Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure sufficient nursing staff and accessible, functional call lights for dependent residents. Several residents reported waiting from 30 minutes to hours for call bell responses, sometimes having to go to the nurses’ station themselves or, in one case, calling 911 when no call bell was available. During observation, multiple residents in bed had call lights on the floor and out of reach, and one room’s call system did not activate until an RN adjusted the wall connection. LPNs reported caring for 20–38 residents per shift, described triaging call lights due to workload, and stated they could not consistently meet expected response times. Grievance logs documented repeated, non-specific “call bell issues” over multiple review periods, and the Activities Director confirmed that residents continued to voice ongoing problems with delayed call light response during resident council meetings.
The facility failed to provide enough nursing staff to meet resident needs and failed to keep call lights within reach and working for multiple residents. Residents reported waiting 30 minutes to hours for help with toileting, water, and other care, and one resident said he had to call 911 when no call light was available. Staff described heavy assignments and said call light response expectations were not consistently met, while the grievance log showed repeated call light complaints over several months.
Surveyors found that multiple residents had unsecured medications left at bedside, including melatonin gummies, eye vitamins, nasal decongestant spray, antacid tablets, arthritis powder, and vaporizing rub stored on nightstands and overbed tables. Nursing staff, the ADON, and the DON all stated that medications should not be kept unlocked in resident rooms and should instead be locked in a med cart or, for residents with self-administration orders, in a locked box. The facility’s written policy requires all drugs and biologicals to be stored in locked compartments and specifies that compartments containing medications must be locked when not in use.
Surveyors found that the facility's designated resident smoking area in the courtyard lacked a required self-closing metal butt can for cigarette disposal, as mandated by NFPA 101. The Maintenance Director confirmed the absence of this fire safety equipment during the inspection.
A resident with right-sided hemiplegia and aphasia, dependent on staff for ADLs, did not receive ordered passive range of motion (PROM) exercises or brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of the Treatment Administration Record showed no documentation of the required care, resulting in a deficiency for failure to maintain or improve range of motion.
Surveyors identified expired medications in two medication carts during a review, including an expired bottle and a gel for a resident that was past its use date. The facility's policy requires checking expiration dates before administration, but the DON confirmed expired medications should not be present and noted that cart checks occur weekly but need better follow-through.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications to a resident, despite both being contraindicated for crushing. The facility's policies and physician orders required staff to avoid altering medications when contraindicated, and both the consultant pharmacist and DON confirmed the error. This deficiency was observed during a survey and was based on direct observation, record review, and staff interviews.
The facility did not ensure RN coverage for at least 8 consecutive hours on two reviewed days, as required by federal regulations. Staffing records and time sheets showed that on these days, RN hours fell short, and staff interviews confirmed no other RN was present to meet the requirement.
A resident with significant physical and cognitive impairments did not receive prescribed passive range of motion exercises or brace application as ordered in their care plan and physician's orders. Staff were unaware or did not implement the required interventions, and documentation confirming these treatments was absent.
A resident with a right hand contracture and history of stroke did not receive ordered passive range of motion (PROM) exercises or splint/brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of records confirmed no documentation of PROM or splint use during the review period.
The facility did not provide RN services for the required 8 consecutive hours on two days, as staffing records and time sheets confirmed that RN coverage fell short. Staff interviews verified that no other RN was present and no call-offs occurred, resulting in a deficiency in meeting minimum RN staffing requirements.
Surveyors found expired Acetaminophen and Lorazepam topical gel on two medication carts, despite facility policy requiring expiration date checks before administration. The DON confirmed expired medications should not be present and noted that weekly cart checks were not consistently followed.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications—Metoprolol Succinate ER and Klor-Con M20—by mixing them in pudding for a resident, despite facility policy and drug guidelines contraindicating this practice. Both the consultant pharmacist and DON confirmed that these medications should not have been crushed, and alternative forms should have been used.
A resident with a history of falls and medical conditions fell and sustained a major injury due to inadequate supervision and assistance. Despite having a care plan with interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall. The facility failed to document specific interventions or monitoring frequency, and the resident's call light was not within reach. Staff monitoring was inconsistent, and no new interventions were added to the care plan to prevent further incidents.
A resident with a history of falls and sensory impairments fell while attempting to use the bathroom unassisted, resulting in a major injury. Despite having a care plan that included assistance with toileting and the use of a call bell, the resident was found on the floor with the call light not engaged. Staff interviews revealed inconsistent monitoring, and the care plan had not been updated with new interventions to prevent further falls.
The facility failed to provide a clean and comfortable environment, with issues such as stained floors, peeling wallpaper, and malfunctioning equipment. A resident reported difficulties with a non-functioning bed control, which had been unresolved despite informing staff. The Administrator acknowledged the environmental concerns and a failure in the work order process.
Insufficient Nursing Staff and Call Light Accessibility Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and ensure accessible, functional call lights for dependent residents, as required by its own call light policy and federal regulations. The facility’s written policy states that residents must have a call light within reach, that call lights must be answered promptly by facility personnel, and that all personnel are expected to respond. During an initial tour at 8:45 a.m., multiple dependent residents were observed in bed with their call lights on the floor and not accessible, and the DON confirmed that these residents should have had call bells within reach. Photographic evidence was obtained of call lights on the floor. Multiple residents reported prolonged delays in call light response and difficulty obtaining assistance. One resident stated she had recently filed a grievance about call light response times and reported waiting about 30 minutes to an hour before anyone answered, sometimes having to walk to the nurses’ station herself. Another resident reported waiting “hours” after pressing the call bell and said that when staff did not come, she would go to the desk in her wheelchair; she believed there was not enough help at night and on weekends. A third resident reported that sometimes it took a very long time for staff to answer the call light, and that on one occasion when he did not have a call bell at his side, he yelled repeatedly and ultimately called 911 from his phone to get help. Additional residents described ongoing problems with unanswered call lights and unmet care needs. One resident reported that it could take up to an hour for staff to respond and that at the time of interview he had been waiting about an hour for a simple request for water; when he activated his call light, the indicator above the door did not illuminate until an RN adjusted the wall connection, confirming the call light had not been working. Another resident stated he had filed grievances about staff not answering call lights and reported that he sometimes waited two hours or more for toileting assistance, resulting in soiling himself; he said he did not think there was enough staff and that this had been an ongoing issue. Nursing staff interviews further described workload and response-time issues. One LPN stated that all staff are responsible for answering call bells, that the required response time was within 30 minutes, and that she had to triage which residents to see first; she reported sometimes being unable to respond timely and described working night shift with 35–38 residents, saying she did not feel her license or the residents were safe. Another LPN stated that everyone was responsible for answering call lights and that the expectation was a response within 10 minutes, but that this did not occur because staff were too busy; she reported caring for 20–29 residents per shift and had told management that, given resident acuity and needs, this was too many. Review of the grievance logs showed repeated, non-specific complaints about call bell issues over multiple review periods. For one review period, there were seven call light grievances, all documented as “call bell issues” and handwritten by the Activities Director, without specific times or dates. The facility’s documented resolution for these grievances was staff education and call bell audits, but the same audit documentation was used across different review periods, and for some periods there was no documentation that audits or education were actually completed. The Activities Director stated she wrote all resident grievance forms, knew many residents had issues with timeliness of call light response, and that residents could not recall specific times or dates. She reported that during resident council meetings, residents continued to voice that delayed call light response remained an ongoing problem. In an interview, the Administrator acknowledged that answering call lights was a “work in progress” and stated that they kept educating staff. He noted that when the issue was raised in resident council, residents would start to complain about it and that there were many similar complaints on the same day, sometimes from the same residents. He also stated that he could only staff according to what his management allowed. The DON reiterated that call lights should be within reach of each resident and answered as quickly as possible, stating that any time a call light is set off it could be an emergency. Despite these stated expectations, the observations, resident interviews, staff interviews, and grievance documentation collectively showed that dependent residents did not consistently have accessible, functional call lights and experienced significant delays in staff response, reflecting insufficient nursing staff to meet residents’ needs.
Call Lights Not Accessible or Answered Timely; Staffing Insufficient for Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staffing to meet the needs of 10 dependent residents reviewed, and failed to keep call lights within reach and functioning for multiple residents. During an initial tour, five residents were observed in bed with their call lights on the floor and not accessible to them. The Director of Nursing later verified that two of those residents were in bed and their call lights were on the floor. The facility policy stated that residents are to have a call light within reach, answered promptly, and kept functional. Several residents reported long delays in getting staff assistance after using call lights. One resident said she had recently filed a grievance about call light response times and sometimes waited 30 minutes to an hour, while another said she sometimes waited hours and would go to the nurses station herself if no one came. A third resident said he had once had no call light at his side, yelled for help, and eventually called 911 using his phone. Another resident said staff sometimes took upwards of an hour to respond and, during the interview, the call light indicator above the room door did not illuminate when activated. A nurse later verified that the call light was not working until the cord was adjusted at the wall. Additional residents reported needing help with toileting, bathing, dressing, water, and other care but waiting one to two hours or more, with one resident stating he would soil himself if staff did not come in time. Nursing staff also reported heavy assignments, including one LPN caring for 35 to 38 residents on third shift and another caring for 20 to 29 residents per shift, and both stated they did not feel staffing was sufficient or safe. The grievance log showed repeated call light complaints in January, February, March, and April 2026, with documentation that was incomplete or duplicated across months, and staff interviews confirmed that call light response problems were ongoing and that residents continued to voice the same concerns in resident council.
Unsecured Medications Left in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s safe storage of medications when multiple residents were observed with unsecured medications at bedside. On two consecutive days, one resident’s room was observed to contain an unlocked bottle of Melatonin 10 mg gummies and a bottle of brand-name eye vitamin soft gels on the nightstand. Another resident’s room was observed on two days with an unsecured bottle of Allergy Nasal Mist (Oxymetazoline HCl 0.05% nasal decongestant) on the overbed table. A third resident’s room was observed on two days with an unlocked bottle of Antacid Extra Strength tablets, a box of Aspirin Pain Reliever/Caffeine/Pain Reliever Aid arthritis powder, and a bottle of vaporizing rub on the overbed table. Photographic evidence was obtained for each of these observations. In interviews, LPN staff members acknowledged that these medications should not have been stored in residents’ rooms and stated that medications should be locked in the medication cart at all times. The Assistant Director of Nursing stated that medications should not be in any resident’s room unless the resident has an order to self-administer, in which case they must be locked in a box in the room; otherwise, medications are to be locked in the medication cart. The Director of Nursing stated that medications should never be left in a resident’s room unlocked and should be locked at all times. Review of the facility’s “Medication Storage and Labeling” policy, issued 3/21 and revised 1/24, documented that all drugs and biologicals are to be stored in locked compartments, with compartments containing drugs and biologicals locked when not in use and unlocked medication carts never left unattended.
Noncompliance with Smoking Area Fire Safety Requirements
Penalty
Summary
During a fire life safety survey, it was observed that the facility failed to comply with National Fire Protection Association (NFPA) 101 smoking regulations. Specifically, the established smoking area in the courtyard, which was the only designated area for residents to smoke, did not have a self-closing metal butt can as required by the standard. This deficiency was identified during a facility tour conducted between 1:00 p.m. and 5:00 p.m. with the Maintenance Director present. The surveyor noted that the absence of a self-closing metal container for cigarette disposal in the smoking area was a direct violation of NFPA 101 (2012 and 2021 Editions) section 19.7.4(6). The regulation mandates that metal containers with self-closing cover devices, into which ashtrays can be emptied, must be readily available in all areas where smoking is permitted. The report also clarified that smoking tower disposal receptacles do not meet the requirement for ashtrays or self-closing metal containers. The Maintenance Director acknowledged the findings during the interview that was conducted concurrently with the observations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report. The deficiency was based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , an order was placed for two new red cigarette butt cans by the Director of Maintenance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , the Maintenance Director, and Administrator will conduct an audit on facility's red cigarette butt cans to identify potential issues with the cans and to ensure they are opening and closing fully. Any issues identified were corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. The cans and to ensure they are opening and closing fully. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.
Failure to Provide and Document Range of Motion Interventions
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility. The resident, who had a history of right-sided hemiplegia and aphasia following a cerebrovascular event, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the right side, with specific instructions for timing and monitoring. Despite these documented interventions, observations and record reviews revealed that the resident did not receive the ordered PROM or brace application. The Minimum Data Set (MDS) assessment indicated that the resident had not received passive or active range of motion or brace assistance for at least 15 minutes in the previous seven days. Interviews with staff members, including CNAs and LPNs, showed a lack of awareness or implementation of the prescribed interventions, with one CNA stating that the resident did not have anything in place for the right side at the time of observation, and an LPN not being aware of any device for the resident's right side. Further review of the Treatment Administration Record (TAR) confirmed the absence of documentation that PROM or brace application had been performed as ordered. The Director of Nursing verified the lack of documentation and confirmed that the resident had an active order for these interventions. The failure to provide and document the required care and services led to the deficiency under the federal regulation for maintaining or improving range of motion and mobility.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken, On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ . Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Expired Medications Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove expired medications from two of four medication carts reviewed, specifically the "Colonial 1" and "Heritage" carts. During observations, one bottle with an expired date was found on the Colonial 1 cart, and a bottle of gel 0.5 mg/mL for a resident was found on the Heritage cart with packaging that specified it should not be used after a certain date. Photographic evidence was obtained for both findings. The facility's policy requires that the expiration or beyond-use date on medication labels be checked prior to administration. In an interview, the DON acknowledged that expired medications should not be present in the medication carts and stated that medication carts are checked on Sundays, but indicated there was a need to improve follow-through with these checks.
Plan Of Correction
F755-Pharmacy Services/Procedures/Pharmacist/Records (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On the expired and gel were removed from the medication carts. Audit was conducted of remaining medication carts with no other concerns were noted related to the alleged deficient practice. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; An audit was completed by the Director of Nursing/designee on all medication carts and medication rooms to ensure there were no outdated or expired medications. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By current licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee. Newly hired licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee will conduct audits of medication carts and medication weekly for 4 weeks, then once a week for 4 weeks, and then monthly for 1 month to ensure that there are no expired or outdated medications present and medications are stored properly. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications to a resident, despite both medications being contraindicated for crushing. The physician's order allowed for medications to be crushed or diluted unless contraindicated, but the extended-release formulations specifically should not have been altered in this way, as confirmed by reference sources and the facility's consultant pharmacist. The facility's policies require medications to be administered according to prescriber orders and for staff to consult with a physician or pharmacist if there are concerns about medication appropriateness or potential adverse consequences. Both the consultant pharmacist and the Director of Nursing confirmed that the extended-release medications should not have been crushed and that alternative formulations or orders should have been sought. The incident was identified during an unannounced recertification survey, and the deficiency was based on direct observation, record review, and staff interviews.
Plan Of Correction
F759-Free of Medication Error Rate of 5% or More (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Staff A was educated regarding medication administration and the "Do not Crush" list on medication cart. On Resident #22 was assessed by a licensed nurse with no negative findings. MD was notified of medication error with orders received to change the form of the 2 identified medications. Started treatment on . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On Audit was completed by Director of Nursing/designee on current residents to identify if medications needed to be crushed. Any identified meds were changed to the appropriate form. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , Current Licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee. Newly hired licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct observations of medication administration 3x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that licensed Nurses are administering medications properly. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least 8 consecutive hours per day, 7 days a week, as required by federal regulations. Record review of staffing forms and RN time sheets revealed that on two separate days, the number of RN hours worked fell below the required 8 consecutive hours. Specifically, on one day, only 7.87 hours were worked, and on another, only 5.42 hours were worked. Further examination of RN time sheets confirmed that on these days, the RN clocked in and out in a manner that resulted in less than the required consecutive hours of coverage. Interviews with the Labor Coordinator and the Nursing Home Administrator confirmed that no other RN worked on those days to supplement the hours, and there were no call-offs reported. The Labor Coordinator acknowledged the discrepancy as a mistake, and the Administrator verified the shortfall in RN coverage. The deficiency was identified through review of facility records and staff interviews, with no mention of resident-specific incidents or medical histories related to the deficiency.
Plan Of Correction
F727-RN 8 Hrs/7 days/wk What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Administrator completed a comprehensive review of RN hours for the previous 2 weeks and found that there were 8 consecutive hours of RN coverage. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , Audit was completed by Administrator/designee of Staffing hours for past 2 weeks to ensure that Staffing requirements are met, Including 8 consecutive RN hours every day of the week day. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By /205, the Staffing coordinator, Administrator and Human Resources and Director of Nursing will be educated on the components of F727 with an emphasis on 8 consecutive hours seven days a week of RN hours per day and schedule requirements by the Regional Vice President of Operations/Designee. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/Designee to conduct audits of staffing report 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that Staffing requirements are met and that there are 8 consecutive RN hours every day of the week. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Brace Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with significant physical and cognitive impairments. The resident, who had a history of hemiplegia, hemiparesis, and aphasia, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the affected limb, with specific instructions for timing and monitoring. However, observations revealed that the resident did not have the prescribed device in place, and staff interviews indicated a lack of awareness or implementation of the required interventions. Review of documentation, including the Treatment Administration Record (TAR) and CNA Kardex, showed no evidence that PROM or brace application had been performed as ordered. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these treatments. As a result, the facility did not meet the licensure requirement to provide adequate and appropriate health care and services consistent with the resident's care plan and physician's orders.
Plan Of Correction
F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On , the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By , Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ , Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Splinting Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with a right hand/wrist contracture and a history of hemiplegia and hemiparesis following a stroke. The resident was dependent on staff for activities of daily living and had severely impaired cognitive skills, making them rarely or never understood. The care plan and physician's orders specified that passive range of motion (PROM) and splint/brace application should be performed, with detailed instructions for timing and monitoring. However, observations revealed that the resident did not have a splint in place, and staff interviews indicated a lack of awareness or implementation of the splinting intervention. The resident was noted to experience significant pain with hand movement, and there was no evidence that PROM or splint/brace application had been provided as ordered. Review of documentation, including the Treatment Administration Record (TAR), showed no record of PROM or splint application for the resident during the specified period. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these required treatments. The facility's failure to follow the care plan and physician's orders resulted in a lack of appropriate care to maintain or improve the resident's range of motion.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on two separate days during a 14-day staffing review period. Review of staffing records and RN time sheets showed that on the specified dates, the RN coverage was 7.87 hours and 5.42 hours, respectively, both falling short of the required 8 consecutive hours. Interviews with the Labor Coordinator confirmed that no other RN worked on those days and there were no call-offs, indicating a scheduling error. The Nursing Home Administrator verified the deficiency in RN coverage for those days.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from two of four medication carts reviewed. Specifically, one bottle of Acetaminophen with an expiration date of 5/2025 was found on the Colonial 1 medication cart, and one bottle of Lorazepam topical gel labeled 'Do not use after 7/10/25' was found on the Heritage medication cart for a resident. The facility's Medication Administration policy requires staff to check expiration or beyond use dates prior to administering medications. During an interview, the Director of Nursing acknowledged that expired medications should not be present in the carts and stated that medication carts are checked weekly, but follow-through on these checks needs improvement.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications—Metoprolol Succinate ER 25 mg and Klor-Con M20 (Potassium Chloride Extended Release)—to a resident by mixing them in pudding. The physician's order allowed medications to be crushed or diluted as needed unless contraindicated. However, both medications are extended-release formulations, and crushing them is contraindicated according to standard drug references. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that extended-release tablets should not be crushed, and alternative formulations should have been sought if the resident was unable to swallow the tablets whole. The facility's policies require medications to be administered as prescribed and for any deviations or concerns to be documented and communicated to the prescriber. These procedures were not followed in this instance, resulting in a medication error that contributed to the facility's elevated error rate.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident with a history of falls and other medical conditions. The resident, who was legally blind and hard of hearing, had a care plan that included interventions such as assistance with toileting and reminders to use the call bell for help. However, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury that required hospital admission and surgical repair. The incident occurred when a registered nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing (DON) acknowledged that the resident had toileting times in place and was known to be at risk, but there was no documentation of specific interventions or monitoring frequency. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and room door made observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The facility's Quality Assurance Performance Improvement Plan showed no reduction in incidents, and education was provided to staff, but there was no documentation of new care plan interventions to prevent further accidents. The facility's failure to implement and document adequate supervision and interventions contributed to the resident's fall and injury.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #8500's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk for to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, Licensed Nurses and Certified Nursing Assistants were educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident #850, who had a history of falls and was legally blind and hard of hearing. The resident's care plan included interventions such as assistance with toileting, encouraging the use of a call bell, and wearing appropriate footwear. Despite these interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury requiring hospital admission and surgical repair. The incident occurred when a Registered Nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing acknowledged that the resident had no prior falls since admission and that interventions were in place, but there was no documentation of specific supervision or monitoring times. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and door were often closed, making observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The Director of Rehab noted that the resident required assistance with all activities and could roll over in bed with minimal help. Despite the facility's efforts to educate staff on fall prevention, the care plan for Resident #850 had not been updated with new interventions to prevent further falls, and there was no documentation of increased supervision or monitoring.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #850's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Licensed Nurses and Certified Nursing Assistants were educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents' care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Environmental and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, sanitary, and comfortable environment for its residents, as evidenced by multiple environmental issues observed during a tour. These issues included stained and cracked floors in the activity room, missing and peeling cove base in several rooms, a dried black substance on a handrail, peeling wallpaper with orange discoloration in common hallways, and dirty, scuffed walls in various rooms. Additionally, corners and crevices where floors meet walls were found to have caked-in dirt. Photographic evidence was obtained to document these deficiencies. A resident reported that his bed had not been functioning properly since his arrival at the facility a few months prior. The control to adjust the bed's head position was not working, requiring the resident to physically get out of bed to make adjustments, which was difficult for him. Despite informing multiple staff members, including the Administrator, the issue remained unresolved. Interviews with staff revealed a lack of awareness and communication regarding the bed's malfunction, with the Maintenance Director only becoming aware of the issue during the survey. The Administrator acknowledged the environmental concerns and noted a failure in the work order process, which contributed to the unresolved maintenance issues.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Beneva | 0.6 mi | ★★★★★ | 16 | 4 |
| Sarasota Point Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Indian Beach Nursing And Rehab Center | 1.9 mi | ★★★★★ | 5 | 0 |
| Aviata At Sarasota | 2.1 mi | ★★★★★ | 4 | 0 |
| Harborview Sarasota | 2.1 mi | ★★★★★ | 15 | 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 July 2026) and official state health department websites.