Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 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 Aventura At The Bay during CMS and state inspections, most recent first.
A resident with a stage 3 sacral pressure ulcer, malnutrition, and quadriplegia had repeated gaps in NPWT care, including times when the wound vac was not in place, supplies were unavailable, and clinic visits occurred without the vac or cannister. In another case, a resident with multiple neurologic and medical conditions had an inaccurate skin assessment that failed to document sacral redness and an open area, even though the wound provider identified a stage 3 sacral/coccyx pressure ulcer.
Inadequate Fall Supervision and Intervention: A resident with dementia, hemiplegia, weakness, impaired cognition, and a history of falls had repeated unwitnessed falls and one witnessed fall, with injuries including a forehead bruise, reopened knee skin tear, and eye swelling. Survey review found incomplete fall investigations, missing or inconsistent neuro checks, unclear documentation of the resident’s position and last observation before several falls, and no individualized fall interventions documented for multiple events.
Insufficient nursing staffing and ADL care left multiple residents without needed assistance. A single RN covered a 40-resident secure unit with four aides, while residents were observed wandering unsupervised, soiled with feces, wearing wet or mismatched clothing, and lacking help with bathing, hygiene, toileting, and skin care. Interviews confirmed the RN could not complete all duties, and staff described missed turning/repositioning and inconsistent monitoring of residents with cognitive impairment and incontinence.
A facility failed to maintain a clean, sanitary, and homelike environment on a secured unit. Surveyors observed stained chairs, fecal odors, trash with soiled incontinent products, feces in a closet, an unflushed BM, bug carcasses, roach droppings, urine, dirty floors, and other stains and debris in resident rooms and bathrooms. Staff interviews described inconsistent cleaning practices, limited oversight, and reports of bugs in resident rooms, while the NHA stated feces, urine, and stained chairs should not have been present.
Failure to Protect Resident From Neglect and Unsafe Conditions: A resident with dementia and total-care needs was found in a room with a soiled brief on the floor, caked dried fecal material on both feet, and a mattress with dried fecal smears and odor. A male resident with severe dementia was observed wandering the secure unit and entering her room without staff monitoring or redirection. Staff were unaware of the fecal soiling, the room-based activity record was absent, and the resident had no TV in her room.
Failure to Develop and Implement Person-Centered Care Plans: The facility did not develop or implement care plan interventions for a resident’s wandering into other residents’ rooms and defecation behaviors, another resident’s room-to-room wandering, or a third resident’s room-based preferences and podiatry needs. Staff observed unmet ADL and skin care needs, including an uncovered wound, incorrect footwear, dirty feet, fecal contamination of a mattress, and missed weekly skin checks, while the DON and MDS Coordinator confirmed key behaviors and needs were not care planned.
Failure to Document and Process Resident Grievances: A resident with a stage 3 sacral pressure ulcer, quadriplegia, and neurogenic bladder repeatedly voiced concerns about delayed turning, wound vac issues, catheter care, missed transport, and fluids. Staff said concerns were often passed along verbally to the unit clerk, nurse leadership, or DON, but only two grievances were documented, and other complaints noted in progress notes were not consistently entered into the grievance log or handled through the facility’s grievance process.
Failure to timely report resident-to-resident abuse allegation: A resident with dementia-related diagnoses and another resident with cognitive impairment were involved in an altercation after one resident reported being called an expletive, striking the other resident, and then falling when the other resident grabbed their arm. Staff documented the event, but the RN, DON, and Risk Manager were not notified when it occurred, and the incident was later discovered through chart review rather than immediate reporting.
Improper catheter care and missing documentation for two residents. One resident with a suprapubic catheter and recurrent UTI history had an order for daily site cleansing, but the TAR lacked documentation on multiple days and staff noted the care was scheduled overnight despite frequent refusals; the resident's RR said she had repeatedly asked staff to call her when refusals occurred. Another resident with severe cognitive impairment had a Foley reinserted after pulling it out, but the chart contained no ongoing catheter orders, no catheter care documentation, and no clear record of when the catheter was removed; the DON confirmed there was no way to verify the care from the record.
Resident food items were found unlabeled and undated in nourishment room refrigerators and freezers, and unit temp logs were incomplete or missing. Kitchen observations showed a cook wearing a smartwatch while preparing food, failing to perform hand hygiene between tasks, and allowing a thermometer string to contact food without cleaning it afterward. The dish machine had sanitizer and rinse temp issues, and the walk-in freezer had ice buildup with debris also found around the dumpster area.
The facility failed to keep resident rooms and nourishment areas free from accident hazards and did not adequately supervise smoking and hot liquid access. In the memory unit, accessible thumbtacks, nails, staples, mouthwash, nail clippers, wipes, and a pinned badge were found in resident rooms, and staff gave inconsistent answers about whether these items were hazards. Two residents were observed smoking on facility property, including one resident who was using oxygen, despite the facility’s non-smoking policy. Surveyors also found coffee and hot water machines in multiple nourishment rooms, with staff not checking beverage temperatures and using inconsistent methods to judge whether drinks were too hot.
Medication administration errors exceeded the allowed rate for a resident when an LPN prepared and gave multiple medications, including several that were on the cart’s do-not-crush list. The MAR also showed medications documented as given before they were actually administered, and the LPN later stated she charted some medications early or late and documented a medication that was not actually given as recorded.
Resident council concerns were not consistently documented as grievances or shown as resolved in the grievance log. Residents reported missing clothing, supply shortages, delayed call lights, staff entering rooms without knocking, cold food, and lack of written resident rights information. Staff said they recorded generalized complaints in council minutes but did not file grievances for the group, while SSD staff confirmed grievances were expected to be documented even when concerns were addressed quickly.
MDS assessments were inaccurate for three residents because active diagnoses were not marked in Section I. One resident had PTSD documented in the chart and trauma-related care plan interventions, another had Parkinson’s disease, dementia, psychosis, and depression-related orders, and a third had dementia documented with a donepezil order, yet the MDSs did not reflect those diagnoses. The RN/MDS Coordinator confirmed the diagnoses were missed.
Inaccurate PASARR screening and missing Level II evaluations were found for multiple residents with MI, dementia, epilepsy, bipolar disorder, psychosis, depression, anxiety, and alcohol dependence. Records showed Level I PASARRs that did not match the residents’ diagnoses or omitted key conditions, while required Level II determinations were not found for several residents receiving psychotropic or related medications. The SSD stated she reviewed diagnoses against hospital records and relied on others with system access to update PASARRs, but several records remained incomplete or inaccurate.
Failure to provide hearing assistive devices for a resident with documented HOH and communication deficits. The resident reported no hearing in one ear and difficulty hearing in the other, and staff had to speak very loudly and repeat information multiple times for the resident to understand. Records showed repeated audiology referrals and notes that the resident hoped to receive hearing aids, but the resident was not listed as having hearing aids or hearing aids pending.
A resident with a tracheostomy and chronic respiratory failure received humidified oxygen, but the facility did not obtain a physician order for the humidity percentage. Staff reported the oxygen was set at 2.5 L and the humidifier at 28%, while the resident’s records referenced humidified oxygen via trach mask and a 3008 form listing 28% humidity. The facility’s physician orders policy did not address the need for orders for trach humidification or related respiratory care interventions.
A resident with PTSD, dementia, and other psychiatric diagnoses was not provided trauma-informed care because staff and records did not identify her specific trauma history, triggers, or trauma-based behaviors. Although the care plan noted PTSD related to witnessing a traumatic event involving her son, staff, the POA, and psych services could not describe what to watch for or how her trauma affected her care, and behavior monitoring remained general rather than trauma-specific.
An unlocked treatment cart was observed on the C-Wing, and the medication room refrigerator contained four expired immunizations. A separate observation of the C-Wing HIGH med cart found three expired medications, and the ADON, RN, and DON all acknowledged the expired items should not have been there. Facility policy required expiration dates on labels and stated expired medications will be discarded.
A resident with a strict pain management regimen did not receive scheduled hydrocodone-acetaminophen doses on two occasions because the nurse documented the resident as sleeping and did not attempt to wake her, despite the resident's preference to be woken for medication. The missed doses were not communicated to the physician or the resident's representative, and there was no documentation in the care plan or progress notes regarding the missed medications.
A resident with a strict pain management regimen did not receive scheduled hydrocodone doses on two occasions because the nurse documented the resident as sleeping and did not attempt to wake her or notify the physician or family representative. Staff interviews and record reviews confirmed that facility policy requires attempts to wake residents for scheduled medications and prompt notification of missed doses, but these steps were not followed or documented.
Several residents with documented food allergies, intolerances, and preferences were served meals that did not accommodate their needs, resulting in one resident experiencing an allergic reaction requiring epinephrine. Other residents received food in forms they could not safely eat or with ingredients they had specifically requested to avoid, despite these requirements being documented on meal tickets and in care plans. Staff interviews and committee minutes revealed ongoing issues with meal ticket accuracy and communication between dietary and nursing staff.
Two residents experienced major injuries due to repeated falls and inadequate supervision, with one sustaining a thumb and rib fracture and another suffering a femur fracture. Despite known high fall risk and total care needs, care plans were not consistently updated after incidents, and staff interviews revealed gaps in awareness and documentation. The facility did not maintain a hazard-free environment or provide adequate supervision as required by policy.
The facility did not maintain the area around the outside trash compactor free of refuse, with observations showing scattered trash such as used gloves, opened trash bags, and food containers on the ground. The Maintenance Director confirmed ongoing issues with trash from multiple departments and wildlife interference, and there was no documentation of regular monitoring or a policy addressing cleaning of the compactor's surroundings.
The facility did not ensure that residents with intact cognition were properly informed about the optional nature of the binding arbitration agreement during admission. Several residents signed the agreement without clear understanding that it was not required, and staff could not provide documentation or policy confirming residents' rights to refuse or contact state personnel.
The facility's arbitration agreement did not allow for the mutual selection of a neutral arbitrator, instead specifying that arbitration would be conducted by a predetermined entity or one chosen solely by the facility, without input from residents. This was confirmed through record review and staff interviews, with staff acknowledging the lack of resident choice and the absence of a related policy.
Multiple failures in infection prevention and control were observed, including staff entering rooms on special contact/droplet precautions without proper PPE, missing or incorrect isolation signage, and inconsistent hand hygiene practices. Residents on precautions were seen in hallways without masks, and shared medical equipment was not cleaned between uses. Additional issues included improper catheter bag placement and staff with artificial nails, all contrary to facility policy and care plans.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors found widespread deficiencies in the cleanliness and maintenance of resident rooms, bathrooms, and equipment, including water leaks, bio growth, stained fixtures, and non-cleanable surfaces. Staff interviews revealed confusion about reporting and resolving these issues, and maintenance logs were lacking. Facility policies for cleaning and HVAC maintenance were not consistently followed, resulting in ongoing environmental concerns.
The facility failed to ensure safe and appropriate respiratory care by not administering oxygen therapy according to physician orders for four residents. Residents were observed receiving oxygen at incorrect flow rates, with staff unable to locate or confirm the correct orders, and care plans containing conflicting information. Staff interviews revealed uncertainty about proper oxygen settings and order documentation.
Surveyors identified multiple deficiencies in medication management, including prescription creams and medications left unsecured in resident rooms, an unlocked office with accessible medications, and medication carts containing personal items, loose pills, and undated glucose test strips. Staff and the DON confirmed that these practices did not follow facility policy, and medications were also improperly disposed of in a trash can.
Multiple residents reported not being routinely offered evening snacks, with some staff stating snacks were unavailable or only providing them upon request. Only one CNA was identified as regularly offering snacks, and the facility's meal schedule resulted in a 15-hour gap between dinner and breakfast. Staff interviews confirmed snacks were not proactively offered to all residents, and a resident with diabetes emphasized the need for an evening snack.
Multiple residents were found to have non-functioning or inaccessible call lights, with some call lights not working upon admission and others placed out of reach, such as in closed dresser drawers. Staff interviews revealed inconsistent practices for reporting and ensuring call light functionality, and there was no formal policy in place. Maintenance was not always notified of issues, and routine checks were insufficient to prevent these deficiencies.
The facility did not consistently document or resolve grievances raised by residents, family members, or through committee meetings, particularly regarding meal preferences, staff conduct, and care concerns. Multiple residents reported that their complaints were not addressed or followed up on, and staff interviews confirmed that grievance documentation and tracking were incomplete or missing for several months.
The facility failed to sustain an effective QAPI process after prior survey deficiencies, and surveyors again found widespread problems. Medication carts and storage areas contained loose pills, expired meds, undated insulin pens, and personal or miscellaneous items stored with medications; an unsecured nursing office and unlocked treatment cart were also observed. Food service issues included unlabeled nourishment-room items, repeated dishwasher sanitizer test failures, and a leaking walk-in refrigerator fan dripping onto food. Infection control problems continued as staff entered an isolation room without PPE or hand hygiene, PPE caddies were incomplete, and staff reported no training. The arbitration agreement still contained improper language.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Staff did not ensure that all residents seated at the same table were served meals at the same time, resulting in some residents waiting without food or drink while others ate. CNAs and an RN confirmed that trays were distributed in room order rather than by table, contrary to facility policy and expectations for resident dignity during dining.
A resident with multiple mental health diagnoses, including mood disorder, dementia, and bipolar disorder, was not properly assessed through the PASRR process, as the facility failed to submit a required Level II evaluation. The ADON confirmed that only limited audits were performed and demonstrated a lack of understanding regarding which diagnoses necessitate Level II submission. The facility also lacked a formal PASRR policy.
Two residents did not receive catheter care as required, with one resident's suprapubic catheter site left uncleaned and dressing unchanged for several days, and another resident's catheter care not documented on multiple shifts. Staff interviews confirmed lapses in care and documentation, and one resident developed a UTI. Facility policy required catheter care every shift and proper documentation, which was not followed.
A resident with multiple chronic conditions and under hospice care experienced severe, ongoing pain that was not managed in a timely manner. Despite repeated reports of high pain levels and a new order for Baclofen, staff failed to administer the medication promptly due to confusion about its availability and delays in obtaining it from the pharmacy or emergency drug kit. The DON acknowledged the resident should have received the medication as ordered.
Two residents were not offered the COVID-19 vaccine upon admission, as required by facility policy. Both individuals were later diagnosed with COVID-19 after being sent to the Emergency Department, and their medical records lacked documentation of vaccine consent or refusal. The Infection Preventionist confirmed the omission, noting it should have been part of the admission process.
The facility did not provide enough nursing staff to meet resident needs, as shown by multiple residents experiencing long wait times for assistance, including help with toileting and mobility. Residents with significant medical conditions were left unattended, and staff interviews confirmed ongoing staffing shortages and unpredictable assignments. Resident Council meeting minutes documented repeated concerns about delayed call light responses, and the staffing coordinator admitted that required staffing levels were not always met, especially on weekends.
The facility failed to implement adequate policies and procedures to prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Employee files for six staff members, including LPNs, RNs, and CNAs, lacked timely addition to the Background Clearinghouse and did not include reference checks for prior employment. The facility's policy did not provide procedures for employee screening or employment verification, contributing to the deficiency.
A resident's preference for female caregivers was not honored, despite being documented in her care plan. The resident, who was mentally intact, had requested female caregivers for incontinence care, but male caregivers were assigned on several occasions. The facility's leadership acknowledged the issue and confirmed the availability of female caregivers during those times.
The facility failed to address grievances from two residents regarding delayed call light responses, improper meal setup, and medication issues. Despite filing grievances, the residents did not receive feedback or resolution, and the facility's grievance log lacked documentation. The facility's grievance policy was not followed, leading to unresolved concerns and a deficiency in honoring residents' rights.
A resident with pressure ulcers and paraplegia did not receive timely repositioning and incontinence care, leading to skin irritation and emotional distress. Additionally, a CNA conducted a lift transfer without assistance, against protocol. Another resident's call light was out of reach, preventing them from requesting assistance. Medication administration was also deficient, with missed doses due to untimely reordering.
The facility failed to provide sufficient nursing staff, resulting in inadequate care for residents. Observations revealed unchanged bandages, delayed call light responses, and insufficient assistance with ADLs and meals. Staff shortages were evident, with reports of call-offs and no-shows, leading to neglect of resident care and an Immediate Jeopardy determination.
The facility failed to update its emergency plan and secure safe evacuation locations during two hurricanes, leading to chaotic and unsafe conditions for residents. The Nursing Home Administrator did not secure an alternative location after the termination of an evacuation agreement with a local church. During evacuations, residents were moved to unsuitable locations, resulting in overcrowding, lack of supplies, and safety risks. Local authorities had to intervene to relocate residents to safer locations. Staff and residents reported disorganization and distress during the evacuations.
The facility's failure to update its emergency plan and secure an approved evacuation location led to a chaotic and unsafe evacuation during Hurricane [NAME]. Residents were moved to an unapproved church location, deemed unsafe by local authorities, resulting in the relocation to a county shelter. Two residents suffered harm due to lack of supplies and supervision. The governing body was unaware of the terminated evacuation agreement, and the facility's emergency plan was outdated, leading to immediate jeopardy for residents.
A LTC facility failed to protect residents from neglect, resulting in multiple incidents of harm. A resident with dementia suffered a hip fracture during a transfer, with inadequate investigation and communication. Another resident fell from bed due to improper handling by a CNA, leading to significant injuries. A third resident fell during an evacuation due to lack of supervision and organization. The facility's care plans lacked specific assistance requirements, contributing to these incidents.
Missed wound vac care and inaccurate skin assessment documentation
Penalty
Summary
Failure to provide appropriate pressure ulcer care was identified for one resident with a stage 3 sacral pressure ulcer, malnutrition, and quadriplegia. The resident’s care plan called for wound specialist treatment, and physician orders directed cleansing and packing the wound, followed by negative pressure wound therapy at 125 mmHg with dressing changes three times weekly and as needed. The record showed repeated gaps in carrying out the wound vac order, including periods when the wound vac was not in place after the resident returned from the wound clinic, when the facility did not have a cannister available, and when the resident went to the wound clinic with wet-to-dry dressing instead of the wound vac. Documentation also showed no entry for one scheduled wound vac change date. Wound clinic notes documented that the facility had not ordered the wound vac when the clinic believed it was the facility’s responsibility, and later that the resident arrived without the wound vac connected or without the cannister needed for treatment. The wound clinic NP stated the resident’s weekly appointments were important, especially with a wound vac and debridement, and noted that the resident missed scheduled follow-up appointments. Facility interviews confirmed confusion about who was responsible for obtaining the wound vac, delays in obtaining cannisters and foam supplies, and that the resident did not have the wound vac from admission until it was finally placed later. The DON and ADON also acknowledged there was no documentation explaining why wound vac supplies were unavailable on certain dates and no documentation addressing the missed wound care order. Failure to conduct accurate skin assessments was identified for another resident who had hemiplegia, COPD, bipolar disorder, vascular dementia, cognitive communication deficit, and muscle weakness. The resident’s care plan identified risk for impaired skin integrity and included weekly skin sweeps, pressure relief measures, barrier ointment, and turning and positioning assistance. A weekly skin observation documented abrasions and a skin tear but did not document sacral redness. Later the same day, another weekly skin observation documented sacral redness with an open area, and the wound provider documented a stage 3 pressure ulcer to the sacrum/coccyx. The resident’s progress note from that same assessment period stated there were no skin issues on bony prominences, buttocks, or heels, and the MDS coordinator stated the note should have been accurate and should have included sacral documentation.
Inadequate Fall Supervision and Intervention
Penalty
Summary
The facility failed to provide adequate supervision and effective fall-prevention interventions for one resident with significant fall risk. The resident had diagnoses including left-sided hemiplegia, COPD, bipolar disorder, generalized muscle weakness, vascular dementia, and cognitive communication deficit. The resident’s mental status score indicated moderate cognitive impairment, and the care plan identified multiple fall risks, including dementia, gait and balance problems, impaired cognition, impaired communication, incontinence, a history of falls, and inability to recognize safety needs. The resident experienced repeated unwitnessed falls and one witnessed fall over a 30-day period, with transfer to a higher level of care on two occasions. The fall log and progress notes documented multiple events in different locations, including the hallway, resident room, bedside, bathroom area, dining room, and floor mat. Several events involved the resident being found on the floor or next to the bed or wheelchair, and in multiple instances staff could not state when the resident was last observed before the fall or whether the resident was found in a prone or supine position. One fall involved a bruise to the forehead, another involved a reopened skin tear to the knee, and another involved swelling to the left eye. The resident was also documented as throwing herself onto the floor during one witnessed event. Survey review found that fall investigations were incomplete and inconsistent with the medical record in several instances. The Risk Manager stated that each fall should be thoroughly documented and that interventions should be put into place, but for multiple falls no interventions were found in the fall care plan for the relevant time frames. Neuro-check documentation was missing for at least one fall, and in another instance a neuro-check sheet showed a staff signature time that was 15 minutes before the fall event. The facility’s own fall management guidelines required post-fall assessment, investigation, documentation, notification, and review of the care plan, but the record showed repeated falls without clear documentation of the resident’s condition before the falls, the circumstances of the events, or consistent individualized interventions tied to the incidents.
Insufficient Nursing Staffing and Inadequate ADL Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to meet the ADL needs of multiple residents, including residents with cognitive impairment, incontinence, wandering behavior, and assistance needs for bathing, hygiene, and skin care. The report states that six of twenty-one sampled residents were affected, and that the lack of sufficient staffing resulted in harm to Residents #4, 7, 9, 16, 17, and 18. The facility’s own staffing assignment for the secure memory unit showed one RN and four aides for a census of 40 residents, and the RN on duty stated that usually two nurses worked that shift but she was the only nurse that day and that it was difficult to get all duties completed. Resident #9 was observed independently ambulating with matted, oily hair, mismatched shoes, and later with an uncovered, oozing wound on the chest while rubbing the wound and then wiping her hands on her clothing and the handrail. Resident #16 was observed independently wandering the hall, entering and exiting resident rooms without staff monitoring or redirection. Resident #18 was observed walking in the hall with wet, stained socks and a visible trail of wetness on the floor, with no staff assisting him to change clothing or socks. Staff interviews reflected that Resident #16 was new to the unit and that staff had not heard of him wandering into other residents’ rooms, despite observations showing that behavior. Resident #17 was found in a room with a strong feces odor, a soiled brief on the floor, dried brown matter on the soles of both feet, visible scabs on the legs, and a mattress smeared with dried brown matter and no linens. Resident #7 was observed in bed with smeared feces on the sheet and a strong feces odor in the room. Resident #4 was heard repeatedly yelling for a towel while in the shower by himself, and staff confirmed he should receive assistance with showers. Resident #5 reported being left turned on his side for four hours because staff were busy with other residents, and a nurse confirmed the resident repeatedly voiced concerns about turning and repositioning. The facility’s own policies and job descriptions required nursing rounds at least every two hours, prompt response to toileting and hygiene needs, and CNA assistance with ADLs, but the observations and interviews showed these needs were not consistently met.
Unsanitary Conditions and Pest Issues on Secured Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the 200 hall secured unit. Observations showed stained and discolored chairs, unclean floors, brown streaks, and an odor of feces in the common area. A clear trash bag containing soiled incontinent products, an open milk carton, and other trash was also observed in the common area, along with additional stained chairs and a soiled floor in a recessed area of the unit. Multiple resident rooms and bathrooms on the secured unit were observed with unsanitary conditions. One room had dried clumps of feces and smeared fecal matter in an open closet, a sticky-looking liquid substance on the floor near the bed, a soiled brief on the floor, a mattress with dried brown matter smeared across the top and sides, and a padded chair with smears and discoloration. The bathroom in that room contained an adult washcloth package, a used washcloth, an unflushed bowel movement, and fragments of a large bug carcass in the shower floor. Other rooms had a dead roach by a bed, dirty floors with sticky-appearing stains, insect droppings in drawers, brown substance smeared on a light switch, trash left in a room trash can, debris under a bed, pills on the floor behind beds, urine on a bathroom trash can and surrounding floor, brown stains on a lotion bottle and sandals, and dark brown, green, and red stains on floors, shower walls, and bathroom surfaces. Staff interviews showed inconsistent cleaning practices and limited oversight of the secured unit. A housekeeper stated she had seen bugs in residents’ rooms and would just kill them, while another housekeeper stated she was the only staff member working on the unit lately and believed the facility was short-staffed. The housekeeping manager stated resident rooms were cleaned daily but also stated there was no specific checklist for individual rooms. The unit clerk stated CNAs were responsible for checking rooms after meals and that housekeeping would wash and sanitize areas where urine or feces were observed. The NHA stated feces, urine, or blood should not be present on surfaces, stained chairs should be removed immediately, and consistent morning rounds should have identified the environmental concerns, but she had not received notification that feces-stained chairs remained in the hallway for two days.
Failure to Protect Resident From Neglect and Unsafe Conditions
Penalty
Summary
The facility failed to protect one resident from neglect and failed to ensure a safe, clean, and supervised environment. Resident #17, who was admitted in 12/2025 with diagnoses including dementia, COPD, coronary artery disease, and depression, had care plans indicating she required total assistance with bathing, grooming, and toileting and should appear neat, tidy, and free from body odor. Her activity care plan also indicated a need for stimulation, encouragement, and daily interaction. Her BIMS dated 06/15/2026 documented a score of 99, indicating she refused to participate or gave nonsensical responses for multiple items. During observation, Resident #16, a male resident with severe dementia and a care plan for redirection related to wandering, was seen independently ambulating in the secure memory unit and entering and exiting multiple resident rooms without staff monitoring or redirection. On 06/22/2026 at 4:30 p.m., he was observed exiting Resident #17's room and closing the door behind him, then entering another resident's room. No staff were present in the hallway during these observations. Resident #16's care plan did not address room-to-room wandering, and the MDS Coordinator/RN stated such behavior should be documented and added through the 24-hour report system. Resident #17 was observed in her room with a hospital gown loosely draped over her torso, a soiled brief on the floor, and both feet covered with visibly caked, dried, cracked brown material with an odor of bowel movement present. The mattress surface on the door side of the room had dried brown smears consistent with fecal material and also emitted an odor of bowel movement. Staff J, RN, stated she had Resident #17 on her assignment and said she had checked her residents when she came on shift, "for the most part." Staff F, RN, later stated Resident #17 required total care in bed and was unaware of any fecal smearing behaviors or the soiled mattress. Resident #17 was also noted to have no television in her room, and activities staff stated room visits were not being performed for the secure unit, with no documentation of room visits available for Resident #17.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plan interventions for three sampled residents. Resident #9 had diagnoses including unspecified dementia with mood disturbance, heart failure, COPD, muscle weakness, unsteadiness on feet, and cognitive communication deficit. Her care plan addressed impaired skin integrity risk, falls, antiplatelet therapy, and ADL assistance, but it did not include interventions for wandering into other residents’ rooms or for defecation behaviors in other residents’ rooms. Staff confirmed that she entered other residents’ rooms, dropped her pants and defecated, and that these behaviors were cleaned up but not documented as care plan issues. Resident #9 was observed ambulating independently with oily, matted hair, mismatched shoes worn incorrectly, and an uncovered open wound on her chest that was later seen oozing. Staff stated she needed help dressing and that no one had brought the skin issue to the RN’s attention. The RN reviewed the chart and stated the resident was receiving triple antibiotic to her arms, that the last skin check showed no issues, and that there was no report of new skin problems. The DON stated that a new skin issue form and progress note should have been completed for a new wound, but the weekly skin assessments dated 06/16/2026, 06/22/2026, and 06/23/2026 did not document the chest wound. Resident #16 had diagnoses including COPD, Alzheimer’s disease, and dementia with agitation, with severe cognitive impairment on BIMS. His care plan included redirection during wandering and exit-seeking, but it did not address wandering into other residents’ rooms. He was observed independently entering and leaving multiple resident rooms without staff redirection, including exiting a female resident’s room and entering another room. The MDS Coordinator confirmed there was no care plan addressing room-to-room wandering and stated such behavior should have been added. Resident #17 had diagnoses including COPD, unspecified dementia, coronary artery disease, and depression. Her care plan addressed ADL assistance, activity participation, and skin integrity, but it did not include room-based activities, her preference to stay in her room, or podiatry needs. She was observed lying in bed with her gown loosely draped, a soiled brief on the floor, caked dried brown material on both feet, a strong fecal odor, and dried brown fecal matter smeared on the mattress. Her toenails were observed to extend beyond the toes and appear cracked. The RN stated the feet were dirty, the toenails could be cut by a podiatrist, and the mattress with BM on it should have been reported and cleaned because of infection control concerns. The DON confirmed no weekly skin assessment had been completed on the scheduled day and that there was no documentation explaining the omission. Bathing records showed only one shower in the prior 30 days despite scheduled bathing, and the MDS Coordinator confirmed the resident was not care planned for staying unclothed or staying in her room, and that podiatry services had not been arranged until the interview date.
Failure to Document and Process Resident Grievances
Penalty
Summary
The facility failed to ensure the grievance process was followed for one resident who repeatedly voiced concerns about his care. The resident, who had diagnoses including a stage 3 sacral pressure ulcer, quadriplegia, kidney and ureter disorder, and neuromuscular bladder dysfunction, reported that he had communicated grievances several times to staff and was unsure whether they were written down. He described concerns that the facility was short staffed and said he had been left turned on his side for four hours before a CNA came to assist him. The resident’s record showed multiple care concerns documented in progress notes, including delayed wound vac placement, missed or delayed suprapubic catheter flushing, problems with catheter clogging, missed wound clinic transportation, inadequate turning and repositioning, and concerns about not receiving enough fluids. The grievance log contained only two documented grievances for the resident, related to a CNA sitting outside the room on the phone and a staff member not completing rounds before the end of a shift. Other concerns documented in provider notes were not reflected in the grievance log, and one nursing huddle note addressed catheter flushing and repositioning concerns but did not include all of the resident’s reported issues. Interviews with staff showed that concerns were often communicated verbally to the unit clerk, nurse manager, DON, or other nursing leadership, but staff were not consistent about documenting them as grievances. The unit clerk stated she was sure grievances existed but never documented them herself and relied on others to write them. The SSD, ADON, and DON each stated that grievances should be documented and followed through, even when resolved quickly, but the resident’s repeated complaints were not consistently captured in the grievance process as described in the facility policy.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident physical abuse was reported within 24 hours for two residents. Resident #9 had diagnoses including unspecified dementia with mood disturbance, heart failure, COPD, muscle weakness, unsteadiness on feet, need for assistance with personal care, and a cognitive communication deficit. Resident #8 had diagnoses including dementia with anxiety, unspecified acute kidney failure, and need for assistance with personal care, and had a care plan addressing verbally abusive and physically aggressive behaviors toward staff or other residents. A progress note for Resident #8 documented that the resident was found sitting on the floor in the hallway and stated that Resident #9 called them an expletive, which upset them, and that they hit Resident #9, who then grabbed their arm and caused them to lose balance and fall to the floor. The note also documented that Resident #8 denied hitting their head and complained of pain to the left knee, with no injuries noted at that time. Staff F stated the incident occurred around 3:30 a.m. and agreed it should have been reported to leadership because it involved resident-to-resident contact and was a potential abuse situation. The DON stated she was not notified until 7:00 a.m. that morning, and the Risk Manager stated the incident was not reported to her, the NHA, or the DON when it occurred. The Risk Manager said the event was discovered by reviewing the progress note and that she was still determining whether it met abuse criteria. The DON confirmed that Resident #9's record did not contain documentation of the incident and stated that a skin sweep was completed that morning. The facility policy stated that resident-to-resident altercations are to be reviewed as a potential situation of abuse and that alleged violations are to be reported and investigated within required timeframes.
Improper catheter care and missing documentation for two residents
Penalty
Summary
The facility failed to provide proper catheter care for two residents with indwelling urinary catheters. One resident was admitted with multiple diagnoses including urinary retention, neuromuscular dysfunction of the bladder, chronic kidney disease, dementia, and recurrent UTI history, and had a suprapubic catheter with an order to cleanse the site daily with mild soap and water and apply a dry dressing. The record showed no catheter care documentation, and no documentation of refusal, for multiple dates in the TAR. Progress notes also showed the resident refused catheter site cleaning on several days, and the resident representative stated she had repeatedly raised concerns about catheter care and frequent UTIs and had asked staff to call her when the resident refused care so she could help gain compliance. Staff interviews confirmed the catheter site cleaning was scheduled on the overnight shift, with times documented between early morning hours, and that no one had attempted to move the timing to later in the day to see whether the resident would be more cooperative. The RN confirmed the site cleaning was not done on day shift and the ADON confirmed the resident frequently refused care, that staff knew to call the family member when refusals occurred, and that the early scheduling had not been reconsidered. The ADON also acknowledged that frequent refusals of catheter site cleaning could be contributing to the resident's frequent UTIs. The second resident was admitted with diagnoses including UTI, unspecified dementia, and neuromuscular dysfunction of the bladder, and had a BIMS score of 00 with severe cognitive impairment. The record showed the resident had a Foley catheter reinserted after pulling it out, but there were no subsequent progress notes, no active or discontinued orders for catheter care or catheter removal, and no catheter care documentation in the TAR. When observed, the resident did not have visible catheter tubing or a drainage bag. The DON stated the resident did not currently have an indwelling urinary catheter and confirmed that without orders or documentation in the TAR or progress notes, there was no way to verify catheter care had been completed or how long the catheter had been in place before removal.
Unlabeled Food, Incomplete Temperature Logs, and Poor Kitchen Infection Control
Penalty
Summary
Food storage and sanitation practices were not maintained in multiple nourishment rooms and in the kitchen. On 3/2/2026, the 100 wing nourishment room refrigerator was observed at 58 to 59°F and the freezer at 40°F, with resident food items left unlabeled and undated, including cottage cheese, fruit, popsicles, a 20-ounce bottle of lemon lime soda, and pound cake dated 1/31. The 300 wing nourishment room also contained unlabeled and undated resident food items, including two small containers with unidentifiable food, a brown paper bag with an unidentifiable food item in red sauce, a clear container of lettuce mix without a resident name or date, and a water bottle in the freezer without identification. Temperature monitoring was also incomplete. The 100 hall temperature log did not document the refrigerator/freezer temperature for 3/1/26, and the 400 hall nourishment room had a temperature log only through 2/27/26 with no March 2026 documentation present. The kitchen manager stated nursing staff were responsible for documenting unit refrigerator and freezer temperatures and for labeling and dating resident items, and that nursing staff had received education on those tasks approximately three months earlier. The 100 hall refrigerator/freezer had previously been found at 39°F in the refrigerator and 18°F in the freezer, and the director of maintenance stated the unit was later removed after temperatures continued to increase. Kitchen equipment and infection control practices were also not followed as observed. A cook was observed preparing food while wearing a smartwatch, and later was observed taking meal temperatures without removing gloves and performing hand hygiene between tasks. During tray line monitoring, the thermometer string touched a Salisbury steak while temperatures were being taken, and the string was not cleaned or sanitized afterward. In the dish machine area, staff reported inconsistent sanitizer output and a final rinse temperature below the expected level, while the kitchen manager documented a compliant rinse temperature in the log. The walk-in freezer had ice buildup on and under the fan and on stored seafood products, and the dumpster area contained debris and used gloves around the sides and back of the dumpster.
Accident Hazards Not Controlled in Resident Rooms, Smoking, and Hot Liquids
Penalty
Summary
The facility failed to keep resident rooms and common areas free from accident hazards and failed to provide adequate supervision related to sharp objects, smoking, and hot liquids. On the memory/dementia unit, surveyors observed accessible thumbtacks stuck in corkboards in multiple resident rooms, including rooms with residents who were confused, had dementia or Alzheimer’s disease, and wandered in and out of other residents’ rooms. Staff interviewed during the survey acknowledged that the thumbtacks were accessible, could be removed by residents, and were not being treated as injury hazards. The Nursing Home Administrator also confirmed the unit housed residents with cognitive deficits and wandering behavior and stated the thumbtacks should not have been used in that unit. Additional observations in the secured/memory unit found other potentially hazardous items in resident rooms, including a bottle of mouthwash left accessible on a shelf, a nail clipper in a nightstand, a nail protruding from a corkboard, a hanging staple from a corkboard, a bottle of wipes containing cleaning agents on a side table, and a pinned badge with sharp points on a table near a bed. Staff interviews showed inconsistent understanding of which resident belongings were allowed and whether these items were hazards. One CNA stated mouthwash, toothpaste, toothbrushes, and nail clippers should be secured or returned to staff, while an RN stated residents were allowed to keep items such as badges with pins, nail clippers, and mouthwash. The facility also failed to address smoking hazards for two residents who smoked on the premises. One resident had diagnoses including nicotine dependence, cigarette dependence, supplemental oxygen use, and need for assistance with personal care, and had a BIMS score of 15. Surveyors observed that resident smoking on facility property while wearing a nasal cannula and carrying a portable oxygen tank. Another resident also smoked with the first resident in the covered patio area. Interviews showed the residents retrieved cigarettes from the front desk or carried them themselves, and staff acknowledged the facility had residents who smoked. The facility’s non-smoking policy stated smoking was prohibited anywhere on the premises and that residents were not permitted to have smoking paraphernalia in their room or on their person. The facility further failed to eliminate potential hot liquid hazards in nourishment rooms on four units. Surveyors observed single-service coffee and hot water machines in the 100, 200, 300, and 400 unit nourishment rooms, and the kitchen manager stated staff were not checking or recording beverage temperatures. Staff interviews showed coffee was dispensed hot from the machines, with some staff relying on creamer, steam, or touch to judge temperature, while others stated residents could decide for themselves if the beverage was too hot. The DON stated staff had been educated about hot liquids and using carafes, but the facility did not have a policy for accident hazards related to hot liquids.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure the medication error rate remained below 5% for one sampled resident, resulting in 8 errors out of 25 medication administration opportunities for a 32% error rate. During an observation of medication administration, Staff V, an LPN, prepared and administered medications for Resident #31 at the medication cart. The MAR showed some medications marked green, indicating they had already been completed, while the nurse was observed preparing medications during the medication pass. Staff V crushed and administered 8 pills to the resident, including medications listed on the cart’s do-not-crush list: Keppra, Carbidopa-Levodopa, and aspirin enteric coated. The medication audit report showed 5 medications documented as given at 9:26 a.m. and 9:27 a.m., but Staff V later stated those medications were not actually administered at that time because another resident needed medications first. She said the medications were actually given during the observation ending at 11:34 a.m. and were documented later in the shift at 12:48 p.m. She also stated she did not give levetiracetam 500 mg and should not have documented it as administered because she gave Keppra 250 mg, 2 tablets, and that methocarbamol had only been administered once during her shift.
Resident Council Concerns Not Documented as Grievances
Penalty
Summary
The facility failed to ensure voiced concerns from resident council meetings were documented as grievances and acted upon during three resident council meetings reviewed. Residents attending the meetings reported missing clothing items despite items being labeled, shortages of supplies such as toilet paper, towels, sheets, blankets, and absorbent pads, staff entering rooms without knocking, delayed call light responses, cold food, and concerns about resident rights information not being provided in writing. Residents also stated they had raised these concerns with social services and the administrator weeks earlier, but the concerns were not addressed. A review of resident council meeting minutes showed that concerns were discussed on 12/10/2025, 1/16/2026, and 2/6/2026, including call light response, staff use of personal items, staffing board issues, dietary concerns, brief quality, medications left at bedside, cleanliness of bathrooms, and the request for the ombudsman to discuss resident rights. However, the grievance logs for 12/2025, 1/2026, and 2/2026 did not show documented concerns from the resident council group, and the individual concerns raised by residents were not documented on the dates of the resident council meetings. During interview, the activities assistant stated she recorded generalized complaints in the resident council minutes because she did not know whether she was supposed to name individuals, and she confirmed she had not written a grievance on behalf of resident council. The social service director and social service assistant stated grievances were expected to be documented even if they could be resolved immediately, but they were not aware of resident council concerns such as missing food items or dietary concerns and confirmed there were no documented grievances for several residents. The nursing home administrator stated she reviewed resident council concerns in meetings and interactions with residents, and said she documented grievances if concerns came from an individual resident and/or the group. The facility policy required grievances expressed orally or in writing to be documented on the day received or as soon as possible after the event.
MDS Assessments Were Inaccurate for Resident Diagnoses
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for three residents by not marking active diagnoses in Section I of the assessments. For Resident #134, the record showed an admission and readmission history with diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, and a behavioral health progress note identified post-traumatic stress disorder (PTSD); however, the annual MDS did not mark PTSD. The resident’s care plan also addressed anxiety related to trauma, including privacy before care, preference for female staff when available, and staff approaching anxiety or behaviors with empathy and caring. During interview, the RN/MDS Coordinator stated the PTSD diagnosis had been missed and should have been updated during the GDR meeting. For Resident #211, the admission record listed diagnoses including urinary tract infection, Parkinson’s disease, unspecified dementia, hypertensive chronic kidney disease, and chronic kidney disease stage 3, but the quarterly MDS did not mark non-Alzheimer’s dementia, Parkinson’s disease, or any psychiatric/mood disorder diagnoses. The physician orders included Nuplazid for Parkinson’s psychosis, Sinemet for Parkinson’s, and duloxetine for depression. The MDS Coordinator later confirmed a progress note documented psychotic disorder with delusions due to a known physiological condition and stated the diagnoses were missed. For Resident #226, the admission record listed alcohol dependence with withdrawal, difficulty walking, generalized muscle weakness, and need for assistance with personal care, but the comprehensive MDS did not mark dementia even though the physician orders included donepezil for dementia.
Inaccurate PASARR Screening and Missing Level II Evaluations
Penalty
Summary
The facility failed to ensure accurate PASARR screening for residents with mental disorders, intellectual disability, or related conditions. Based on record review and interviews, five of six residents reviewed had PASARR records that did not match their diagnoses or did not contain required Level II evaluations when indicated. The deficiency involved residents with diagnoses including dementia, bipolar disorder, depression, anxiety, psychotic disorders, epilepsy, alcohol dependence, and Parkinson’s disease-related psychosis. For one resident, the Level I PASARR listed depressive disorder, but the medical record also showed psychotic disorder with hallucinations, unspecified dementia with mood disturbance, depression, epilepsy, and use of psychotropic medications including sertraline, donepezil, quetiapine, and lorazepam. No Level II PASARR evaluation or determination was found. Another resident’s record showed epilepsy, generalized anxiety disorder, dementia, mood disorder due to a physiological condition, major depressive disorder, and unspecified psychosis, with orders for lorazepam and valproic acid; the Level I PASARR listed depressive disorder, anxiety disorder, and mood disorder, but no Level II evaluation or determination was found. A third resident had diagnoses of bipolar disorder and major depressive disorder, with orders for trazodone and oxcarbazepine, yet the Level I PASARR only marked anxiety and depressive disorder and no Level II evaluation or determination was found. A fourth resident’s record showed psychotic disorder with delusions due to a physiological condition, dementia with behavioral disturbance, and adjustment disorder with anxiety, while the Level I PASARR listed Parkinson’s disease and dementia but did not include psychotic disorder, and no Level II evaluation or determination was found. A fifth resident’s Level I PASARR showed no diagnoses marked under MI or suspected MI, even though the record included alcohol dependence with withdrawal and dementia, and the resident was receiving quetiapine and anti-psychotic behavior monitoring. During interview, the Social Service Director stated she reviewed Level I PASARRs against hospital records and diagnoses, kept a log for updates, and relied on others with system access to make changes; she also acknowledged that some residents’ PASARRs needed to be updated and that certain diagnoses, such as dementia, bipolar disorder, epilepsy, and psychotic disorder, should have been reflected and may have required Level II evaluation.
Failure to Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to ensure a resident had assistive devices to maintain hearing abilities for one resident with communication and sensory problems. The resident had an original admission date of 3/21/2023 and a readmission date of 11/17/2025, with a primary diagnosis of acute gastroenteropathy due to Norwalk agent. The resident’s care plan identified difficulty with communication due to hearing deficit and included interventions such as facing the resident when speaking, reducing environmental noise, and referring to audiology as needed. During observation and interview, the resident stated there was no hearing in the left ear and difficulty hearing in the right ear, and staff had to speak loudly and repeat information multiple times for the resident to hear and understand. Record review showed social services notes documenting the resident’s hope to receive hearing aids, agreement to wear headphones if provided, and audiology referrals sent in 2024 and 2025. Interviews with staff confirmed the resident needed loud speech to hear, that an audiology consult had occurred, and that the resident’s name was not listed on the facility’s vendor list for hearing aids or hearing aids pending.
Missing Physician Order for Tracheostomy Humidity Setting
Penalty
Summary
The facility failed to obtain physician orders for the percent of humidity used to provide supplemental oxygen by tracheostomy for one resident reviewed for respiratory care. Resident #5 had diagnoses including acidosis, disorders of the diaphragm, acute and chronic respiratory failure with hypoxia, pneumonitis, and chronic respiratory failure, and was observed on 03/02/2026 with oxygen set to 3 L. The resident’s 3008 form dated 12/12/25 listed oxygen at 6 L per minute and 28% humidity, and the order recap report dated 3/4/26 showed an order for continuous humidified oxygen 2.5 L via trach mask. The resident’s care plan identified a tracheostomy related to chronic respiratory failure and included the intervention to give humidified oxygen as prescribed via trach mask. During interviews, an LPN stated she knew the setting was 2.5 liters and that RT took care of the humidifier, another LPN stated the humidifier setting was 28%, and an RN stated there should be an order for a mist setting. After reviewing the 3008 form, the RN stated there should be an order for 28% humidity and said she was going to fix the order right away. The facility’s Physician Orders policy did not include guidance or relevant information regarding the requirement for physician orders for tracheostomy humidification or respiratory care interventions according to professional standards of practice.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident with a diagnosis of PTSD. The resident had diagnoses including psychotic disorder, dementia, psychosis, paranoid disorder, anxiety, PTSD, and depression, and her annual MDS showed a BIMS score of 5, indicating cognitive deficits that prevented her from speaking to her medical care and services. During observations, she was seen in the dining room eating breakfast and appeared pleasant, but later was observed seated alone in her room looking out the window and appearing isolated. When asked whether she liked sitting in her room by herself with the door closed, she responded, "I don't know." Record review showed psychiatric assessments documented PTSD, but they did not identify the resident's PTSD history, specific triggers, or trauma-based behaviors. The CNA care plan kardex for the prior three months did not include documentation of specific behaviors or triggers related to PTSD, and the behavior monitoring orders and MAR documented general behavior monitoring without identifying trauma-related behaviors. Although the current care plan included a focus area stating the resident had a history of PTSD related to witnessing a traumatic event with her son and listed an avoidance intervention for discussing the trauma, staff interviews confirmed the plan did not detail specific experiences, triggers, or behaviors to monitor. Interviews with the POA, MDS staff, RN, LPN, CNAs, and the Nursing Home Administrator showed staff knew the resident had PTSD but did not know the specific trauma history or what behaviors and triggers to watch for. The POA stated the trauma was not discussed during care plan meetings and he was not told what might trigger the resident. The facility's Trauma Informed Care policy stated that trauma-informed care should identify triggers, minimize re-traumatization, and use individualized care plan interventions, but the resident's record and staff knowledge did not reflect specific trigger identification or trauma-based care planning.
Unsecured treatment cart and expired medications found in storage areas
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because a treatment cart on the C-Wing was observed unlocked, and the medication room on the C-Wing contained four expired immunizations in the refrigerator. An additional observation of the C-Wing HIGH medication cart found three expired medications: Sodium Chloride Tablets 1 gram expired 11/2025, Vitamin D Tablets 400 expired 12/2025, and Zinc Oxide expired 1/2026. The ADON stated the immunizations should not have been in the refrigerator and that the medication storage rooms were messy. The RN stated the expired medications should not have been in the cart, and the DON stated all nurses are responsible for removing expired medications from medication carts and refrigerators. The facility policy titled Labeling & Storage stated labels must include expiration dates and expired medications will be discarded.
Failure to Notify Physician of Missed Scheduled Pain Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified of missed doses of scheduled pain medication for one resident. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict pain management regimen with hydrocodone-acetaminophen scheduled every four hours. On two separate nights, the resident did not receive the 2:00 AM dose of pain medication because the nurse documented the resident as sleeping and did not attempt to wake her, despite the resident's stated preference to be woken for scheduled doses. There was no documentation in the care plan indicating the resident refused medications or did not want to be woken up, and the resident consistently expressed the importance of maintaining the medication schedule to prevent pain. Record review and staff interviews confirmed that the missed doses were not communicated to the resident's physician or representative, and there was no documentation in the progress notes regarding the missed medications. Facility staff, including the LPN, Unit Manager, and DON, acknowledged that the expectation was to attempt to wake residents for scheduled medications and to document any refusals or missed doses. The facility's pain management guidelines also required collaboration with the physician and documentation of interventions to manage pain, which was not followed in this instance.
Failure to Administer Scheduled Pain Medication and Notify Physician/Family
Penalty
Summary
A deficiency occurred when the facility failed to ensure that scheduled pain medications were administered as ordered and that appropriate notifications were made to the physician and family representative for a resident requiring consistent pain management. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict regimen of hydrocodone-acetaminophen every four hours to prevent pain, as per physician orders. On two occasions, the resident did not receive the scheduled 2:00 AM dose because the nurse documented the resident as sleeping and did not attempt to wake her or provide the opportunity to refuse the medication. Interviews with staff, including the Unit Manager, LPN, and DON, confirmed that the facility's policy requires staff to attempt to wake residents for scheduled medications and to notify the physician and family representative if a dose is missed or refused. However, there was no documentation of any such attempts or notifications for the missed doses. The resident herself reported waking up in pain and expressed the importance of maintaining her medication schedule to prevent breakthrough pain. A review of the resident's care plan and progress notes revealed no documentation regarding medication refusals or instructions not to be woken for medications. The facility's pain management guidelines and medication administration policy both emphasize the need for consistent pain management, proper documentation, and communication with the physician and family representative when scheduled medications are missed. These procedures were not followed in this case, resulting in the identified deficiency.
Failure to Honor Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and preferences were honored for four residents out of six sampled for dietary concerns. One resident, who had documented allergies to fish, seafood, and tomatoes, was served a fish sandwich and stewed tomatoes despite these allergies being listed in both hospital and provider records available in the facility. The resident experienced an allergic reaction after consuming the fish sandwich, requiring administration of an epinephrine auto-injector. Staff interviews revealed a lack of awareness and communication regarding the resident's allergies, and the Director of Nursing acknowledged that the allergy information was present in the medical record but not acted upon. Another resident with chewing and swallowing difficulties, as well as a broken wrist, was repeatedly served food that was not cut into bite-sized pieces as required by their care plan and tray card instructions. The resident reported difficulty eating and swallowing the food provided and stated that requests for dietary consultation were not addressed. The Registered Dietician confirmed the need for a mechanically altered diet and that food should be cut into small pieces, but the resident continued to receive whole pieces of meat. Two additional residents reported that their food preferences and dislikes, such as avoiding gravy, were not honored, with meal tickets indicating dislikes that were not followed by dietary staff. Both residents stated that they had informed staff of their preferences, but the issues persisted. Food committee meeting minutes and staff interviews confirmed ongoing problems with meal ticket accuracy and repeated errors in honoring resident preferences and allergies, despite in-services and audits. Facility policies required identification and accommodation of allergies and preferences, but these were not consistently implemented.
Failure to Prevent Accidents and Maintain Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent major injuries for two residents and to maintain a hazard-free environment for another, as evidenced by multiple falls and injuries. One resident with a history of Parkinson’s disease, dementia, and high fall risk experienced repeated falls, some resulting in injuries such as a laceration above the eye, a thumb fracture, and rib fractures. Despite these incidents, care plan interventions were often repeated rather than updated with new strategies, and there was a lack of timely documentation and interdisciplinary team (IDT) review following several falls. Staff interviews revealed inconsistent knowledge of the resident’s care plan and fall history, and the care plan was not always updated after each incident as required by facility policy. Another resident, who was non-verbal, bed-bound, and dependent for all care due to a traumatic brain injury and spastic hemiplegia, developed significant bruising and swelling to the left leg. The injury was initially attributed to spasticity, but subsequent assessments and imaging revealed a displaced femur fracture. Staff interviews indicated a lack of awareness regarding how the injury occurred, with some staff recalling rumors of a fall or transfer incident but no direct observation or documentation. The facility’s investigation into the injury was inconclusive, and there was no clear evidence of adequate supervision or environmental safety measures to prevent such an injury in a dependent resident. The facility’s policies required comprehensive accident and incident reporting, timely investigation, and care plan updates following accidents or injuries. However, the report documents lapses in these processes, including delayed or incomplete investigations, repeated rather than revised interventions, and insufficient staff communication regarding resident incidents. These failures contributed to the residents experiencing preventable injuries and an environment that was not consistently free from accident hazards.
Improper Disposal and Maintenance of Trash Compactor Area
Penalty
Summary
The facility failed to ensure the area surrounding the large outside trash compactor was free from refuse and trash debris during the survey. Observations revealed numerous pieces of trash, including used plastic gloves, full bags of opened trash, soiled Styrofoam containers, plastic straws, and crumpled napkins and paper scattered on the ground around the compactor. The compactor door was closed, but debris was present on all sides. The Maintenance Director acknowledged ongoing issues with trash accumulation in the area, noting that trash comes from all departments and that staff are educated on proper disposal. Additionally, the presence of ducks in the area was mentioned as a contributing factor. There was no documentation of continued monitoring of the compactor area, and the facility's trash compactor policy did not specify routine cleaning or maintenance of the surrounding area.
Failure to Ensure Residents' Informed Choice Regarding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their representatives were properly informed about the binding arbitration agreement, including their right to refuse to sign and that signing was not a condition of admission or continued care. Record reviews and interviews revealed that three residents with intact cognition signed the arbitration agreement as part of their admission paperwork. However, these residents either did not recall being informed that the agreement was optional or were unsure if the documents were mandatory. One resident specifically stated not being in the right frame of mind at the time of signing due to illness, and another was uncertain if the documents were optional. Interviews with the admissions staff indicated that while they verbally explained the arbitration agreement and stated it was not required, the agreement itself did not clearly indicate that signing was optional or that residents could still contact state personnel. Additionally, the admissions staff and the Nursing Home Administrator were unable to locate a policy or procedure regarding the signing of the arbitration agreement, and the NHA had not reviewed the agreement. This lack of clear documentation and policy contributed to the deficiency in ensuring residents' informed choice regarding arbitration agreements.
Arbitration Agreement Lacks Mutual Selection of Neutral Arbitrator
Penalty
Summary
The facility failed to ensure that its arbitration agreement allowed for the selection of a neutral arbitrator mutually agreed upon by both parties, as required. Record review showed that the agreement specified arbitration would be conducted by the American Health Lawyers Association (AHLA) through its Alternative Dispute Resolution (ADR) service, and if unavailable, the facility would unilaterally select another ADR entity. This process did not provide residents with a choice in the selection of the arbitrator. The agreement was signed by three residents. During interviews, the Admission Coordinator acknowledged that the agreement did not appear to give residents a choice in arbitration, and the Nursing Home Administrator (NHA) indicated unfamiliarity with the agreement and was unable to provide a relevant policy or procedure.
Infection Control Program Deficiencies: PPE, Isolation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed deficiencies in the use of personal protective equipment (PPE), posting and adherence to isolation precautions, and hand hygiene practices. Staff were observed entering rooms requiring special contact/droplet precautions without donning appropriate PPE, and residents on such precautions were seen moving freely in hallways without masks. Interviews with staff revealed inconsistent understanding of when PPE was required, with some staff only wearing PPE during direct care and others unsure of the correct precautions. In several instances, isolation signage was missing from doors of rooms with residents positive for COVID-19, and staff were unaware of the necessary precautions until prompted by surveyors. Hand hygiene practices were also not consistently followed. Staff were observed administering injections, handling medication carts, and performing blood glucose checks without performing hand hygiene between tasks or between resident contacts. Shared medical equipment, such as blood pressure cuffs and glucose monitoring strip bottles, were not cleaned between uses or after being in resident rooms, and respiratory masks were left uncovered in resident rooms. Staff interviews confirmed that proper hand hygiene and equipment cleaning protocols were not always followed, and the DON acknowledged that these practices were not in line with facility policy. Additional deficiencies included improper management of indwelling urinary catheters, with a resident's catheter bag observed clipped to a garbage can and touching the floor, contrary to physician orders and care plan interventions. Staff were also observed with artificial nails, which is against facility policy for direct care staff. Housekeeping staff demonstrated inconsistent understanding of PPE requirements for different types of precautions, and language barriers further complicated adherence to protocols. Review of care plans and policies confirmed that the observed practices did not align with established infection control procedures.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for residents across all units and over several days. Resident rooms and bathrooms were found with significant cleanliness and maintenance issues, including waterlogged towels used to address leaks, bio growth on shower tiles and grouting, stained and oxidized bathroom fixtures, and non-cleanable surfaces such as torn fall mats and over-bed tables. Equipment such as shower chairs and fabric chairs were also found to be in poor condition, with visible bio growth and surfaces that could not be adequately cleaned. In several instances, resident areas were cluttered with unused wheelchairs and mechanical lifts, blocking access to common spaces. Interviews with staff revealed a lack of clarity and accountability regarding the reporting and resolution of maintenance and cleanliness issues. The unit manager confirmed that all staff are responsible for observing and reporting such concerns, but was unaware of the specific deficiencies identified by surveyors. The maintenance director stated that work orders are addressed by priority but acknowledged that neither he nor his staff conduct daily room checks, relying instead on reports from other staff. There was also confusion regarding departmental responsibilities for equipment maintenance, such as wheelchairs and fall mats, and no maintenance logs were kept for certain items. Additional observations included malfunctioning air conditioning units that were loud and disruptive to residents, water leaks resulting in stained ceiling tiles and puddles in hallways, and privacy curtains and assist rails with visible brownish substances. Facility records showed that some maintenance issues, such as water leaks, were documented in work orders, but there was no documentation regarding the loud air conditioning unit. Facility policies required regular cleaning and maintenance of resident rooms and HVAC systems, but these procedures were not consistently followed, as evidenced by the ongoing issues observed during the survey.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for four residents. In multiple instances, residents were observed receiving oxygen at flow rates different from those prescribed. For example, one resident with COPD and a physician order for 2 L/min via nasal cannula was observed receiving oxygen at 4 L/min and later at 2.75 L/min. The resident’s care plan and orders specified the required oxygen settings, but these were not followed during observations. The Director of Nursing confirmed that the oxygen concentrator was not set to the ordered rate and was unsure if staff knew how to read the flowmeter. Another resident was observed receiving 2.5 L/min of oxygen, but the active physician order did not specify a flow rate. The care plan contained conflicting interventions, listing different flow rates (2 L/min, 2.5 L/min, and 4 L/min), and staff were unable to locate the correct order in the system. Staff interviews revealed uncertainty about the correct oxygen parameters, and a new order was only entered after the deficiency was identified. In a separate case, a resident with a tracheostomy was receiving 3 L/min of humidified oxygen, but the physician order specified 28% humidified oxygen without a corresponding liter flow. Staff were unable to locate the specific order for the oxygen flow rate and expressed uncertainty about the correct setting. Additionally, another resident was observed receiving 1.5 L/min of oxygen, while the physician order had previously specified 4 L/min as needed and 2 L/min for ambulation, both of which had been discontinued. The care plan referenced following orders for oxygen therapy, but the observed administration did not match any active order. The facility’s policy on oxygen administration outlined procedures for infection control and documentation but did not address the discrepancies in following physician orders for oxygen flow rates.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Multiple deficiencies were identified regarding the storage, labeling, and security of medications and biologicals. Observations revealed that prescription creams and medications were left out in resident rooms, including a tube of Triamcinolone Cream on a bathroom counter and Ammonium Lactate cream on a bedside table, along with medicine cups containing unidentified creams. Additionally, an unlocked office labeled 'Nurse Supervisor' was found with prescription medications, iodoform packing, and wound cleanser left unsecured and accessible, with the door open and no staff present on multiple occasions. Audits of medication carts uncovered further issues, such as narcotics stored correctly in a separate locked compartment, but with personal items like hearing aids, chargers, money, and a cell phone stored alongside medications. Loose medication capsules and medication cups with unidentified pills were found in drawers, and staff were unable to identify or account for these medications. Opened glucose test strips were found undated in multiple carts, and staff acknowledged that these should be dated upon opening. In one instance, a medication refused by a resident was improperly disposed of in a trash can instead of following the facility's disposal protocol. Interviews with staff and the DON confirmed that these practices were not in accordance with facility policy or professional standards. Staff admitted to not knowing the origin or intended use of some medications found, and the DON acknowledged that medications and personal items should not be stored together, and that medications should not be left unsecured or improperly disposed of. The facility's policy requires all medications and biologicals to be stored in locked compartments and for medication storage areas to be maintained in a clean, safe, and sanitary manner, which was not consistently followed.
Failure to Offer Evening Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing evening snacks to seven residents who were sampled for dining, as evidenced by multiple resident interviews and record reviews. Several residents reported that evening snacks were not routinely offered, and when requested, staff sometimes stated that snacks were unavailable or had run out. Only one CNA was identified as regularly offering snacks, typically cookies, during his shifts, while other staff did not proactively offer snacks to residents. Residents expressed that the lack of evening snacks was particularly concerning due to the significant time gap between dinner and breakfast, which was confirmed to be approximately 15 hours according to the facility's meal delivery schedule. Staff interviews revealed that while snacks were available on the units, they were only provided to residents who specifically requested them or had a physician's order, rather than being offered to all residents. The Dietary Manager confirmed that snacks were delivered to the units but was unaware if staff were distributing them to residents. Facility policy states that the time between the evening meal and breakfast should not exceed 14 hours unless a substantial snack is served at bedtime, yet this was not consistently practiced. One resident with diabetes specifically noted the need for an evening snack, highlighting the importance of this service for residents with medical needs.
Failure to Ensure Functioning and Accessible Call Light System
Penalty
Summary
The facility failed to ensure that a functioning call light system was available and accessible for multiple residents. Several residents reported or were observed to have non-functioning call lights in their rooms and bathrooms. One resident stated that upon admission, the call light did not work and it was not fixed until the following day, during which time no alternative means to summon staff was provided. Another resident reported a non-working call light, which was confirmed by staff, and there was no indication that maintenance had been notified in a timely manner. Observations and interviews confirmed that call lights in several rooms were either not functioning or not present, and in one case, a call light was found out of reach in a closed dresser drawer, making it inaccessible to the resident. Staff interviews revealed inconsistent practices regarding the placement and reporting of non-functioning call lights. Some staff stated that call lights should be within reach of residents and that maintenance should be notified through a paper form or work order system if a call light was not working. However, there was no evidence of a formal policy on call light functionality, and maintenance staff indicated that they were not always notified of issues. The maintenance director reported that monthly checks were performed in a limited number of rooms and that pre-admission checklists included call light functionality, but these measures did not prevent the deficiencies observed. Multiple staff members confirmed that call lights should not be placed in drawers or out of reach, and that non-functioning call lights should be reported immediately. Despite these expectations, several rooms were found to have call lights that were either not working or not accessible to residents. The lack of a consistent system for ensuring call light functionality and accessibility contributed to the deficiency, as evidenced by the observations, interviews, and record reviews documented in the report.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly documented and resolved, as required by policy and regulation. Multiple residents reported ongoing issues with meal choices, meal ticket accuracy, and the honoring of food preferences and dislikes. For example, one resident repeatedly received meals with items listed as dislikes on her meal ticket, such as gravy, and did not receive requested alternatives like a chef salad, despite having standing orders. Another resident with a history of ulcers received tomatoes on her tray, which she had specifically requested to avoid. These concerns were voiced to staff but were not consistently documented as grievances or followed up with appropriate dietary consultations. Resident Council and Food Committee meetings revealed recurring concerns about meal ticket errors and other issues, such as staff using personal phones during care, call lights not being answered, and cleanliness problems. Despite these issues being raised repeatedly in meetings and committee minutes, there was a lack of corresponding documentation in the grievance log for several months. Residents and their representatives also reported that grievances were not being followed up on or communicated back to them, and that the process for addressing grievances was unclear or inconsistently applied. In some cases, grievances submitted by family members or surrogates were not fully documented or tracked, and some issues were marked as resolved without evidence of comprehensive follow-up. Interviews with facility staff, including the Nursing Home Administrator, Certified Dietary Manager, and Social Services staff, confirmed gaps in grievance documentation and tracking. Staff acknowledged that grievances were not always logged, especially those arising from committee meetings or voiced informally by residents. The facility's own policy requires prompt documentation, investigation, and written resolution of all grievances, but records showed that this process was not consistently followed. As a result, residents' rights to voice grievances without discrimination or reprisal, and to have those grievances promptly addressed, were not upheld.
QAPI Failure With Ongoing Medication, Infection Control, Food Safety, and Arbitration Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI process to identify and correct repeated deficient practices related to medication storage, infection control, food safety and sanitation, and arbitration agreements after the recertification survey. The report states that the facility’s prior plans of correction had a completion date of 9/28/25, yet on the 10/22/25 revisit survey, surveyors continued to find the same types of problems in multiple departments and locations. The DON acknowledged that expired medications should have been removed, that medication carts and storage rooms should have been audited, and that the education completed after the prior survey had been focused more narrowly on the narcotic box, which may have caused confusion about storage expectations across the entire medication cart. Medication storage deficiencies were observed in several areas. In the nursing supervisor office on C-Wing, the office was open and unsecured while wound cleanser, Procrit packing strips, and skin ointments were inside. A treatment cart on A-Wing was left unlocked outside a resident room. Multiple medication carts contained loose pills, medications stored with syringes, flushes, drug destroyer, sanitizing wipes, Kleenex, and other miscellaneous items. One cart contained an undated insulin pen, another had an expired nasal spray, another had an expired insulin pen and a second insulin pen with an open date but no expiration date, and one cart contained a resident hearing aid case stored with medications. In the medication storage room on D Wing, surveyors found expired saline nasal spray and a box of resident medications that included multiple expired medications belonging to residents no longer in the facility. Food safety and sanitation concerns were also observed. In nourishment rooms, surveyors found unlabeled and undated drinks, frozen beverages, open food containers, and food items stored without resident identification or opening dates. During testing of the dishwasher, sanitizer strips repeatedly failed to show the required color change, and the CDM stated she did not know why the tests were failing. Surveyors also observed the walk-in refrigerator fan leaking clear liquid onto boxes of food, with wet boxes, a bent metal plate, and a soiled area on the fan. The CDM stated she did not know how long the fan had been leaking and noted a missing screw. The DOM later stated the dishwasher had not been serviced since the prior annual survey and that the sanitation strip failures were related to air bubbles in the line. Infection control deficiencies remained present during the revisit survey. Resident #18 had a special droplet/contact precaution sign posted, but the PPE caddy did not contain the required PPE, and staff entered the room without PPE or hand hygiene. A speech pathologist, housekeeping staff, and nursing staff all stated they had not received training regarding infection control or PPE use, and several staff members said they did not know why the resident was on precautions. Surveyors also found a hydration cart with an uncovered ice scoop in the hallway, and the NHA stated the facility had no infection control process in place before the annual survey and did not know which residents required isolation precautions. The report also notes that the arbitration agreement still contained language stating arbitration would be conducted by the American Health Lawyers Association through its ADR service.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain resident dignity during meal service in one of four observed dining rooms. Observations revealed that residents seated at the same table were not served their meals simultaneously. On one occasion, four out of six residents at a table were eating while two others had no food or drink, and a CNA was present but not actively assisting. Staff interviews confirmed that trays were distributed in room order rather than ensuring all residents at a table were served at the same time, despite staff acknowledging that simultaneous service was the expectation. Further observation showed a similar pattern, with some residents having finished their meals while others waited without food or drink. Staff again indicated that the current practice was to serve trays in room order, not by table, which resulted in residents at the same table experiencing delays in meal service. Review of facility policies emphasized the importance of preparing the environment to make mealtime pleasant and upholding resident rights to dignity and respect, which were not followed in these instances.
Failure to Complete Accurate PASRR Assessments and Submit Required Level II Evaluations
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were accurate and that a Level II PASRR was submitted for one resident with relevant mental health diagnoses. Record review showed that the resident was admitted with diagnoses including mood disorder, insomnia, dementia, and bipolar disorder. The Level I PASRR indicated no suspicion or diagnosis of Serious Mental Illness or Intellectual Disability, and a Level II PASRR evaluation was not completed, despite the resident's diagnoses. During an interview, the Assistant Director of Nursing (ADON) acknowledged that PASRR audits were being conducted but stated that outside of these audits, no further action had been taken for existing residents. The ADON also indicated a misunderstanding of which diagnoses require Level II submission, as she did not submit for bipolar disorder. Additionally, the facility did not have a PASRR policy in place.
Failure to Provide and Document Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, resulting in deficiencies related to catheter site hygiene and documentation. One resident with a suprapubic catheter reported that the site had not been cleaned or the dressing changed for three days, and this lack of care persisted even after the concern was voiced to staff. The resident, who was dependent for all activities of daily living due to paraplegia and had multiple comorbidities including neurogenic bladder and chronic kidney disease, stated that catheter care had not been performed correctly since a nurse who previously provided her care resigned. Staff interviews confirmed that the catheter site had not been cleaned or the dressing changed as required during the previous shift, and that CNAs were only responsible for emptying the catheter bag, not for site care. Another resident with an indwelling urinary catheter reported that catheter care was not consistently performed every shift as ordered. Review of the treatment administration record revealed multiple shifts where catheter care was not documented as completed. This resident was cognitively intact and had an order for catheter care every shift with soap and water. Laboratory results indicated that the resident developed a urinary tract infection, and an antibiotic was subsequently ordered. Facility policy required catheter care to be performed every shift and documented accordingly, including assessment data and any problems noted. The policy also outlined the importance of maintaining aseptic technique, securing the catheter, and monitoring for signs of infection. The failure to provide and document catheter care as ordered and per policy led to the identified deficiencies for both residents.
Failure to Provide Timely Pain Management for Resident on Hospice
Penalty
Summary
A resident with multiple diagnoses, including pulmonary fibrosis, diabetes, atrial fibrillation, hyperlipidemia, hypertension, and end stage renal disease, experienced ongoing and significant back pain while under hospice care. Despite repeated reports of severe pain and visible signs of discomfort, the resident did not receive timely administration of prescribed pain medication. The resident reported inadequate pain relief and stated that staff could not provide additional medication while waiting for hospice intervention. Pain assessments documented high pain levels, with scores reaching up to 9/10 on several occasions. A new order for Baclofen 10 mg was prescribed by hospice, but the medication was not administered until nearly two days after the order was placed. Staff interviews revealed confusion regarding the availability of the medication, with some staff unaware of its location and others indicating it had not arrived from the pharmacy. The unit manager and LPNs discussed accessing the medication from the emergency drug kit, but delays persisted. The Director of Nursing confirmed that the resident should have received the medication when ordered and acknowledged that staff could have contacted the medical director for an alternative order while waiting for hospice. The facility was unable to provide a medication administration policy when requested.
Failure to Offer COVID-19 Vaccine Upon Admission
Penalty
Summary
The facility failed to ensure that two residents were offered the COVID-19 vaccine as required by facility policy. Both residents were admitted to the facility and subsequently sent to the Emergency Department, where they tested positive for COVID-19 before being re-admitted. A review of their medical records revealed that there was no documentation of COVID-19 vaccine consent or refusal prior to their positive diagnoses. During an interview, the Infection Preventionist confirmed that the residents were not offered the vaccine upon admission, which is a standard part of the facility's admission process. The facility's policy states that all residents are to be evaluated for vaccine status and offered recommended vaccines upon admission unless medically contraindicated.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across all four units, as evidenced by multiple resident interviews, staff interviews, observations, and record reviews. Several residents reported excessive wait times for assistance after activating call lights, with one resident waiting up to an hour and a half and another waiting two hours for help with toileting. These residents had significant medical needs, including hemiplegia, heart failure, muscle weakness, and impaired mobility, and some were unable to perform activities of daily living without staff assistance. Observations also revealed residents left unattended in common areas, including one resident attempting to stand unsafely from a wheelchair and another struggling to move his wheelchair without staff present. Resident Council meeting minutes over several months documented ongoing concerns about delayed call light responses, indicating a persistent issue. A resident representative expressed frustration about unaddressed falls and unanswered call lights, particularly on weekends. Staff interviews consistently described chronic staffing shortages, unpredictable assignments, and difficulty completing tasks, especially during weekends and meal times. Staff members reported frequent call-offs and described staffing as 'hit or miss,' with some stating they had become accustomed to the inadequate staffing levels. The staffing coordinator and DON acknowledged that staffing decisions were primarily based on numbers rather than resident needs, and admitted that required staffing levels were not always met, particularly on weekends and certain shifts. Despite daily reviews of staffing with the NHA and SC, the DON stated being unaware of any staffing concerns. The facility's policy required sufficient staff to meet resident needs according to care plans, but the evidence showed this standard was not consistently met, resulting in unmet resident needs and delayed care.
Failure to Implement Policies to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the employee files of six staff members, including LPNs, RNs, and CNAs. The facility's policy titled 'Resident Rights to Freedom from Abuse, Neglect, and Exploitation' lacked procedures for screening employees or verifying prior employment. Interviews with the Nursing Home Administrator (NHA) revealed that this was the only policy in place, indicating a lack of comprehensive measures to prevent such incidents. The review of employee files showed that while Level 2 background screenings were completed prior to employment, the employees were not added to the Background Clearinghouse in a timely manner, which would notify the facility if an employee was charged with a disqualifying offense. Additionally, no reference checks were completed for prior employment history for any of the six employees reviewed. The NHA stated that the expectation was to have background checks completed before employment, employees added to the Clearinghouse within five days of hire, and reference checks completed prior to employment, but these procedures were not followed, leading to the deficiency.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, compromising the resident's right to a dignified existence and self-determination. Resident #8, who was mentally intact with a BIMS score of 15, had explicitly requested female caregivers for incontinence care, as documented in her care plan. Despite this, the facility's assignment sheets showed that male caregivers, including those the resident specifically did not want, were assigned to her on multiple occasions. Interviews with the Unit Manager and Director of Nursing confirmed these assignments and acknowledged the availability of female caregivers on those days. The Director of Nursing admitted uncertainty about the system in place to ensure resident preferences were honored, despite having provided a list of residents requesting no male caregivers. The Nursing Home Administrator expected that such preferences would be documented in the resident's Kardex and care plan and honored by the unit manager and clinical leadership team. The facility's policy on Resident Rights emphasized treating residents with dignity and respecting their self-determination, which was not upheld in this case.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address grievances filed by two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #3 reported multiple grievances, including delayed response to call lights, improper meal tray setup, and issues with medication administration. Despite filing grievances, the resident did not receive feedback or resolution from the Social Services Director (SSD), and the grievance forms lacked documentation of investigations or actions taken. Resident #8 and their representative also expressed concerns about the timeliness of assistance and filed grievances regarding call light response. However, there was no record of these grievances in the facility's log, indicating a failure to document and address the resident's concerns. The Nursing Home Administrator (NHA) acknowledged speaking with the resident's representative but could not confirm specific actions taken to resolve the issues. The facility's grievance policy outlines procedures for filing, documenting, and resolving grievances, but these procedures were not followed in the cases of Residents #3 and #8. The SSD and other staff members failed to investigate and resolve the grievances, and there was a lack of communication with the residents about the outcomes. This deficiency highlights a breakdown in the facility's grievance process, resulting in unresolved resident concerns and a failure to uphold residents' rights.
Deficiencies in Resident Care and Protocol Adherence
Penalty
Summary
The facility failed to provide timely repositioning, skin integrity checks, and incontinence care for a resident with multiple comorbidities, including pressure ulcers and paraplegia. The resident expressed concerns about not being repositioned or changed for extended periods, leading to fears of wound reopening. Observations and interviews revealed that the resident was left without care from 10 a.m. to 3 p.m., resulting in skin irritation and emotional distress. The CNA responsible admitted to not checking or changing the resident as required, citing a lack of training at the facility. Additionally, the facility did not adhere to its protocol for lift transfers. A CNA transferred the resident using a full body sling lift without assistance, contrary to the care plan that required two-person assistance. The CNA acknowledged the breach of protocol, attributing it to the inability to find help and a lack of specific training at the facility. The DON confirmed that the transfer should have been conducted with two staff members, as per the resident's care plan. The facility also failed to ensure a call light was within reach for another resident, resulting in the resident being unable to request assistance during breakfast. The CNA responsible did not check on the resident after delivering the meal tray, leaving the call light on the floor. Furthermore, the facility did not administer medications per physician orders for the resident with pressure ulcers. The resident's Zolpidem medication was not reordered in a timely manner, leading to missed doses. The DON confirmed discrepancies in medication administration records and acknowledged the failure to reorder the medication promptly.
Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide necessary care and services to residents, resulting in multiple deficiencies. Observations and interviews revealed that residents were not receiving timely wound care, with bandages remaining unchanged for extended periods, leading to concerns about potential infections. Residents expressed dissatisfaction with the lack of response to call bells, inadequate assistance with activities of daily living (ADLs), and insufficient showering and bathing schedules. The facility's staffing shortages were evident, with reports of call lights going unanswered for extended periods and residents not receiving necessary assistance with meals. The deficiency was further highlighted by the inadequate response to residents' needs during mealtimes, where residents were left unattended and without assistance, leading to some residents being unable to eat. Interviews with staff and residents indicated that the facility was consistently understaffed, with CNAs and nurses unable to meet the demands of the resident population. Staff reported working double shifts and being unable to provide more than basic care due to the high workload and insufficient staffing levels. The facility's management was aware of the staffing issues, with reports of call-offs and no-shows exacerbating the problem. Despite attempts to fill positions with agency staff, the facility struggled to maintain adequate staffing levels, leading to neglect of resident care. The deficiency was severe enough to result in an Immediate Jeopardy determination, indicating a significant risk to resident safety and well-being.
Removal Plan
- Current staffing model reviewed and updated to reflect resident needs and acuity.
- Facility assessment reviewed and updated to reflect current resident population needs.
- Reassessed the acuity level of each unit. Reviewed assistance the level of care needs for ADLs including transfer status, mechanical lift usage, and residents requiring a higher level of care due to comorbidities.
- Education provided to the staffing team to include administration, Director of Nursing, and staffing coordinator regarding staffing standards and staffing for acuity on each unit to ensure quality resident care.
- Initial audit completed to compare the AHCA report to the PPD report and compare with schedules to ensure that PPD was met, and ratios were appropriate for the resident acuity. Administrator, staffing coordinator and payroll coordinator reviewed staffing from the previous day to ensure that hours and ratios were achieved according to the staffing plan based on acuity. Payroll ran the PPD report from the payroll software, after editing missed punches, to compare and enter into the AHCA staffing sheets to encompass hours from the previous day. Staffing coordinator reviewed the schedule for the current day and next day to review attendance and staffing needs to ensure that resident needs are met, and staff are within the ratio of the staffing model. It is the administrator's responsibility to ensure that the staffing model is updated, and the facility assessment is completed to reflect resident acuity needs on each unit.
Facility's Failure to Secure Safe Evacuation Locations During Hurricanes
Penalty
Summary
The administration of the facility failed to update their emergency plan and secure a safe evacuation location, leading to a chaotic and unsafe evacuation during two hurricanes. The facility had an evacuation agreement with a local church, which was terminated due to the facility not following agreed-upon safety and cleanliness procedures. Despite being aware of the termination, the Nursing Home Administrator (NHA) did not secure an alternative location and relied on the local County Emergency Management for assistance, which was not provided. As a result, during the evacuation for the first hurricane, residents were moved to an unsafe location, leading to police and emergency services intervention. During the evacuation for the second hurricane, the facility again failed to secure a safe location, resulting in residents being moved to a church that was deemed unsuitable by local authorities. The conditions at the evacuation site were overcrowded, lacked necessary supplies, and posed significant safety risks, including inadequate space, lack of fire suppression, and insufficient power for medical equipment. The local authorities had to intervene and relocate the residents to a more suitable location, highlighting the facility's failure to ensure the safety and care of its residents during emergencies. Interviews with staff and residents revealed the disorganization and lack of communication during the evacuations. Staff reported confusion, inadequate supplies, and insufficient staffing to care for residents properly. Residents experienced discomfort and distress due to overcrowding and lack of proper facilities. The facility's failure to plan and execute a safe evacuation resulted in immediate jeopardy, with ongoing concerns about the safety and well-being of the residents.
Inadequate Emergency Preparedness Leads to Unsafe Evacuation
Penalty
Summary
The facility failed to maintain an effective governing body that was aware of and updated the facility's emergency plans, leading to a chaotic and unsafe evacuation during Hurricane [NAME]. The governing body was not informed that the facility's evacuation agreement with a local church had been terminated, and no alternative evacuation location was arranged. As a result, when an evacuation was ordered, the facility staff moved 226 residents to an unapproved and unsafe church location. The conditions at this location were deemed unsafe by local authorities, leading to the relocation of residents to a county shelter. During the evacuation, two residents suffered harm due to the lack of supplies and supervision. One resident sustained a fracture after falling, and another resident did not receive necessary wound care treatment. The facility's emergency management plan was outdated and not properly communicated to the governing body, resulting in a lack of preparedness and organization during the evacuation. Staff interviews revealed confusion, inadequate staffing, and insufficient resources to care for the residents during the evacuation. The facility's failure to secure an approved evacuation location and the lack of a comprehensive emergency plan created a situation of immediate jeopardy for the residents. The governing body was not aware of the termination of the evacuation agreement, and the facility did not have a plan in place to ensure the safety and care of its residents during an emergency. This led to a worsened condition for two residents and posed a serious risk to all facility residents.
Neglect and Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to protect residents from neglect, resulting in multiple incidents of harm. Resident #3, who required maximum assistance with activities of daily living due to dementia and other health conditions, suffered a hip fracture during a transfer. The investigation into the incident was inadequate, with conflicting accounts from staff and no clear determination of how the injury occurred. The facility did not report the incident as abuse or neglect, and there was a lack of proper documentation and communication with the resident's primary care provider. Resident #8, who was dependent on assistance for all activities of daily living, fell from bed due to improper handling by a CNA. The CNA attempted to clean the resident alone, despite the resident's known behavioral issues and the slippery nature of the air mattress. The facility's care plan did not specify the level of assistance required, leading to confusion among staff. The incident resulted in significant injuries, including a subdural hemorrhage and nasal bone fractures, yet the facility did not conduct a thorough investigation or provide additional training to staff. Resident #12, who had moderate cognitive impairment and was at risk for falls, was found on the floor during an evacuation. The facility did not assign specific responsibilities to staff during the evacuation, leading to inadequate supervision. The resident was sent to the hospital with stable vital signs, but the facility did not conduct a post-storm assessment to evaluate the impact of the evacuation on residents. The lack of organization and communication during the evacuation contributed to the resident's fall and subsequent hospitalization.
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Illustrative
What surveyors actually found near you
We read the 311 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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) |
|---|---|---|---|---|
| Brighton Bay Center For Rehabilitation And Healing | 0.2 mi | ★★★★★ | 0 | 0 |
| Abbey Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 17 | 0 |
| Vivo Healthcare St Petersburg | 2.1 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Gateway | 3.4 mi | ★★★★★ | 1 | 0 |
| Vivo Healthcare Laurellwood | 3.6 mi | ★★★★★ | 2 | 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.