconsistent with their requests. A test tray confirmed the lack of seasoning and color variation, while the Food Service Director attributed the blandness to dietary restrictions, though the issue persisted across different diets.
The facility failed to provide the correct pureed diet consistency for several residents, serving meals that were lumpy and contained solid particles. This inconsistency was observed during multiple meal services, affecting residents with conditions like dysphagia and Parkinson's. The Food Service Director acknowledged the issue, and the Speech Language Pathologist confirmed that the pureed food should be smooth, as per facility policy.
The facility failed to maintain food safety and sanitation standards, affecting 106 residents. Observations revealed improper food storage, unclean kitchen equipment, and unsafe food temperatures. Nourishment rooms also had unsanitary conditions, with unclear cleaning responsibilities among staff.
A resident with Quadriplegia expressed a desire to be out of bed by 10:00 AM, as per their care plan, but was consistently left in bed until after 12:00 PM. Despite communicating this preference to staff, the resident was told the schedule was based on staff convenience. A CNA confirmed the resident's request but lacked the authority to change it. The DON was informed of these findings.
A resident with severe cognitive impairment lost his hearing aids, and despite his daughter's report to staff, the facility failed to investigate or update them. Staff interviews revealed a lack of awareness and communication, and the Licensed Social Worker only initiated an investigation after being informed by the surveyor.
The facility failed to provide timely assistance to residents, leading to prolonged waits for toileting help. A resident with quadriplegia was left in a fetal position for two hours without receiving a needed suppository. Another resident with cerebral infarction and diabetes reported frequent delays in receiving toileting assistance, sometimes waiting up to one and a half hours. A third resident with hemiplegia and spinal stenosis experienced a half-hour wait for help while on the toilet. Staff interviews suggested potential staffing inadequacies.
A resident with limited ROM did not receive a left hand splint as ordered by the physician. Despite multiple observations showing the resident with a contracture and no splint, staff interviews revealed a lack of awareness and documentation regarding the splint order. The Restorative team was responsible for applying the splint, but there was no record of its application in the electronic system.
A facility failed to provide adequate supervision during a Hoyer lift transfer, as a CNA used the lift without a second staff member, contrary to policy. Additionally, an oxygen tank was improperly stored beside a resident's bed, against facility policy. The resident required continuous oxygen therapy due to respiratory issues. Staff interviews revealed inconsistent practices in oxygen tank storage.
The facility failed to accurately reconcile controlled substances for two residents. One resident's Alprazolam administration was not documented in the controlled drug record, while another resident's Oxycodone administration was not recorded in the MAR. Staff interviews revealed lapses in following documentation protocols.
The facility failed to secure treatment and medication carts and did not dispose of expired medications. An unlocked treatment cart was observed in the Delta unit, and an LPN left a medication cart unattended during a resident altercation. Expired medications were found in a medication cart, despite regular checks by staff.
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. One resident lacked EBP guidelines in their care plan, and observations showed missing PPE and signposts. CNAs assisted the resident without gowns due to urgency and lack of PPE. Another resident also lacked EBP guidelines, with no signpost or PPE readily available. Staff relied on verbal reports for EBP adherence, indicating a failure in infection prevention and control.
The facility failed to maintain functional emergency call devices in two bathrooms on the Alpha Unit, with pull cords wrapped around grab bars and dragging on the floor. Staff interviews confirmed the cords should not be wrapped, and the DON acknowledged the absence of a policy on call devices.
The facility failed to follow physician's orders for wound treatment for two residents. One resident's dressing was not changed as required, and another resident had a skin tear dressing without a physician order. Both discrepancies were confirmed by staff and documented inaccurately.
Food Service Sanitation and Tray-Line Handling Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the Main Kitchen during multiple observations. In the walk-in refrigerator, a full 6-inch deep two-third-sized hotel pan of loosely wrapped raw white mushrooms was dated 05/08/26 and observed to be browned and discolored, and the Dietary Manager stated mushrooms can be refrigerated for up to 30 days. In the food processing area, the convection oven had a large amount of food residue on the interior top and bottom, and a metal sheet tray inside the oven had burnt-on food residue. In the cooking prep area, a knife drawer contained food residue and debris, and five knives had food residue or buildup in the grooves and handles. A food processor in the prep area had food particles on the blade when disassembled, and there was no sign or tag identifying it as not in use. A bug zapper was mounted above a stainless-steel prep table and had no collection tray or cover, with dust-like debris buildup on the appliance. Additional observations in the dish machine area showed white dried liquid splashes and buildup on shelves above the dish table and on the backsplash where clean dishes exited the washer and were placed to dry. Broken floor tiles were present where water accumulated and sat. In the steam table area, two plates inside the plate-warmer had dried food debris and dried coffee-colored liquid stains. During a later kitchen observation, an 8-ounce water bottle and an orange-colored Bluetooth speaker were found on a stainless-steel prep table near the oven next to single-use gloves and food equipment. During tray-line service, Staff I used plastic-handled portion scoops with bare hands, and the scoop for pureed bread sank into the food down to the handle and release mechanism that had been in contact with the staff member's bare hand; this also occurred with the pureed meat, starch, and vegetable items after it was pointed out by the surveyor.
Menu Items and Portion Sizes Not Followed
Penalty
Summary
The facility failed to follow the approved menu for the lunch meal served on 05/18/26 for residents ordered regular texture foods. The approved menu called for a 4-ounce portion of chicken marinated, but during observations in the Delta Blue Dining Room and later on the Alpha Unit and Main Dining Room, the chicken portions served to residents with regular texture diets appeared smaller than required. At 12:14 PM, the regular texture chicken on the steam table was weighed at 2.7 ounces, and the Dietary Manager acknowledged the issue and directed staff to provide two pieces per plate. The facility also failed to provide all menu items for two residents during meal observations on 05/19/26. Resident #65, who had severe cognitive impairment with a BIMS score of 04, was observed eating breakfast with a tray ticket listing oatmeal, but no oatmeal bowl was on the tray even though the approved menu included a 1/2 cup serving of cereal oatmeal and the resident stated he liked oatmeal. Resident #43, who had diagnoses including cancer, autoimmune gastrointestinal disease, diabetes, and hyperlipidemia and a BIMS score of 15, was observed at lunch with a tray ticket indicating no pork; the approved menu required an alternate meal of beef Swiss steak with tomatoes and parslied potatoes, but the tray did not include the parslied potatoes and the resident stated he liked potatoes and would have wanted them. In addition, on 05/20/26, staff were observed plating soft and bite sized fish using a 3-ounce scoop that was only about two thirds to half full, resulting in incorrect portioning for residents ordered that diet consistency.
Pureed Diets Served in Improper Consistency
Penalty
Summary
The facility failed to provide pureed foods in a form designed to meet the individual needs of 17 residents with orders for pureed diets. The facility stated it used the International Dysphagia Diet Standardization Initiative (IDDSI) 2.0 guidelines for pureed consistency, and its own recipes for pureed sauteed squash and pureed garlic mashed cauliflower described the food as able to hold its shape on a plate, not flow easily, and not be pourable. However, during observations, the pureed foods were found to be thin, runny, and not holding shape as described by the facility's standards. Resident #9 had dementia, depression, chronic gingivitis, a BIMS score of 01, and an order for puree with thin liquids. Resident #31 had anxiety, seizures, depression, and could not complete a BIMS because the resident was rarely or never understood. Resident #53 had diabetes and a CVA with hemiplegia and a BIMS score of 10. On observation, Residents #9 and #31 were eating lunch with pureed pork loin, noodles, mushrooms, and bread that appeared thin and runny, pooled on the plate, and did not hold shape. A tray line observation showed pureed bread, fish, cauliflower garlic mash, and squash medley were not thick or holding shape, with scoops sinking into the food and the items being poured onto plates with a liquid residue. Resident #53 was later observed with a pureed meal that also did not hold its shape and puddled on the plate. The Dietary Manager and Speech Language Pathologist stated the facility followed IDDSI guidelines for pureed food consistency.
Informed Consent Not Obtained for Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychoactive medications for Resident #98, who was reviewed during a Dementia Care investigation. Record review showed the resident had been prescribed Quetiapine 25 mg at bedtime for hallucinations and Duloxetine 30 mg at bedtime for depression, as well as Duloxetine 60 mg once daily at 9:00 AM for depression. The resident’s record contained informed consent only for Duloxetine 30 mg 1 capsule by mouth at bedtime for depression, and no informed consent was found for the other psychoactive medications ordered by the physician, NP, or PA. During an interview with the Administrator, the facility’s QAPI review included a Performance Improvement Program for informed consent for psychoactive medications, which had been completed on 5/1/26.
PASARR Diagnoses Were Not Accurately Reflected
Penalty
Summary
The facility failed to ensure accuracy of diagnoses included on PASARR screenings for residents with mental disorders or intellectual disabilities for 3 of 4 residents reviewed. For one resident, the PASARR identified dementia as the primary diagnosis even though the admitting diagnosis was chronic combined systolic and diastolic congestive heart failure, and the psychiatric evaluation after admission identified major depressive disorder, PTSD, and insomnia. During interview, the Social Services Director and MDS Coordinator acknowledged that the PASARR had been coded incorrectly and that the diagnosis information used from the hospital records did not match the PASARR entry. For another resident, the PASARR dated before admission had no diagnoses checked on the screen decision-making section related to mental illness or suspected mental illness, even though the resident’s admission diagnoses included psychotic disorder and depression. The Social Services Director reviewed the PASARR and stated it was not filled out correctly and should have included the resident’s diagnoses of depression and psychotic disorder. The Social Services Director stated she would complete a new PASARR. For a third resident, the record showed a prior Level I PASRR completed before admission that documented bipolar disorder and depressive disorder, and later records listed multiple psychiatric diagnoses including anxiety disorder, depression, bipolar disorder, PTSD, vascular dementia, major depressive disorder, dementia, and psychosis. The resident’s care plan and psychiatric note also documented ongoing treatment and monitoring for depression, anxiety, PTSD, bipolar disorder, dementia, insomnia, and psychotropic medication management. During interview, the Admissions Coordinator stated the admissions nurse requests the PASARR when a resident comes from the hospital or another facility and reviews it for accuracy, and that the psychiatrist may identify new diagnoses after admission.
Care planning deficiencies for PTSD behaviors and fall prevention
Penalty
Summary
The facility failed to develop and implement a care plan with measurable goals and interventions for a resident with behavioral and psychiatric needs. Resident #7 was admitted on 12/20/23 and, on the most recent quarterly MDS with a reference date of 03/18/26, had a BIMS score of 14 indicating cognitive intactness. The MDS documented little interest in doing things 2-6 times during the 14-day look back period, feeling down, depressed, or hopeless 2-6 days during the look back period, and feelings of loneliness or isolation sometimes. The assessment also identified anxiety disorder, depression, bipolar disorder, and PTSD. Record review showed there were no care plans with measurable goals and interventions for PTSD symptoms, including triggers and behaviors. During interview, the resident stated her PTSD was related to witnessing a sibling being abused and beaten by a parent, identified touching as a trigger, and indicated that male staff providing care was not acceptable to her. She described the reaction to triggers as feeling uneasy and unsafe, with shrugging and shivering. The facility also failed to follow the care plan interventions for a resident with falls. Resident #65 had diagnoses including dementia, benign prostatic hypertrophy, chronic kidney disease stage 3, colon cancer, and prostate cancer, and the quarterly MDS dated 04/07/26 showed a BIMS score of 04, indicating severe cognitive impairment. The resident was dependent for toileting and used a wheelchair or walker to ambulate. After falls on [DATE] and 03/16/26, the care plan was updated with a toileting schedule before meals, after meals, at bedtime, and as needed, totaling at least 7 offers per day. However, the Point of Care History Report for 04/21/26 through 05/21/26 showed the resident was offered toileting an average of 3 times per day and not at the times specified in the care plan. Staff and the Risk Manager acknowledged the toileting schedule was not being followed as documented, and staff were unable to provide written documentation of the resident's toileting schedule.
Failure to Update Fall Interventions After Repeated Falls
Penalty
Summary
The facility failed to investigate and update interventions in the care plan to prevent additional falls for Resident #65. The resident was admitted with diagnoses including dementia, benign prostatic hypertrophy, chronic kidney disease stage 3, colon cancer, and prostate cancer. The Quarterly MDS dated 04/07/26 showed a BIMS score of 04, indicating severe cognitive impairment. The resident was dependent with toileting and used a wheelchair or walker to ambulate. The care plan dated 01/07/26 included fall-related approaches such as encouraging out-of-room activities to increase supervision, bilateral 1/4 upper side rails while in bed, keeping pathways dry and clear, keeping the bed in the lowest locked position, and reviewing medications. The resident had falls on [DATE] and 03/16/26. After the first fall, the event assessment documented that the resident fell in his room and stated he was coming from the bathroom when he fell. After the second fall, the event assessment documented that he was found on the bathroom floor and stated he fell while urinating. The Risk Manager stated that a full assessment was completed after a fall and that the Falls Committee discussed causes and interventions, but for this resident no new approaches were added after the first fall other than neuro checks and monitoring for 3 days. The facility provided a Fall Review form for the 03/16/26 fall, but could not provide the form for the earlier fall, and the Risk Manager agreed that no new approaches were added to address the fall.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide care and services that were trauma informed and culturally competent for 2 of 5 residents reviewed for behavior, involving residents with PTSD and other psychiatric diagnoses. The facility assessment documented that it offered mental health and behavior services, including identifying and implementing interventions for anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. However, staff interviews showed inconsistent knowledge about PTSD and no clear method to verify understanding of the training that had been provided. A unit clerk, CNA, nursing supervisor, RN supervisor, and the staff development coordinator gave differing responses about PTSD training, and the staff development coordinator stated that staff watched a video and signed a sheet, with no assessment to ensure understanding. For one resident, the record showed diagnoses including anxiety disorder, depression, bipolar disorder, and PTSD, with a quarterly MDS documenting mood symptoms such as little interest in doing things, feeling down or depressed, and feeling lonely or isolated. The resident’s trauma-informed screening at admission documented no trauma history, yet the resident later stated that her PTSD was related to witnessing her sister being abused and beaten by their father. The resident identified touching as a trigger and described feeling uneasy and unsafe. Staff interviews reflected limited awareness of the resident’s trauma history and triggers, with one CNA stating she was not aware of trauma and an RN stating there was no behavior she did that would trigger the resident. The resident was also observed crying in bed with dried tears on her face and unable to verbalize why she was crying while requesting a fan, which staff had removed for safety reasons. For the other resident, the record showed diagnoses including Parkinson’s disease, PTSD, insomnia, major depressive disorder, depression, and unspecified psychosis, with a quarterly MDS documenting depressed mood symptoms. The care plan identified distress/PTSD related to trauma and listed triggers such as loud noises and fireworks, with interventions to acknowledge trauma, identify triggers, maintain consistency, and provide a safe environment. During interview, the resident described combat in Vietnam, stated he had been instructed on how to react, and identified explosions and loud noises as triggers. Staff interviews noted behaviors such as becoming aggressive when things were not done in a certain order and not liking lights left on or doors left open, but staff responses focused on general behavior management and did not reflect consistent trauma-informed understanding of the resident’s PTSD history and triggers.
Missing Behavior Monitoring for Antidepressant Use
Penalty
Summary
The facility failed to document behavior monitoring for one resident with dementia who was prescribed psychotropic medications. Resident #98 had orders for Quetiapine 25 mg at bedtime for hallucinations and Duloxetine 30 mg at bedtime and Duloxetine 60 mg each morning for depression. A review of the May 2026 MAR showed monitoring for the antipsychotic Quetiapine, but no monitoring was found for Duloxetine, the antidepressant. A review of progress notes also found no documentation of behavior and/or mood changes related to depression or the use of Duloxetine. During interviews, an LPN stated the facility had a protocol to monitor behaviors and mood changes for antidepressant medication and that this monitoring should be included on the MAR, but no order for Duloxetine monitoring was found. An RN stated that when a resident with dementia is prescribed antidepressants, antianxiety medications, and/or antipsychotic medications, behavior and mood monitoring is supposed to be ordered and documented in the MAR, and if it was not ordered, she would still document mood and behavior in the progress notes.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a timely manner for a resident, leading to a deficiency in providing adequate nutritional care. The resident, who had a history of right adrenalectomy, bipolar disorder, dementia, and hypertension, experienced multiple significant weight losses over a period of time. Despite these changes, the facility did not implement effective nutritional interventions or communicate effectively among the multidisciplinary team to address the resident's nutritional needs. The facility's policies required the dietitian to work closely with the interdisciplinary team to assess and address nutritional issues. However, the dietitian did not consistently attend risk meetings or communicate significant weight loss to the resident's practitioner or nursing staff. The resident's weight was monitored, but the dietitian's recommendations were not timely or sufficient to prevent further weight loss. The resident's nutritional supplements were reduced based on meal consumption, but this decision did not consider the ongoing weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's severe weight loss. The nurse practitioner was not informed of the significant weight loss until it was visibly noticeable, and the dietitian did not contact the practitioner or nursing staff about the resident's condition. The facility's director of nursing and other staff members were aware of the weight loss but did not take appropriate action to address it. This lack of communication and timely intervention contributed to the deficiency in maintaining the resident's nutritional health.
Failure to Provide Fresh Fruit as Per Menu
Penalty
Summary
The facility failed to adhere to its own menu guidelines by not providing fresh fruit to residents as specified. Observations and interviews with eight residents revealed that they were not receiving fresh fruit daily as indicated on their meal tickets. Residents reported receiving fresh fruit, specifically bananas, only once or twice a week, contrary to the menu that promised fresh fruit for breakfast daily. This discrepancy was noted during breakfast observations in the main dining room and in residents' rooms. The residents involved in this deficiency were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores of 15, except for one resident who was rarely or never understood. The facility's diet technician confirmed the weekly delivery of bananas and the substitution of other fresh fruits but could not explain why fresh fruit was not provided to all residents on the observed date. This failure to follow the menu affected residents with various diagnoses, including Hypokalemia, Hemiplegia, Depression, Dysphagia, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Type 2 Diabetes, Hypertension, Parkinson's, and Anxiety Disorder.
Facility Fails to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide palatable, appetizing, and flavorful food to eight residents, as observed through interviews and record reviews. Residents expressed dissatisfaction with the quality and taste of the food, describing it as bland, unappetizing, and inconsistent with their requests. For instance, one resident complained about the inconsistency in receiving eggs cooked to their preference, while another mentioned that meals were incomplete and did not match the menu. Additionally, a test tray revealed that the food lacked seasoning, color variation, and was served in an unappealing manner. Several residents, despite having varying levels of cognitive impairment, consistently reported that the food was not flavorful and did not meet their expectations. One resident with severe cognitive impairment stated that the food was horrible, while another with no cognitive impairment mentioned that the staff reacted negatively when complaints about the food were made. The residents' medical conditions, such as chronic kidney disease, amyotrophic lateral sclerosis, and diabetes, were noted, but the primary concern was the lack of appetizing and flavorful meals. The Food Service Director acknowledged that many residents were on a No Added Salt diet, which contributed to the bland taste of the food. However, the test tray was conducted on a Regular diet, indicating that the issue was not solely related to dietary restrictions. The deficiency in providing palatable meals was evident across multiple residents, regardless of their dietary needs or cognitive status, highlighting a systemic issue in the facility's food service operations.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for nine residents who were prescribed a pureed consistency diet. Observations revealed that meals served to these residents were not smooth and contained lumps or solid particles, which is inconsistent with the requirements for a pureed diet. This issue was observed during multiple meal services, where residents were served pureed entrees that appeared lumpy and contained small pieces that required chewing. The Food Service Director acknowledged the inconsistency after a surveyor's observation and tasting of the meals. The facility's policy on pureed food consistency, which requires a smooth texture without solid particles, was not adhered to. Specific residents affected included those with conditions such as dysphagia and Parkinson's, who require a pureed diet to prevent complications with chewing or swallowing. For instance, one resident with Parkinson's and dysphagia was served a meal with visible pieces of corn, and another resident with dysphagia was served lumpy pureed corn. The Speech Language Pathologist confirmed that the pureed food should have a smooth consistency and expressed concern over the presence of solid particles in the meals served. The facility's failure to provide the correct diet consistency had the potential to affect 14 residents prescribed the pureed diet.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions, impacting 106 of 112 residents. During an initial kitchen tour, several deficiencies were noted, including the presence of personal food stored improperly in the walk-in refrigerator, debris on the floor of the Arctic walk-in freezer, and unclean equipment such as a metal backsplash with black and brown streaks, a clear plastic bin with dried residue, frying pans with burned debris, a large stock pot with black debris, and a meat slicer with rusty and brown residue. These observations indicate a lack of proper cleaning and maintenance of kitchen equipment and storage areas. Further issues were identified during a follow-up tour, where food temperatures were found to be above the safe standard of 41°F, with chocolate pudding at 48°F and puree Black Forest Cake at 54°F. Additionally, the nourishment rooms had unsanitary conditions, including brown residue on refrigerator shelves and door handles, and a microwave with brown residue on its interior surfaces. The refrigerator in the Delta Yellow nourishment room was also above the safe temperature at 44°F. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities, contributing to the unsanitary conditions observed.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding their preferred scheduled bedtime, as outlined in their care plan and interest assessments. The resident, who was admitted with Quadriplegia, C1-C4 incomplete, and had a BIMS score indicating no cognitive impairment, expressed that it was very important for them to choose their bedtime. Despite this, observations showed the resident was still in bed undressed late in the morning on multiple occasions. The resident expressed a desire to be out of bed by 10:00 AM, but was consistently left in bed until after 12:00 PM. The resident communicated this preference to the staff, but was told that the schedule was based on what was best for the nursing staff. A CNA confirmed the resident's request but stated she did not have the authority to change the schedule. The Director of Nursing was informed of these findings.
Failure to Address Grievance Regarding Lost Hearing Aids
Penalty
Summary
The facility failed to address a grievance regarding the loss of hearing aids for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Traumatic Subdural Hemorrhage and Major Depressive Disorder, reported losing his hearing aids two weeks prior to the survey. Despite the resident's daughter reporting the loss to both laundry and nursing staff, no action was taken to investigate or resolve the issue, and the resident was not updated on the status of his hearing aids. Interviews with staff revealed a lack of awareness and communication regarding the resident's grievance. A Certified Nursing Assistant (CNA) and a Charge Licensed Practical Nurse (LPN) were unaware of the resident's loss of hearing aids. The Licensed Social Worker (LSW) explained the facility's process for reporting lost items, which involves completing a Care and Concern form and initiating an investigation. However, no such form was completed for the resident's hearing aids, indicating a breakdown in the reporting process. The resident's daughter expressed concern about her father's difficulty in communicating due to the loss of his hearing aids. Despite her efforts to report the issue, she received no updates from the facility staff. The LSW acknowledged the reporting failure and initiated the investigation only after being informed by the surveyor. This deficiency highlights the facility's failure to adhere to its grievance policy and promptly address resident concerns.
Failure to Provide Timely Assistance to Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents. Resident #114, who has quadriplegia, was left in a fetal position on his bed for two hours waiting for a suppository that was never administered. This incident was discovered by a CNA who found the resident sweating and with a racing heart, and subsequently assisted him to the bathroom. Resident #34, who has a history of cerebral infarction and diabetes, reported during a resident council meeting that he frequently waits too long for toileting assistance, sometimes up to one and a half hours, despite using the call bell and contacting the front desk for help. Resident #104, who has hemiplegia and spinal stenosis, also reported waiting for half an hour for assistance while on the toilet. A CNA informed him that she could not assist because she was assigned to a different section. Interviews with staff revealed that each CNA was responsible for seven residents, and while they believed they could manage with love and cooperation, there was an implication of insufficient staffing to meet residents' needs promptly. These incidents highlight a failure to provide timely and adequate care, as required by professional standards.
Failure to Apply Left Hand Splint as Ordered
Penalty
Summary
The facility failed to provide a left hand splint as per the physician's order for a resident with limited range of motion. The resident, who was readmitted with diagnoses of hypertension and muscle weakness, had an order dated 11/30/23 to apply a left hand splint and left elbow protector for 8 hours during AM hours. Observations on multiple occasions revealed that the resident was in bed with a contracture on the left hand and no splint in place. The resident confirmed that the splint had not been applied, and staff interviews indicated a lack of awareness and documentation regarding the splint order. Interviews with the facility's Rehab Director, Registered Nurse, and Restorative Certified Nursing Assistant revealed a breakdown in communication and responsibility for ensuring the splint was applied. The Restorative team was responsible for overseeing the placement of splints, but there was no documentation in the electronic system for the resident's splint application. The Restorative CNA was unaware of the order for the left hand splint, and the Registered Nurse confirmed that no documentation was present for the splint's application in the last 14 days. The Director of Nursing was informed of these findings.
Inadequate Supervision and Oxygen Tank Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate supervision during a Hoyer lift transfer for a resident, which was observed when a Certified Nursing Assistant (CNA) used the mechanical lift to lower the resident into bed without the assistance of another staff member, contrary to the facility's policy. The policy requires at least two people to assist during mechanical lift transfers. The CNA acknowledged the difficulty in finding additional staff to assist during busy times, such as breakfast, which led to the unsupervised transfer. This deficiency had the potential to affect 50 residents who used Hoyer lifts in the facility. Additionally, the facility failed to ensure that an oxygen tank was properly secured for another resident. Observations revealed that an additional oxygen tank was standing next to an empty holder beside the resident's bed, contrary to the facility's policy that requires all portable oxygen tanks not in use to be secured and stored in the designated oxygen storage room. Interviews with staff members indicated a lack of consistent practice regarding the storage of oxygen tanks, with some staff stating that extra tanks should not be kept at the bedside and should be returned to the oxygen room when empty. The resident involved in the oxygen tank deficiency had a history of respiratory issues, including COPD and acute respiratory failure, and required continuous oxygen therapy. Despite the facility's policy and the resident's care plan, the unsecured oxygen tank posed a potential hazard. The inconsistency in staff practices regarding the storage of oxygen tanks highlights a gap in adherence to the facility's safety protocols.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for two residents. For one resident, there was a discrepancy in the documentation of Alprazolam administration. The resident's controlled drug record sheet did not reflect the removal of a tablet on a specific date, although the electronic Medication Administration Record (eMAR) indicated it was administered. The Licensed Practical Nurse (LPN) involved acknowledged the oversight, stating she missed documenting the removal in the controlled drug record. The Director of Nursing expressed confusion over the inconsistency between the eMAR and the controlled drug binder. For another resident, there was a failure to document the administration of Oxycodone in the Medication Administration Record (MAR), despite it being signed out on the Controlled Drug Record. The Registered Nurse (RN) confirmed the correct count of the medication, but the administration was not recorded in the MAR. Interviews with nursing staff, including the Director of Nursing, revealed that the protocol requires documentation in both the Controlled Drug Record and the MAR, which was not followed in this instance.
Medication and Treatment Cart Security and Expired Medications
Penalty
Summary
The facility failed to ensure the security of treatment and medication carts, as well as the proper disposal of expired medications. During an initial tour, a treatment cart in the Delta unit was found unlocked and unattended, containing treatment medications labeled with residents' names and a pair of scissors. This cart remained unlocked for an extended period, despite multiple staff members and residents passing by. Additionally, during a medication administration observation, an LPN left a medication cart unlocked and unattended for approximately seven minutes while addressing a potential altercation between two residents. The dispensed medication for a resident was left on top of the cart during this time. Furthermore, a review of medication storage revealed expired over-the-counter medications in a medication cart in the Delta Yellow unit. The expired medications included an antacid and a cough syrup, both past their expiration dates. Staff E, a Senior LPN, expressed surprise at finding expired medications, despite regular checks by the pharmacist and unit nurse supervisor. The Delta Unit Nurse Supervisor confirmed that random checks are conducted, and floor nurses are responsible for checking expiration dates before administering medications.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. Resident #61, who was readmitted with multiple diagnoses including wounds on the right and left heels, did not have Enhanced Barrier Precautions (EBP) guidelines included in their care plan. Observations revealed the absence of EBP signposts on the resident's door and a lack of personal protective equipment (PPE) such as gowns and gloves on the metal shelf. During an incident, two CNAs assisted the resident with toileting without wearing gowns, citing the absence of gowns on the shelf and urgency as reasons. Interviews with staff revealed a lack of clarity on who was responsible for replenishing PPE and the omission of EBP guidelines in the care plan. Similarly, Resident #101, admitted with end-stage renal disease and sacral pressure ulcers, also lacked EBP guidelines in their care plan. Observations showed no EBP signpost or PPE shelf on the resident's door. A wound care RN had to request a PPE gown before entering the resident's room, indicating a lack of readily available PPE. Interviews with staff highlighted that the wound care RN had placed the PPE cart, but there was no EBP signpost, and staff relied on verbal reports to know when EBP guidelines should be followed. These deficiencies indicate a failure to adhere to CDC recommendations for infection prevention and control in the care of residents with wounds.
Deficiency in Emergency Call Device Functionality
Penalty
Summary
The facility failed to ensure that the emergency call devices in the bathrooms of the Alpha Unit were functioning properly. Observations revealed that in two of the twelve bathrooms, the emergency call device pull cords were wrapped around the grab bars, rendering them non-functional. Photographic evidence was obtained to document these findings. Interviews with staff members, including CNAs and RNs, confirmed that the pull cords should not be wrapped around the grab bars, indicating a lack of adherence to proper protocol. Further investigation revealed that the facility did not have a policy in place regarding the proper use and maintenance of emergency call devices. The Director of Nursing confirmed the absence of such a policy during an interview. The Registered Nurse Supervisor acknowledged the issue during a side-by-side observation with the surveyor and attempted to rectify the situation by unwrapping the cords, which were found to be excessively long and dragging on the floor. This deficiency highlights a gap in the facility's procedures for ensuring resident safety in bathroom areas.
Failure to Follow Physician's Orders for Wound Treatment
Penalty
Summary
The facility failed to follow the physician's orders for wound treatment for two residents. Resident #4, who had diagnoses including Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus, and an Unspecified Open Wound on the Lower Leg, was supposed to have his left lower leg dressing changed every other day as per physician's orders. However, observations revealed that the dressing was dated 04/18/24, indicating it had not been changed as required. The Wound Care Nurse and a Registered Nurse confirmed the discrepancy, and the Treatment Administration Record falsely documented that the dressing had been changed on 04/20/24 and 04/22/24. Resident #5, who had diagnoses including Atrial Fibrillation, Diabetes Mellitus, Venous Insufficiency, Cellulitis of the Left Toe, Localized Swelling, Acute Osteomyelitis, and an Open Wound of the Left Foot, had a skin tear on the left shin with a Xeroform gauze dressing. However, there was no physician order for this treatment. The Wound Care Nurse was unaware of the skin tear, and the Director of Nursing confirmed the absence of a physician order for the dressing. An RN later stated that an order for the skin tear was obtained on the day of the surveyor's observation.
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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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Nursing homes near Pembroke Pines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Manor | 0.7 mi | ★★★★★ | 1 | 0 |
| Emerald Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Sierra Lakes Nursing & Rehabilitation Center | 4.9 mi | ★★★★★ | 11 | 1 |
| Gardens Nursing And Rehab Center | 5.1 mi | ★★★★★ | 26 | 0 |
| Nspire Healthcare Miami Lakes | 5.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.