Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens Nursing And Rehab Center during CMS and state inspections, most recent first.
Nonfunctioning resident call systems on the third floor. Multiple residents reported that room and bathroom call lights were not working, and survey observations confirmed that activating the call system did not trigger a light outside the room or an alert at the nurses’ station. One resident with encephalopathy and DM, another with bladder dysfunction, and a third with hemiplegia and hemiparesis all described relying on other means to get help, while a fourth room also failed call-light testing.
Failure to Protect a Vulnerable Resident from Sexual Abuse: A cognitively impaired resident was found in bed with another resident who had a documented hx of sexually inappropriate behavior toward staff and residents. Staff observed thrusting movements and the other resident on top of her, while the resident was later sent to the hospital for rape kit and STD testing as a suspected sexual battery. Records showed the resident had severe cognitive impairment, and the other resident had a care plan for inappropriate sexual behaviors and required 1:1 supervision.
Unsecured Hazardous Rooms and Utility Areas: Multiple hazardous areas were found unlocked, including the laundry chute, janitors' closets, clean utility room with oxygen tanks, soiled utility room, and biohazard room. Staff were observed leaving a janitors' closet unlocked, and an RN was able to access the biohazard room without entering a code to dispose of a red biohazard bag. The DON confirmed staff were required to keep certain rooms locked, and the facility policy stated hazardous materials storage areas are to be locked when not in direct sight of staff.
Failure to Protect Resident Information on Medication Cart and Vitals Machine: An unattended computer screen on a medication cart and an unattended vitals machine screen were left open with residents' information visible. An RN stated the screen should have been closed, and the DON and ADON confirmed staff are to close or lock these devices to protect resident information. The facility's confidentiality policy states resident records will be protected and safeguarded.
A resident with metabolic encephalopathy, transient alteration of awareness, and severe cognitive impairment was observed with bilateral side rails up and the left side of the bed placed against the wall on two occasions, restricting safe exit from the bed. Record review showed the resident required extensive assistance with ADLs and was totally dependent for repositioning and turning in bed, while staff stated the bed against the wall was considered a restraint and should not have been used.
PASRR forms were not accurately completed for two residents with SMI. One resident’s PASRR omitted schizophrenia despite records showing schizophrenia, psychosis, psychiatric treatment, antipsychotic use, and behavior issues including refusal of care and medications. Another resident’s PASRR failed to document depression and did not reflect documented sexual and aggressive behaviors toward others, including entering another resident’s room, genital exposure, and masturbating in front of staff and residents; the DON later acknowledged the form should have included the missing information.
Failure to Continue Post-Discharge Prophylaxis After Sexual Assault: A resident returned from the hospital after a suspected sexual assault with discharge orders for prophylactic antibiotics, but the facility did not enter or continue the medications. Hospital records showed the resident was prescribed Doxycycline and Metronidazole as post-exposure prophylaxis, yet the physician note and MAR had no corresponding orders after readmission, and the DON stated the facility did not carry the orders over.
Improper bedside storage of resident medications: A resident had an over-the-counter topical medication used to relieve oral pain and a medicated lotion left at the bedside without a physician order. An RN was informed and stated residents cannot keep medications at the bedside without an order, and the DON confirmed no order was present. The facility policy required drugs and biologics to be stored in a safe, secure, orderly manner and locked when not in use.
Repeated QAPI Failures to Address Ongoing Deficiencies: The facility's QAPI committee failed to show effective plans of action for repeated deficiencies cited in F689, F761, F880, and F919. Survey history showed prior and current citations involving unsafe smoking supervision, lint in a dryer, unsecured meds at bedside and wound carts, rodent control and infection control issues, separation of soiled and clean laundry areas, and nonfunctioning resident call systems. The Administrator stated QAPI meetings occur monthly and as needed, and the facility's policy describes a data-driven program intended to identify problems, monitor performance, and develop corrective actions.
A Wound Care RN did not follow proper hand hygiene practices during wound care for a resident with a stage 4 sacral pressure ulcer. The RN repeatedly removed and reapplied gloves while cleansing, drying, and redressing the wound, and handled waste in an unlocked biohazard room. The resident had a BIMS score of 14 and required substantial assistance with multiple ADLs, with a care plan noting risk for impaired skin integrity related to impaired mobility and incontinence.
A resident sustained a cut on the bottom of his right foot in the shower after contacting a protruding screw on the drain cover. Surveyors observed mildew residue, hair in the drain cover, and the loose screw in the shared bathroom shower. The resident, who had epilepsy, TIA, MDD, chronic pain, and weakness, was cognitively intact and required set-up and clean-up assistance for ADLs.
Surveyors found that food items brought in by visitors and family for residents were stored in nourishment refrigerators without proper labeling or dating. Staff confirmed the items belonged to residents, and facility policy requires labeling with resident names and use-by dates, but this was not followed.
A resident with a history of schizophrenia and psychosis left the facility AMA without the responsible party being successfully notified, despite multiple attempts by the DON and facility policy requiring such notification. The resident's advocate later reported not being informed of the discharge, and documentation confirmed the notification process was incomplete.
A resident with disorganized schizophrenia and a colostomy left AMA without a safe discharge plan, valid destination, or notification to their advocate or representative. Facility staff did not involve social services in the discharge process, failed to promptly inform medical providers, and did not conduct a wellness check or notify authorities. The resident's location remained unknown at the time of the survey.
A resident was unable to have food brought in by family reheated by staff after a prior incident where her food was burnt, leading the dietary manager to refuse further reheating. The facility had removed microwaves from each floor and maintained a policy that only dietary staff could reheat outside food, but staff were not permitted to do so, resulting in multiple resident complaints.
A resident with a history of schizophrenia and psychosis left the facility AMA without the required notification to their designated representative. Despite attempts by the DON to contact the responsible party by phone, no direct communication or documentation of notification occurred, and the resident's advocate later reported not being informed of the discharge.
A facility failed to develop a discharge care plan for a resident with a trimalleolar fracture, who was to be discharged home with family. Despite the resident's independence in some daily activities and a 30-day notice to vacate due to unpaid bills, no discharge plan was created. Interviews revealed confusion among staff about care plan responsibilities, contrary to facility policy.
Two residents in an LTC facility were observed with improperly secured drainage bags, increasing the risk of dislodgement and infection. One resident had severe cognitive impairment and was noncompliant with treatment, while the other had mild cognitive impairment. Staff acknowledged the risks but failed to ensure proper placement and monitoring.
A resident in an LTC facility did not receive a timely Drug Regimen Review (DRR) despite being on high-risk medications. The resident, who was admitted after an accident, was observed with symptoms like drooling and sleepiness, leading to the discontinuation of a medication. The facility failed to conduct the required monthly DRR, resulting in a deficiency.
The facility failed to develop a discharge care plan for a resident with a displaced tri-malleolar fracture, despite the resident's choice to be discharged home. Additionally, two residents were observed with unsecured urinary drainage bags, increasing the risk of complications. The facility did not adhere to its policies requiring comprehensive care plans and proper management of medical equipment.
Two residents in a facility were observed with improperly managed drainage bags, increasing the risk of dislodgement. One resident was seen carrying the bag in his hand and placing it on the floor, while another had the bag and tubing near wheelchair wheels. Staff acknowledged the risks and attempted to educate the residents, but the issues persisted, highlighting a deficiency in providing adequate healthcare.
A LTC facility failed to address a rodent infestation and implement proper infection control measures. Despite reports of rodents, the administration did not act promptly, and food was improperly stored. Infection control lapses included mishandling a Glucometer and inadequate hand hygiene during wound care. The facility also failed to separate soiled and clean laundry, risking cross-contamination. The infection preventionist lacked required training.
The facility's Administrator failed to address a rodent infestation despite being aware of the issue for months. The Administrator did not follow pest control policies, relying on in-house maintenance instead of external services. A resident reported seeing rodents and inadequate housekeeping, while the DON communicated the issue to the Administrator without documenting it. Staff reported multiple sightings, but the Administrator did not take effective action, leading to Immediate Jeopardy due to potential disease spread.
The facility failed to implement an effective pest control program, leading to a rodent infestation that was not addressed in a timely manner. Despite reports from a resident and staff about rodent sightings, the facility did not follow its pest control policy, resulting in a lack of documentation and communication. The pest control technician was not informed of specific areas needing treatment, and the Administrator was unaware of the extent of the issue. This deficiency affected the quality of care for 111 residents.
A resident with a PEG tube experienced severe weight loss due to the facility's failure to follow physician's orders for tube feeding and complete a timely nutritional assessment. The resident's feedings were often delayed or missed, and staff were unclear about feeding schedules. The facility did not adhere to its policies on nutrition and weight management, leading to inadequate care.
The facility failed to maintain food safety standards, with issues such as soiled and rust-laden equipment, improper storage of staff items, and incorrect food temperatures. Observations included mold-like substances in the refrigerator, high chemical concentrations in cleaning buckets, and flying insects in food areas. Cold foods were not held at the required temperatures, posing potential risks to residents.
The facility failed to ensure the designated Infection Preventionist (IP) completed required training. The DON, assigned as the IP, had not finished the necessary modules or obtained certification. The ADON completed the training but did not assume the IP role, leaving the deficiency unaddressed.
The facility was found to have significant cleanliness and maintenance issues, including soiled and stained floors, walls, and furniture across various areas. Residents were affected by these deficiencies, with complaints about room conditions, roach sightings, and inadequate furniture. Wheelchairs and Geri chairs were also in poor condition, impacting residents' comfort and safety.
The facility failed to provide residents with reasonable access to private phone use, as observed on the second floor where residents used the nurses' station phone without staff intervention. Conversations, including sensitive financial and medical discussions, were overheard by staff and other residents. Despite the availability of cordless phones for private use, they were uncharged and inaccessible, indicating a lack of awareness and action by the staff to ensure privacy.
A resident's smoking care plan was not revised by the interdisciplinary team after each assessment, despite the resident's diagnoses including COPD and Nicotine Dependence. The care plan had not been updated since its target date, and interviews revealed confusion over documentation processes. The DON and ADON acknowledged the lack of revisions and absence of electronic care plans.
The facility did not post current nurse staffing information daily in a prominent location. During a tour, outdated staffing data was observed, and a nurse confirmed the absence of comprehensive staffing data, only knowing assignments for her floor.
The facility failed to administer medications timely for a resident with multiple diagnoses, leading to frequent late administration and missed doses. Another resident received a discontinued medication, and discrepancies in drug records were found for three other residents, indicating failures in medication administration and record-keeping.
The facility failed to properly monitor and document behaviors for residents on psychotropic medications, as evidenced by incomplete records and misunderstandings among staff. Residents with various psychiatric diagnoses were not adequately observed, with behavior monitoring records lacking required documentation. Interviews revealed staff confusion about the documentation process, contributing to the deficiency.
The facility failed to secure medications and biologicals, with a bottle of Dakin's solution found in an unlocked closet and a resident having unauthorized access to Cortisone cream. Additionally, wound treatment carts were left unlocked and unattended, contrary to facility policy. These incidents highlight lapses in medication storage and security protocols.
The facility failed to provide a nourishing, palatable, well-balanced diet to 107 residents, as observed during breakfast meals. Residents were served a watered-down tropical punch instead of the preferred orange juice, and there was a shortage of sausage links and fresh bananas, which were not substituted. The Certified Dietary Manager confirmed the unavailability of orange juice and other citrus juices, and dietary staff noted that bananas were not regularly available.
The facility failed to adhere to approved menus for resident meals, affecting 107 out of 111 residents. For lunch, a smaller portion of chili was served, canned pineapple replaced watermelon, and pureed regular bread was given instead of pureed cornbread. At breakfast, bananas were not provided, and there was an insufficient supply of sausage links. The facility cook admitted to not following the menu and being unaware of specific dietary requirements.
The facility did not adhere to standardized recipes for meal preparation, affecting the quality of food served to 107 residents. The Turkey Patty Melt was prepared with incorrect ingredients and cooking methods, resulting in an unappetizing meal. A staff member admitted to not using the standardized recipe, leading to this deficiency.
The facility failed to implement effective corrective actions for deficiencies in maintaining a safe environment, pharmacy services, QAPI activities, and pest control, affecting 111 residents. Despite having a comprehensive QAPI program, repeated issues were identified during surveys, indicating a lack of adherence to procedures.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect classification of medications. A resident with cardiac conditions was documented as receiving an anticoagulant but not an antiplatelet, despite orders for both. Another resident with cerebral infarction was documented as receiving an anticoagulant, though only antiplatelets were prescribed. A third resident with heart disease was similarly misclassified. The MDS Coordinator's misunderstanding of medication classifications was confirmed by the facility's Consultant Pharmacist.
The facility failed to maintain minimum nursing staff levels, impacting resident safety and care. Staffing records showed nursing staff averages below the required minimum, attributed to late punches. Observations revealed a CNA monitoring residents from inside due to being short-staffed, and another staff member expressed concerns about staffing levels.
A long-term care facility failed to maintain a functioning call light system for residents, affecting their ability to request assistance. Several residents, including those with cognitive awareness and mobility issues, reported non-working call lights, with some issues persisting for months. Staff were aware of the malfunctions, but repairs were delayed due to the need for specific parts. This deficiency compromised residents' ability to communicate their needs effectively.
The facility failed to address grievances related to non-functional call lights for four residents, leading to inadequate care. Residents reported issues with call lights not working, forcing them to find alternative ways to seek assistance. Despite complaints, the facility's grievance log did not document these issues, and staff interviews revealed inconsistencies in the grievance process.
A resident left the facility against medical advice (AMA) without proper documentation of family notification. The Assistant DON acknowledged notifying the family but failed to document it. The resident's emergency contact confirmed being informed but questioned the resident's mental capacity to leave AMA.
The facility failed to ensure handrails were securely affixed on the 3rd floor, as observed during a tour. Loose handrails were found in several locations, including near rooms and the elevator. The Administrator acknowledged the issue, noting a similar problem had been addressed on the 2nd floor.
The facility failed to ensure call lights were within reach for four residents, leading to potential safety risks. A resident with slight cognitive impairment fell while trying to use the bathroom without assistance due to an inaccessible call light. Another resident, cognitively intact but dependent on staff, could not reach the call light wrapped around the bed rail. A third resident, rarely understood, indicated the call light was out of reach, and a fourth resident with cognitive impairment had the call light on the floor behind the bed.
The facility failed to implement comprehensive care plans for antipsychotic medications for three residents and an advance directive for one resident. One resident with Alzheimer's and Anxiety Disorder was prescribed Seroquel without a care plan. Another resident with severe cognitive impairment had no care plan for insulin and clonazepam. A third resident with Dementia and Depression was prescribed Olanzapine without a care plan for antipsychotics. Additionally, a resident with a full code status had no care plan for advanced directives.
A resident with cognitive impairment and dysphagia was left unsupervised with a lunch tray, leading to coughing and regurgitation of food. The resident required maximum assistance with eating and honey-thick liquids, as per her care plan, but was observed eating with her hands. The CNA assigned was unaware of who placed the tray, highlighting a lapse in supervision and adherence to the care plan.
A resident with COPD was inadequately supervised while smoking, as staff monitored from inside and could not see all residents. The smoking patio had scattered cigarette butts and trash in a bin, and the laundry area showed excessive lint buildup due to missed cleaning schedules.
A resident with hypertension was nearly given an incorrect dose of Labetalol due to a medication administration error by an RN. The RN prepared only one 100 mg tablet instead of the prescribed 1.5 tablets (150 mg). The error was caught by a surveyor before administration, and the RN corrected the dose.
A resident with cognitive impairment and dysphagia was found with non-thickened water and eating pureed food unsupervised, leading to coughing and regurgitation. The resident required honey-thick liquids and maximum assistance, but was left with inappropriate food and liquid consistency. Additionally, regular consistency grits and scrambled eggs were served to residents on a pureed diet due to the cook not reviewing the approved menu, violating the facility's policy for thickened liquids.
Nonfunctioning resident call systems on the third floor
Penalty
Summary
The facility did not ensure that resident call systems functioned properly on the third floor, including in resident rooms and bathrooms, and did not maintain a reliable communication system for residents to request staff assistance from their rooms to the nurses’ station. Four residents on the third floor reported that the call system was not working, and observations confirmed that call lights in multiple rooms did not activate a light outside the room or an audible alert at the nurses’ station when used. Resident #16, who had diagnoses including encephalopathy and type 2 diabetes mellitus with other specified complication and a BIMS score of 13/15, reported the call light had not worked for over a month; inspection of the bathroom call system showed no light or sound when activated. Resident #46, who had a BIMS score of 15/15 and a diagnosis of other neuromuscular dysfunction of bladder, reported there had been no call light in the room since admission and that the resident sometimes had to scream for help. Resident #52, who had hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and a BIMS score of 15/15, stated the call light had not worked for a long time and waited for someone to enter the room; when the button was pressed, no light or sound was noted at the room or nurses’ station, and no staff entered the room for extended periods. In Resident #12’s room, the surveyor activated the call light and no alert was observed outside the room or at the nurses’ station.
Failure to Protect a Vulnerable Resident from Sexual Abuse
Penalty
Summary
The facility failed to adequately protect a vulnerable resident from sexual abuse by another resident with a documented history of sexually inappropriate behavior toward staff and other residents. On 03/17/2026, facility staff observed the cognitively impaired resident in bed with the other resident on top of her, and the resident was not wearing a brief at the time. The resident was later sent to the hospital for a rape kit and STD testing as a precaution, and the hospital summary described the admission as medical clearance following a suspected sexual battery. The resident involved had severe cognitive impairment, with a BIMS score of 3, and diagnoses that included Alzheimer's disease, psychosis, cerebral infarction, depressive episode, and mood disorder. Her clinical record and hospital discharge needs indicated she required ongoing monitoring and prophylaxis after the suspected assault. A nursing note documented that she was found in bed, alert and disoriented, with no visible injury, and the physician was notified and ordered transfer to the hospital for sexual battery evaluation. The other resident involved had a BIMS score of 15 and diagnoses including paranoid schizophrenia, generalized anxiety disorder, and depressive episodes. His care plan documented inappropriate sexual behaviors toward staff and other residents and included interventions for 1:1 supervision as much as possible. Multiple interviews and records showed the facility had acknowledged his prior sexually inappropriate conduct, including exposing his genitals and masturbating in front of staff and residents. Staff gave differing accounts of the incident, including observations of thrusting movements and the resident being on top of the vulnerable resident, while the resident himself stated he had entered the room to use the restroom and tried to help her onto the bed.
Unsecured Hazardous Rooms and Utility Areas
Penalty
Summary
The facility failed to maintain an environment free from accident hazards in multiple potentially hazardous areas on all three floors where residents lived. Observations showed the third-floor laundry chute was unlocked, the third-floor janitors' closet door was unlocked, the third-floor clean utility room that stored oxygen tanks was unlocked, and the third-floor soiled utility room was unlocked. On the second floor, Staff F from Housekeeping exited the janitors' closet without locking the door, and the Director of Nursing later confirmed the room contained hazardous materials. The second-floor biohazard room was also observed unsecured, and the Wound Care RN was able to open the door without entering a keypad code to dispose of a red biohazard bag from wound care. During interview, the DON stated staff were required to keep the laundry chute and soiled utility rooms locked and said she did not know whether a resident could inadvertently become locked inside the laundry chute room. The Director of Environmental Services stated he changed the locks for the third- and second-floor laundry chutes and replaced and installed keypads and combination locks on some doors that did not have keys. The facility policy on chemical storage stated chemicals and hazardous materials are to be stored and handled to minimize injury risk, and that chemical storage rooms and cabinets are to be locked when not in direct sight of a staff member.
Failure to Protect Resident Information on Medication Cart and Vital Signs Machine
Penalty
Summary
The facility did not keep residents' personal and medical records private and confidential when an unattended computer screen on the west side medication cart was left open and displaying residents' information. On 03/23/2026 at 9:49 AM, observation on the third floor showed the computer screen open on the unattended west side medication cart with residents' information visible, and photo evidence was obtained. When asked about it at 10:00 AM, Staff D, RN stated the screen should have been closed by hitting the icon to protect residents' information and said it was left open because she was helping a resident. A second observation on 03/24/2026 at 8:47 AM on the facility's second floor found an unattended vital signs machine screen left open with residents' information visible. Staff E, RN stated at 8:50 AM that it should be closed. The DON stated staff are to lock computer screens by turning them off or pressing the hide button to protect residents' information, and the Assistant DON stated staff are to close the vitals machine once finished because it displays residents' information. The facility policy titled Confidentiality of Records, effective 5/29/2023, states the facility will protect and safeguard residents' confidentiality.
Bed Positioned Against Wall Restricted Resident Access
Penalty
Summary
The facility failed to ensure that one resident was free from the use of a physical restraint when the left side of the resident’s bed was positioned against the wall on two separate observations, which restricted the resident’s ability to exit the bed safely. On 03/23/2026 at 9:58 AM, the resident was observed with bilateral side rails up and the left side of the bed against the wall, and the same condition was observed again on 03/25/2026 at 9:20 AM, with photo evidence provided on both occasions. Record review showed the resident was admitted with diagnoses including metabolic encephalopathy and transient alteration of awareness. The MDS dated 02/19/26 documented a BIMS score of 02 out of 15, indicating severe cognitive impairment, along with substantial assistance needs for eating, toileting, showering, sit-to-lying, and upper and lower body dressing, and impairment on both sides of the upper and lower extremities. The care plan identified weakness, encephalopathy, fatigue, chronic disease burden, hospital deconditioning, cognitive fluctuation, altered mental status, and functional decline, and stated the resident was totally dependent on staff for repositioning and turning in bed, personal hygiene and oral care, and required a mechanical lift with two staff for transfers. Staff interviews confirmed the bed should not have been placed against the wall and that it was considered a restraint, while the DON stated she was not aware the resident was confused or attempted to get out of bed.
PASRR Forms Omitted Mental Health Diagnoses and Risk Behaviors
Penalty
Summary
The facility did not accurately complete Level I PASRR forms for two residents diagnosed with serious mental illness. For one resident, the Level I PASRR omitted schizophrenia even though the resident was admitted with diagnoses that included schizophrenia, generalized anxiety disorder, mood disorder, and psychosis. The resident’s records also showed antipsychotic use, psychiatric evaluation, and a care plan addressing refusal of care, refusal of medications, delusions, and other behavior problems. The DON stated the schizophrenia diagnosis was not included on the PASRR because it was not listed in the psychiatric note at the time of return from hospitalization, and acknowledged the PASRR was incorrect. For the second resident, the Level I PASRR did not include documentation of behaviors that posed potential risks to others. The resident’s records showed diagnoses including paranoid schizophrenia, generalized anxiety disorder, and other depressive episodes, along with orders for antipsychotic, antidepressant, and anti-anxiety medications. The resident’s care plan documented curses, noncompliance, yelling out, mood swings, inappropriate sexual behaviors toward staff and other residents, refusal of medications, and the need for 1:1 supervision as much as possible. A federal report also documented that staff reported the resident was found in another resident’s room on top of the other resident, and interviews later confirmed repeated genital exposure and masturbating in front of staff and residents. The DON reviewed the PASRR for this resident and stated depression should have been checked on the form. When asked why a new PASRR had not been completed to include the resident’s recent behaviors toward others, the DON later stated a new PASRR was completed that day and included depression and a response indicating the individual had exhibited actions or behaviors that may make them a danger to self or others, requiring a Level II review. The facility policy stated that appropriate PASRR screenings are to be conducted and results obtained prior to admission and that if it is learned after admission that a Level II screening is indicated, Social Services/designee is responsible for coordinating the screening and obtaining the results.
Failure to Continue Post-Discharge Prophylaxis After Sexual Assault
Penalty
Summary
The facility failed to provide adequate and appropriate health care for a resident who returned from the hospital after being sexually assaulted in the facility with discharge orders for prophylactic medications. The resident was observed by facility staff in bed with another resident on top of her and was not wearing a brief at the time of the incident. She was sent to the hospital for a rape kit and sexually transmitted disease testing as a precaution, and the hospital admitted her for medical clearance following suspected sexual battery. Hospital records showed orders for Doxycycline 100 mg twice daily and Metronidazole 500 mg every 8 hours as prophylaxis treatment, and the discharge care plan called for ongoing monitoring and completion of the post-exposure prophylaxis regimen. After the resident was readmitted to the facility, the physician progress note did not address continuation of the prophylaxis medications, and the March 2026 physician order sheet contained no orders for those medications. During interview, the DON stated the facility referred to the discharge list but did not carry the prophylaxis orders over.
Improper bedside storage of resident medications
Penalty
Summary
The facility failed to store medications and biologics properly for 1 of 7 sampled residents, Resident #84. During observation on 03/23/2026 at 10:03 AM, a container of [brand] over-the-counter topical medication used to temporarily relieve oral pain was seen on the side table in the resident’s room, and a medicated lotion was observed on the nightstand. Photo evidence was obtained. At 10:19 AM, Staff E, RN, was informed of the concern and stated that residents cannot have medications at the bedside without a physician’s order. During an interview on 03/23/2026 at 10:46 AM, the DON confirmed that Resident #84 did not have a physician’s order to keep the over-the-counter topical medication used to temporarily relieve oral pain or the medicated lotion at the bedside. Record review of the facility’s Medication Storage policy, effective 12/08/2023, stated that drugs and biologicals shall be stored in a safe, secure, and orderly manner, in their original packaging or dispensing systems, and that compartments containing drugs and biologicals shall be locked when not in use.
Repeated QAPI Failures to Address Ongoing Deficiencies
Penalty
Summary
The facility's QAPI committee failed to demonstrate that effective plans of action were implemented to identify and address repeated quality deficiencies in the areas of F689 Free of Accident Hazards and Supervision and Devices, F761 Label and Store Drugs and Biologicals, F880 Infection Prevention and Control, and F919 Resident Call System. These repeated deficiencies were identified during a prior recertification survey with exit dated 09/13/2024 and again during the current survey with exit dated 03/26/2026, affecting the facility's 112 residents at the time of survey. The survey history showed prior citations for unsafe smoking supervision, lint accumulation in a dryer, unsecured medications at bedside and wound treatment carts, rodent control and infection control concerns, separation of soiled and clean laundry areas, and nonfunctioning resident call systems in rooms and bathrooms. During interview, the Administrator stated that QAPI meetings are held monthly and as needed, with the last meeting on 02/25/2026 and a stabilization meeting on 03/12/2026. The Administrator identified the required QAA committee members and described that issues are identified through department reports, staff reporting, clipboards at nursing stations, communication among department heads, and daily rounds. The facility's QAPI policy stated that the program is intended to review care and services, identify areas for improvement, establish performance indicators, monitor progress, and develop corrective actions for medical errors and adverse events, including one annual performance improvement project.
Infection Control Lapses During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after Staff C, the Wound Care RN, did not follow proper hand hygiene practices during wound care for a resident with a stage 4 sacral wound. During observation of wound care, Staff C gathered supplies, performed hand hygiene, and applied gown and gloves, then removed the old dressing and repeatedly removed and reapplied gloves while cleansing, drying, and redressing the wound with saline, honey impregnated dressing, and a border dressing. After completing the procedure, Staff C removed gloves again, applied clean gloves to discard trash into the biohazard bag, took the waste to the biohazard room, and then removed gloves and used hand sanitizer after leaving the room. The resident involved was admitted with a diagnosis including pressure ulcer of the sacral region, stage 4. The quarterly MDS showed a BIMS score of 14, indicating no evidence of cognitive impairment, and the resident required substantial assistance for eating, toileting, showering, sit to lying, and upper and lower body dressing, with impairment on both sides of the upper and lower extremities. The resident's skin integrity care plan identified risk for impaired skin integrity related to positioning preferences/tolerance, impaired mobility, and incontinence. During interview, Staff C stated they normally perform hand hygiene throughout treatment but were nervous during the observation and noted the biohazard room should always be locked, although it was open at the time.
Unsafe Shower Drain Hazard Caused Resident Foot Injury
Penalty
Summary
The facility failed to ensure a safe bathing environment for Resident #100 when the resident sustained a cut on the bottom of the right foot in the shower from a protruding metal screw that secured the metal grate drain cover. During the Residents’ Council meeting, Resident #100 reported the injury, and later was observed sitting in his room with a bandage on the bottom of the right foot. When the bandage was removed, a cut measuring approximately 1.5 inches long with scant yellow drainage was noted. The resident stated the cut had been treated by an RN on 03/24/2026. Inspection of the shared bathroom shower showed visible mildew residue on the floor tiles, hair collected in the round metal grate drain cover, and one of the three metal screws securing the drain cover protruded and was not fastened properly. Resident #100’s record showed diagnoses including epilepsy, TIA, major depressive disorder, recurrent, chronic pain, and weakness, and the MDS indicated the resident was cognitively intact and required set-up and clean-up assistance for ADLs. A skin/wound note documented evaluation of the wound under the right plantar foot, and the DON noted the resident said he had sustained the cut while in the shower and had not reported it at the time.
Failure to Label and Date Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in both nourishment refrigerators located on the resident units. Specifically, food items brought in by visitors and family members for residents were found in the refrigerators without proper labeling or dating. On one floor, there were multiple unlabeled grocery bags and plastic containers, some of which were dated but lacked resident names, while others had neither dates nor names. Similar issues were found in the refrigerator on another floor, where several plastic bags with food items were also unlabeled and undated. Interviews with facility staff confirmed that these food items belonged to residents and were stored in the pantry refrigerators. The Assistant Director of Nursing acknowledged that food should be labeled with the resident's name and a discard date, and that perishable items should be discarded after three days. Review of the facility's policy indicated that perishable foods must be stored in resealable containers, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding perishable foods on or before the use-by date. The observed practices did not align with these requirements.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x four weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Notify Resident Representative of AMA Discharge
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident left the facility Against Medical Advice (AMA). The resident, who had diagnoses including Disorganized Schizophrenia and Psychosis, was admitted with a responsible party listed as an advocacy group. The resident was taking antipsychotic medications and had an active discharge plan for return to the community. On the day of the incident, the resident was found missing by staff, later located in another resident's room, and expressed a strong desire to leave the facility. The DON consulted with the physician, who advised allowing the resident to leave AMA. The resident refused to sign the AMA form and subsequently left the facility. Despite the facility's policy requiring notification of the resident's representative when a resident leaves AMA, the responsible party was not successfully notified. The DON reported making three or four phone calls and leaving a voicemail, but no response was received. The Social Services Director confirmed that the health care proxy should be notified about any incident and is the person designated to sign a resident out AMA. The resident's advocate stated during an interview that they were not notified of the resident's departure and expressed concern for the resident's safety and need for medication. Documentation reviewed included the resident's demographic sheet, admission/discharge/transfer list, MDS, physician's orders, care plan, and progress notes. The facility's policy on AMA discharge clearly outlined the requirement to notify the resident's representative and document the notification in the medical record. However, the lack of successful notification and documentation of the responsible party's awareness of the resident's AMA discharge constituted a failure to meet the regulatory requirement for notification of changes.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 7/31/2025. (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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. The same monitoring process will be repeated: through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Inappropriate Discharge of Resident with Schizophrenia
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of disorganized schizophrenia and colostomy status left the facility against medical advice (AMA) without a safe and appropriate discharge plan. The resident, who was cognitively intact but had a history of delusional thinking and required ongoing antipsychotic medication, expressed a desire to leave and was presented with an AMA form, which he refused to sign. The facility did not obtain a valid address for the resident's next place of residence, nor did they inform the resident's advocate or representative about the AMA discharge. At the time of the survey, the resident's location was unknown. Facility staff failed to ensure that the resident was safely discharged to a location where ongoing clinical care could be provided. The Social Services Director was not involved in the discharge process and was not notified until after the resident had left. The resident's primary care physician and psychiatrist were not promptly informed of the resident's departure, and the facility did not conduct a wellness check or notify law enforcement, as no police or missing person reports were filed. The facility's own policy required notification of the resident's representative and documentation in the medical record, but these steps were not completed. Interviews with facility staff revealed confusion and lack of coordination regarding the resident's whereabouts and the discharge process. The Director of Nursing and Administrator acknowledged that the resident left without providing a destination and that attempts to contact the advocate were limited to leaving voicemails. The Social Services Director confirmed that she was not involved in the process and did not have a discharge location to perform a wellness check. The resident's advocate and medical providers expressed concern about the resident's safety and the lack of communication from the facility.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident isft AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quailty review over the last 30 days by the DON/designee to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Follow Policy for Reheating Outside Food
Penalty
Summary
The facility failed to follow its own policy regarding the reheating of food brought in by family or visitors for one resident. Observation revealed that the resident, who was seated in her wheelchair at the bedside, reported a disagreement with the dietary manager after her food was burnt when staff previously warmed it in the kitchen. As a result, the dietary manager refused to warm her food in the kitchen. The resident further explained that microwaves had been removed from each floor and that residents were required to have outside food warmed in the kitchen. Interview with the dietary manager confirmed that there were no microwaves available for residents and that staff were not permitted to reheat outside food, a longstanding policy despite multiple resident complaints. Review of the facility's policy indicated that only dietary staff are allowed to reheat outside food to prevent injury.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident Council Meeting to be held 7/2/2025 to review the policy r/t Food Brought in from Outside Visitors/Family. A copy of the Food Brought in from Outside Visitors/Family policy was placed in the admission packet by the ED 7/23/2025 and will be reviewed with new admissions, re-admissions and/or the resident representative as part of the admission process. Resident #13 grievance initiated and resolved 6/26/2025. Resident #13 educated on the policy r/t Food Brought in from Outside Visitors/Family by the ED 6/26/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of grievances received over the last 30 days from residents/visitors and/or staff with concerns related to not being able to have their food re-heated to be completed by the ED 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current facility staff re-educated by the ED/designee on the components of this regulation and the policy titled "Food Brought in from Outside Visitors/Family" to be completed by 7/31/2025. (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 ED/designee to conduct ongoing quality monitoring through morning meeting r/t grievances regarding food not being able to be re-heated to ensure residents/visitors and staff have been provided education on the policy titled "Food Brought in from Outside Visitors/Family" 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Notify Resident's Representative of Change in Condition During AMA Discharge
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition when the resident, who had a diagnosis of Disorganized Schizophrenia and Psychosis, left the facility Against Medical Advice (AMA). The resident was admitted with a responsible party listed as an advocacy group and was taking antipsychotic medications. Documentation showed that the resident had no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, and was actively involved in discharge planning for a return to the community. On the day of the incident, the resident insisted on leaving the facility, and the physician advised allowing the resident to leave AMA. The resident refused to sign the AMA form, and the responsible party was not present or notified in person. Interviews and record reviews revealed that the Director of Nursing attempted to contact the responsible party by phone several times and left voicemails, but no response was received. The Social Services Director confirmed that the health care proxy should be notified and is the person authorized to sign a resident out AMA, but this did not occur. Facility policy requires notification and documentation of the resident's representative when a resident leaves AMA, but this was not completed as required. The resident's advocate stated they were not informed of the resident's departure and expressed concern for the resident's safety and need for medication.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident, which was identified during a survey. The resident was admitted with a diagnosis of a displaced trimalleolar fracture of the right lower extremity and was expected to be discharged home with family. Despite the resident's choice to be discharged and the absence of any medical equipment or home health requests, the facility did not create a discharge care plan. The resident's clinical records indicated that they were independent in some activities of daily living, such as eating and personal hygiene, but required assistance with others, like bathing and dressing. The facility's records showed that the resident was given a 30-day notice to vacate due to an unpaid bill, yet there was no evidence of a discharge care plan being developed to facilitate the transition home. Interviews with facility staff revealed a lack of clarity regarding responsibilities for care plan development. The Social Services Director stated that they were not responsible for care plans, while the MDS Coordinator acknowledged the absence of a discharge care plan for the resident. This oversight was contrary to the facility's policy, which mandates the development of a comprehensive care plan within seven days of a resident's comprehensive assessment.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (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; MDS Coordinator/Social Service Director/designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Improper Placement of Drainage Bags
Penalty
Summary
The facility failed to ensure the secure placement of drainage bags for two residents, leading to potential risks of dislodgement and infection. Resident #7 was observed in the hallway with his drainage bag resting on his lap and at times placing it on the floor without a privacy bag. Despite staff performing 15-minute checks, the bag was not noticed on the floor, indicating a lapse in monitoring. The resident's medical records revealed a history of severe cognitive impairment and noncompliance with treatment regimens, which included allowing the drainage bag to drag on the floor. Resident #8 was similarly observed with his drainage bag and tubing positioned in a manner that increased the risk of dislodgement. The tubing was noted to be on the wheelchair's wheels, and the resident was seen moving around with the bag in close proximity to the wheels. The resident's medical records indicated mild cognitive impairment and a history of prostatic hyperplasia, with no toileting program in place. The care plan for Resident #8 included interventions to manage the drainage bag properly, but the resident sometimes allowed the bag to drag on the floor. Interviews with staff, including an LPN and the DON, acknowledged the risks associated with the improper placement of the drainage bags. Despite efforts to educate the residents about the risks, compliance was inconsistent. The facility's failure to secure the drainage bags properly and monitor the residents' behavior led to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects r/t the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and the drainage bag is not on the floor and the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current licensed nurses are re-educated by the DON/designee on the components of this regulation and to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered to be completed by [date]. 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: DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Conduct Timely Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a Drug Regimen Review (DRR) was completed for a resident, identified as Resident #13, within the required time frame. This resident was receiving a combination of medications, including a relaxer and other high-risk medications, which have the potential to cause serious interactions and side effects. Despite the requirement for a monthly review by a licensed pharmacist, the necessary review was not conducted, leading to a deficiency in compliance with federal regulations. Resident #13, who was admitted to the facility following an accident, was observed to be taking multiple medications, including high-risk ones, without a documented attempt at a Gradual Dose Reduction (GDR). The resident's Minimum Data Set (MDS) indicated that no GDR had been attempted, and there was a lack of assessment or follow-up information regarding the medication regimen. The psychiatrist involved in the resident's care acknowledged the effectiveness of the medications but also noted that recommendations for GDR were typically only followed when mandated by the pharmacy. Interviews with the Director of Nursing (DON) revealed that the resident had been observed with symptoms such as drooling and excessive sleepiness, which led to the discontinuation of one of the medications. However, the Medication Regimen Review Log showed no completed reviews for the resident, highlighting a failure in the facility's processes to ensure timely and appropriate medication management. This oversight in conducting the required DRR and addressing potential medication interactions contributed to the identified deficiency.
Plan Of Correction
F 756 Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #13 the psychiatrist reviewed the residents, medications listed below: decreased on from 45mg to 30mg. was decreased from 300mg to 200mg 1mg continue current dose; no changes. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents receiving medication(s) to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; DON and ADON reeducated by the Chief Nursing Officer on the components of this regulation and to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (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; DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen r/t medications 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing, Schedule to be modified PRN based on findings.
Deficiencies in Discharge Planning and Urinary Drainage Bag Management
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident who was discharged home with family. The resident had a clinical diagnosis of a displaced tri-malleolar fracture of the right lower extremity and required orthopedic aftercare. Despite the resident's choice to be discharged, the facility did not create a discharge care plan, which is a requirement under the comprehensive care plan statute. The MDS Coordinator acknowledged the absence of a discharge care plan for the resident. Additionally, the facility did not ensure the security of urinary drainage bags for two residents. One resident was observed carrying their drainage bag in their hand and placing it on the floor, while another resident had their drainage bag tubing caught on the wheelchair's wheels. These practices increased the risk of urological complications if the bags were unintentionally pulled, leading to potential dislodgement. Staff members, including an LPN and the DON, were aware of these issues but did not consistently address them. The facility's policies and procedures require the development of a comprehensive care plan within seven days of a resident's assessment, which includes measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to these policies, resulting in deficiencies related to the lack of a discharge care plan and the improper management of urinary drainage bags.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident # 1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (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: MDS Coordinator/Social Service Director /designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Inadequate Healthcare Leads to Risk of Dislodgement
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare to prevent the potential risk of dislodgement for two residents. Resident #7 was observed in the hallway carrying his drainage bag in his hand and at times placing it on the floor, which increased the risk of dislodgement. Staff, including an LPN and the Director of Nursing (DON), acknowledged the risk and attempted to educate the resident about the dangers of having the bag on the floor. Despite these efforts, the resident did not consistently follow instructions, and was observed ambulating unsteadily in the hallway with the bag in his hand. Resident #8 was observed exiting the elevator with the drainage bag on his lap and the tubing on the wheelchair's wheels, which also increased the risk of dislodgement. The resident was later seen returning to his room after playing bingo, with the bag and tubing positioned close to the wheelchair's wheels. The DON was present and acknowledged the concerns, noting that the resident sometimes moved the bag around. Medical records for Resident #8 indicated a diagnosis of prostatic hyperplasia without lower tract symptoms, and care plans focused on managing the resident's condition to prevent complications. Both residents had specific physician's orders and care plans that included regular care and monitoring of their drainage bags. However, the facility's failure to ensure proper positioning and securing of the bags, as well as the residents' non-compliance with instructions, led to the increased risk of dislodgement. The observations and interviews with staff highlighted the deficiency in providing adequate healthcare to prevent potential risks associated with the residents' conditions.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects from the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and not on the floor, and that the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses are re-educated by the DON/designee on the components of this regulation to ensure drainage bags are secure, not on the floor, and that the drainage bag is covered, to be completed by [date]. 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; DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure and not on the floor.
Rodent Infestation and Infection Control Failures in LTC Facility
Penalty
Summary
The facility failed to address a rodent infestation in a timely manner, leading to potential health risks for residents. Despite reports from staff and residents about rodent sightings, the administration did not take immediate action to eradicate the pests. Observations revealed that rodents were seen in resident rooms, and food was improperly stored, providing a food source for the pests. The facility's pest control policy was not followed, and there was a lack of coordination with local agencies to address the infestation. Infection control procedures were not properly implemented, as evidenced by the mishandling of a Glucometer during blood glucose monitoring for a resident. The staff member placed the contaminated Glucometer in her pocket, contrary to CDC guidelines, which state that supplies should not be carried in pockets and should be cleaned and disinfected after each use. Additionally, during wound care for another resident, proper hand hygiene and the use of personal protective equipment were not observed, increasing the risk of infection transmission. The facility also failed to maintain a clear separation between soiled and clean laundry areas, leading to potential cross-contamination. Observations in the laundry room showed that staff did not consistently use personal protective equipment, and there was no physical separation between areas for soiled and clean linens. The facility's infection preventionist had not completed the required specialized training, further contributing to the systemic failure in infection prevention and control.
Failure to Address Rodent Infestation and Infection Control Deficiencies
Penalty
Summary
The facility's Administrator failed to address a rodent infestation in a timely manner, despite being aware of the issue for several months. The Administrator did not follow up on reported rodent sightings, failed to ensure the designated Infection Preventionist had completed specialized training, and did not coordinate effectively with other department heads or contact local agencies regarding the infestation. The facility's pest control policies were not followed, and the Administrator relied on in-house maintenance rather than engaging a pest control company, despite multiple complaints from staff and residents. Resident #9, who is cognitively intact, reported seeing rodents in her room and noted that housekeeping services were lacking on weekends. The resident pointed out unused traps in her room and expressed dissatisfaction with the pest control measures in place. The Director of Nursing (DON) was aware of the rodent issue and had communicated it to the Administrator, who chose to handle it internally rather than seeking external pest control services. The DON did not document the sightings or notify the Health Department, expecting the Administrator to resolve the issue. Staff members, including a Registered Nurse and the former Maintenance Director, reported multiple rodent sightings, particularly on the second floor. The Administrator was informed of these sightings but did not take effective action to address the problem. The facility's failure to implement an effective pest control program resulted in the determination of Immediate Jeopardy, with the potential to spread diseases to residents. The lack of a pest control log and inadequate communication between the Administrator and the pest control technician further exacerbated the situation.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility's administrative staff failed to implement and maintain an effective pest control program, resulting in a rodent infestation that was not addressed in a timely manner. The facility's policy required coordination between the Administrator and the Maintenance Department to arrange pest control services monthly or as needed, and staff were supposed to report sightings of live pests. However, the facility did not follow its own policy, as evidenced by the lack of documentation in the pest control log and the failure to educate staff members appropriately. This deficiency had the potential to affect 111 residents in the 120-bed capacity facility. Resident #9, who was cognitively intact and able to communicate, reported that housekeeping services were not provided on Saturdays, leading to a dirty environment. She observed pests, roaches, and mice/rodents in the facility, particularly in her room near the air-conditioning area. Despite her requests for appropriate traps, the pest control measures in place were ineffective. During an interview, a Surveyor observed a rodent running in the hallway toward Resident #9's room, confirming the resident's reports of rodent activity. Interviews with various staff members, including the Administrator, Director of Nursing, and Maintenance staff, revealed a lack of awareness and communication regarding the rodent sightings. Although some staff members reported seeing rodents or hearing about sightings from residents, these reports were not documented in the pest control log. The pest control technician, who visited the facility regularly, was not informed of specific areas needing treatment and relied on verbal reports from staff. This systemic failure to ensure effective pest control and infection control interventions resulted in the determination of Immediate Jeopardy.
Failure to Follow Tube Feeding Orders and Nutritional Assessment
Penalty
Summary
The facility failed to adhere to the physician's orders for tube feeding administration, complete a nutritional assessment, and identify a severe weight loss for a resident with a feeding tube. The resident, who was admitted with diagnoses including seizures, dementia, hypertension, and protein-calorie malnutrition, had a PEG tube placed due to high aspiration risk and poor oral intake. Despite the physician's orders for a specific bolus feeding schedule, the facility did not consistently administer the feedings on time, leading to significant delays and missed feedings. The clinical dietitian did not complete the initial nutritional assessment within the required timeframe, and no admission weight was recorded for the resident. Interviews with staff revealed a lack of communication and coordination regarding the resident's feeding schedule and weight monitoring. The resident experienced a severe weight loss of 17% within a month, which was not identified or addressed by the facility. Observations confirmed that the resident was often without the prescribed tube feeding, and staff were unclear about the feeding orders and schedule. The facility's policies on nutrition and weight management were not followed, contributing to the deficiency. The lack of timely nutritional assessment and failure to adhere to feeding schedules resulted in inadequate care for the resident, highlighting significant lapses in the facility's processes and communication among staff.
Food Safety Deficiencies in Kitchen and Food Service
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, distribution, and service, potentially affecting 107 residents. During an initial kitchen observation, several issues were noted, including heavily soiled and stained kitchen utility carts, cracked and stained kitchen floors and walls, and a heavily soiled dry/canned food storage area. Staff personal items were improperly stored on clean food storage shelving, and a chemical test revealed extremely high concentrations of Quaternary Chemical in cleaning cloth buckets. The walk-in refrigerator had a build-up of a black mold-like substance around the gasket area, which was torn and needed replacement. Additionally, the refrigerator's food storage shelves were soiled and rust-laden, and the cooling fan unit was dripping condensation into a pan, posing a risk of food contamination. Other equipment, such as a commercial can opener and aluminum sheet pans, were found to be rust-laden and soiled, with a build-up of black mold-like matter. Further observations revealed numerous small flying insects in the dish room and food preparation areas, and rust-laden racks where clean food preparation equipment was stored. During a breakfast meal observation, it was noted that cold foods were not held at the regulatory temperature of 41 degrees Fahrenheit or below. Specifically, individual portions of milk and orange juice were found to be at 62 and 60 degrees Fahrenheit, respectively, due to being placed on residents' trays too early. These findings indicate a failure to adhere to professional standards for food service safety, potentially compromising the safety and quality of food served to residents.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) had completed the required specialized training. The job description for the IP position mandates certification in Infection Control within the first 90 days of employment. However, the Director of Nursing (DON), who was assigned as the IP, had not completed the necessary training modules or obtained the certification. The DON was unaware of his assignment as the IP until informed by the Administrator two months prior to the survey. Interviews revealed that both the DON and the Assistant Director of Nursing (ADON) were given access to the infection preventionist training modules, but only the ADON completed the training and obtained certification. Despite this, the ADON did not sign the agreement to be the IP, as the DON was handling infection control duties. The DON acknowledged the lack of a designated IP and expressed efforts to hire one, but the deficiency remained unaddressed at the time of the survey.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment, as observed during a survey conducted over several days. The surveyors noted significant cleanliness and maintenance issues across various areas, including residential rooms, dining areas, hallways, and an elevator. The elevator was found to have heavily soiled floors and walls, with exposed sharp plastic near the handrails, and the metal handrail was worn down to the bare metal. The second-floor nurses' station and bathroom were heavily soiled, with dirt and dust buildup, and the dining room had soiled cleaning equipment stored inappropriately. Numerous residential rooms were found in disrepair, with issues such as cracked floor tiles, leaking ceilings, and offensive odors, particularly urine. Several rooms had missing or damaged furniture, such as wardrobe doors and over-bed tables, and heavily stained and worn portable commode seats. The hallways were also noted to be heavily soiled with black stains and offensive odors, and the fire door had large areas of peeling paint. Additionally, the linen and soiled utility rooms were heavily soiled, with mold-like matter observed in the utility room. Residents were directly affected by these deficiencies, with some complaining about the conditions, such as a resident waiting for a window replacement and another reporting roach sightings. Wheelchairs and Geri chairs used by residents were also in poor condition, with missing or worn armrests. On the third floor, issues included a leaking shower handle, insufficient bathroom lighting, and residents complaining about roach sightings and inadequate bed sizes. These observations indicate a widespread failure in maintaining the facility's environment, impacting the residents' quality of life.
Failure to Ensure Privacy in Resident Phone Use
Penalty
Summary
The facility failed to provide reasonable access to and privacy in the use of communication methods for residents. Observations on the second floor revealed that six residents were using the facility telephone located at the nurses' station desk without any staff intervention to ensure privacy. These residents' conversations could be overheard by numerous staff and other residents in the area. Additionally, outside calls were being routed to the nurses' station, where residents were brought to speak aloud in a non-private setting. This lack of privacy was further evidenced when a resident was observed using the phone speaker to discuss sensitive financial information with a banking institution, which was clearly audible to those nearby. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness regarding the need for private phone conversations for residents. Although the Corporate Maintenance Director indicated that two private cordless phones were available for residents' use, one was found uncharged and without a charging connection. Continuous observations noted that residents continued to use the nurses' station phone without staff intervention, including a resident who used the phone speaker to discuss personal medical conditions with a physician and church. This ongoing issue highlights the facility's failure to ensure residents' privacy during phone calls.
Failure to Revise Smoking Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for smoking was revised by the interdisciplinary team after each assessment for a resident who was sampled for smoking. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Nicotine Dependence, had a care plan that was not reviewed or revised since its target date. The care plan included objectives such as educating the resident on the facility's smoking policy and designated smoking areas, assessing smoking safety, and encouraging cessation. Interviews revealed that the Medical Records Personnel misunderstood the Interdisciplinary Care Plan Conference Records as the care plans, indicating a lack of clarity in documentation processes. Additionally, the Assistant Director of Nursing and the Director of Nursing acknowledged that the paper care plans had not been revised and there were no electronic care plans for the resident, except for the advanced directive care plan. This oversight in updating the care plan after each assessment led to the deficiency identified by the surveyors.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent place accessible to residents and visitors. During an initial tour of the facility on the second floor, it was observed that the nurse staffing data posted was outdated, showing the date 08/23/24, while the observation took place on 08/26/24. No other nurse staffing data was found posted elsewhere in the facility. An interview with a Registered Nurse revealed that there was no comprehensive nursing staffing data available, and she was only aware of the staffing assignments for her specific floor, which were noted on a whiteboard.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to administer medications in a timely manner for Resident #70, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Bipolar II Disorder, and Anxiety Disorder. The resident's medication administration records from 08/15/24 to 08/26/24 showed that medications were consistently given more than one hour late, with 57 instances of medications being administered 2 to 6 hours late. During an interview, the resident expressed that the nurses frequently administered medications late and often forgot to provide all medications due at the same time, particularly the protein supplement needed for wound healing. For Resident #52, the facility failed to ensure medications were administered as ordered. The resident, who had diagnoses including Encephalopathy and Parkinson's Disease, had a physician's order for Clonazepam discontinued on 08/07/24. However, the medication was still signed out and documented as administered from 08/09/24 to 08/15/24, despite the discontinuation. This discrepancy was confirmed during a medication cart review and acknowledged by the Assistant Director of Nursing. Additionally, the facility failed to maintain accurate drug records and reconcile controlled drugs for Residents #16, #42, and #54. Resident #16 received an incorrect dosage of Clonazepam on 08/28/24, while Resident #42's medication administration did not match the physician's orders on several occasions. Resident #54 was not administered Clonazepam as per the prescribed schedule on specific dates. These inconsistencies in medication administration and record-keeping were identified through reviews of the Medication Administration Records and Medication Monitoring/Control Records.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor behaviors for residents on psychotropic medications, as evidenced by the lack of proper documentation and monitoring for four residents. Resident #76, who was readmitted with diagnoses including Major Depressive Disorder and Anxiety Disorder, had an order for Risperdal with specific monitoring instructions. However, the behavior monitoring records for August 2024 only showed check marks without the required 'Y' or 'N' documentation, indicating a failure to properly observe and record the resident's condition. Similarly, Resident #306, diagnosed with Dementia and Depression, had an order to monitor for side effects of antipsychotic medication. The behavior monitoring records for this resident also lacked the necessary 'Y' or 'N' documentation, with only check marks present. This indicates that the facility did not follow the prescribed monitoring protocol, failing to ensure that the resident's behaviors and potential side effects were adequately observed and documented. Resident #307, with diagnoses including Bipolar Disorder and Paranoid Schizophrenia, and Resident #56, with Alzheimer's and Anxiety Disorder, also experienced similar deficiencies in behavior monitoring. For Resident #307, the records from mid-August 2024 showed only check marks without the required documentation. For Resident #56, the Treatment Administration Record indicated 'N' for observed behaviors without further documentation in the progress notes, as required. Interviews with staff revealed misunderstandings about the documentation process, contributing to the failure to properly monitor and document resident behaviors.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications and biologicals, as evidenced by several observations and interviews. A bottle of Dakin's solution was found in an unlocked clean utility closet on the third floor, which was intended for a resident who no longer resides in the facility. The Director of Nursing (DON) acknowledged that the bottle should not have been in the closet. Additionally, Resident #28 was observed with two tubes of Cortisone cream on her bed, despite having no physician's order for the cream and no evaluation for self-administration of medication. The DON confirmed that no residents were authorized to self-administer medications, indicating a lapse in adherence to the facility's policy on medication storage and self-administration. Further deficiencies were noted with the handling of wound treatment carts. On two separate occasions, wound treatment carts were left unlocked and unattended. One cart was observed at the third-floor nursing station containing various medications and scissors, with the responsible wound care nurse not present. Staff ZZ, an RN, acknowledged the cart should have been locked. Another incident involved Staff XX, an LPN, who left a wound care cart unlocked in the hallway while attending to a resident's wound care. Staff XX admitted to not having keys to the cart, which led her to leave it open, contrary to the facility's policy requiring locked compartments for medications. These incidents highlight the facility's failure to comply with its own policies regarding the secure storage of medications and biologicals. The lack of secure storage poses potential risks to residents, especially those with cognitive impairments, as evidenced by Resident #28's moderate cognitive impairment and unauthorized access to medication. The facility's policies clearly state that all drugs and biologicals must be stored in locked compartments, yet these observations indicate a significant oversight in maintaining these standards.
Deficiency in Meeting Residents' Dietary Needs
Penalty
Summary
The facility failed to provide 107 out of 111 residents with a nourishing, palatable, well-balanced diet that met their dietary needs and preferences. During a breakfast meal observation, it was noted that residents were served a 4-ounce serving of a light-colored pink liquid instead of the preferred orange juice. The approved menu indicated a 6-ounce portion of Vitamin C juice should be served. Upon investigation, it was found that the juice served was a watered-down tropical punch mix, not following the mixing directions, and providing significantly less nutritional value than required. The Certified Dietary Manager confirmed that orange juice had not been available for two days, and no other citrus juices were available. A list showed that 43 residents requested orange juice, while others requested different juices. Additionally, during another breakfast meal observation, the facility did not prepare enough sausage links for residents on a regular consistency diet, resulting in some residents receiving only one link or none at all. The approved menu required two sausage links per serving. Furthermore, the facility failed to provide fresh bananas as per the approved menu, and no nutritional substitute was planned or served. Interviews with dietary staff revealed that bananas were not regularly available, contributing to the deficiency in meeting residents' dietary needs.
Failure to Follow Approved Menus for Resident Meals
Penalty
Summary
The facility failed to prepare in advance and follow the approved menu for 107 of the facility's 111 residents. During the review of the approved menu for the lunch meal, it was noted that the facility served a 2-ounce portion of homemade chili instead of the required 6-ounce portion, substituted canned pineapple for watermelon cubes, and served pureed regular bread instead of pureed cornbread to residents on pureed diets. An interview with the facility cook revealed that she did not review the approved menu and was unaware of the specific dietary requirements, including the need for watermelon and pureed cornbread. For the breakfast meal, the facility did not provide bananas as required by the approved menu and prepared an insufficient number of sausage links, resulting in some residents receiving only one link or none at all. The facility cook admitted that bananas were never purchased or served according to the menu, and there was an inadequate supply of sausage links. The facility's diet census indicated that there were 71 residents on regular diets, 10 on pureed diets, and 20 on mechanical soft diets, highlighting the widespread impact of these deficiencies.
Failure to Follow Standardized Recipe for Turkey Patty Melt
Penalty
Summary
The facility failed to prepare foods using standardized recipes, impacting the nutritive value, flavor, appearance, and overall appeal of meals served to 107 of the facility's 111 residents. During a review of the approved menu for a lunch meal, it was noted that the Turkey Burger Patty Melt was to be served to residents on Regular, Mechanical Altered, and No Concentrated Sweets Diets. However, the preparation did not follow the standardized recipe, which included specific ingredients and cooking instructions to ensure the meal was appetizing and nutritious. Observations during the lunch meal revealed that the Turkey Patty Melt was prepared and served incorrectly. The turkey burgers appeared white and uncooked, deviating from the recipe's requirement for browning. The sandwiches were made with white bread and American cheese instead of the specified Swiss cheese and sauteed onions, and they were not cooked until golden brown. An interview with a staff member revealed a lack of awareness and use of the standardized recipe, contributing to the deficiency in meal preparation.
Repeated Deficiencies in Environment, Pharmacy, QAPI, and Pest Control
Penalty
Summary
The facility failed to implement effective plans of action to correct identified quality deficiencies in several areas, including maintaining a safe, clean, comfortable, and homelike environment, pharmacy services and procedures, quality assurance and performance improvement activities, and pest control. These deficiencies were identified during a recertification survey and a complaint survey, indicating repeated issues in these areas. The deficiencies have the potential to affect 111 residents residing in the facility at the time of the survey. The facility's policy and procedures outline a comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on various indicators of care outcomes and quality of life. However, the facility's failure to demonstrate effective implementation of corrective actions suggests a lack of adherence to these procedures. The QAPI program is designed to be an ongoing review of care and services, involving leadership and input from staff, residents, and families, but the repeated deficiencies indicate that the program's intended systematic approach to identifying and addressing underlying causes of problems was not effectively utilized.
Inaccurate Medication Classification in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for residents during the Minimum Data Set (MDS) observation period, affecting three residents. Resident #48, who was admitted with conditions including cardiac arrhythmia and dementia, had discrepancies in the MDS documentation regarding medication classification. The MDS indicated the resident was receiving an anticoagulant but not an antiplatelet, despite physician orders for both aspirin (an antiplatelet) and Eliquis (an anticoagulant). Similarly, Resident #100, admitted with cerebral infarction and hemiplegia, was documented in the MDS as receiving an anticoagulant, although physician orders only included antiplatelet medications, aspirin and clopidogrel, with no anticoagulant prescribed. Resident #59, with a history of heart disease and atrial fibrillation, was also inaccurately documented in the MDS as receiving an anticoagulant, while physician orders only included antiplatelet medications. The MDS Coordinator misclassified these medications, as confirmed by the facility's Consultant Pharmacist, who clarified the correct classification of aspirin and clopidogrel as antiplatelets, not anticoagulants.
Staffing Shortages Affect Resident Supervision and Care
Penalty
Summary
The facility failed to ensure minimum nursing staff was provided daily to meet the needs of residents, affecting the safety and well-being of the residents. A review of the facility's State Minimum Nursing Staffing records from June to August revealed that on specific dates, the daily average for nursing staff was below the required minimum of 1.0. The administrator, responsible for completing the Nurse Staffing Calculations, acknowledged the shortfall and attributed it to nurses punching in late. Additionally, there was confusion regarding the inclusion of food/nutrition service staff hours in the direct care staff calculations, which the Director of Nursing (DON) agreed to revise. Observations and interviews highlighted the impact of staffing shortages on resident supervision. On one occasion, a Certified Nursing Assistant (CNA) was observed monitoring residents on the smoking patio from inside the facility, rather than being present outside with them. The CNA explained that typically two staff members are present, but due to being short-staffed, she was alone that day. Another staff member expressed feeling that the facility was short-staffed, although they managed to work together to complete their tasks.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that residents had a functioning call light system to request assistance from staff, affecting five residents. The facility's policy requires that call lights be answered promptly and any malfunctions reported to maintenance or relevant staff. However, several residents reported that their call lights were not working, and staff were aware of these issues but did not resolve them. Resident #6, who is cognitively intact and requires assistance with personal care, reported being left soaking wet in bed due to a non-functioning call light. Resident #9, also cognitively intact, stated that her call light had been malfunctioning for over six months, and despite having manual call bells, staff could not hear them. Resident #19, who uses a wheelchair and requires supervision for toilet transfers, reported that his call light had not worked for over a month. Maintenance staff acknowledged the issue but indicated they were not equipped to fix it. Observations confirmed that the call light system in Resident #19's bathroom did not function, as no auditory signal was heard at the nurses' station. Resident #83 demonstrated that their call light did not activate any notification at the nurses' station, and no staff responded to the call light during the observation period. Similarly, Resident #88's call light did not trigger any notification, and no staff responded when it was activated. Interviews with staff revealed that the call light system had been malfunctioning for an extended period, with one CNA stating that the issue had persisted for the entire six months of her employment. The facility administrator acknowledged that repairs were underway but indicated that the issue could not be resolved immediately due to the need for specific parts. This ongoing deficiency in the call light system compromised the residents' ability to communicate their needs effectively to the staff.
Failure to Address Grievances Related to Non-Functional Call Lights
Penalty
Summary
The facility failed to properly address and resolve grievances related to non-functional call lights for four residents. Resident #6 reported being left soaking wet in bed due to a non-working call light, which staff were aware of but had not fixed. Resident #9 experienced a similar issue, with her call light not functioning for over six months despite maintenance attempts to repair it. She was provided with manual call bells, which staff claimed they could not hear, leaving her without an effective means to request assistance. Resident #19 also faced issues with a non-functional call light for over a month, forcing him to wheel himself out of his room to get staff attention. Maintenance staff acknowledged the problem but indicated they were not equipped to fix it. Resident #206's call light was non-functional during her stay, and despite her son's concerns, the issue was not resolved. A manual bell was provided as a temporary solution, but the call light remained unfixed until her discharge. The facility's grievance log from August 2023 to August 2024 did not document any complaints regarding the call lights from these residents. Interviews with staff revealed inconsistencies in the grievance process, with some staff not filling out grievance forms and others documenting issues in progress notes instead. The Assistant Director of Nursing and Director of Nursing acknowledged the lack of proper grievance documentation, and the Social Services Director, responsible for maintaining the grievance log, confirmed the absence of relevant entries.
Incomplete Documentation of Resident Leaving AMA
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who left against medical advice (AMA). The resident, who had been readmitted to the facility, left AMA without proper documentation of family notification. The resident's Minimum Data Set (MDS) indicated a cognitive response with a Brief Interview of Mental Status (BIMS) score of 15 on one occasion and 14 on another, suggesting some level of cognitive awareness. However, there was no documentation in the nursing notes indicating that the family was informed about the resident's decision to leave AMA. The Assistant Director of Nursing admitted during an interview that she personally notified the family but failed to document the conversation. The resident's emergency contact, who is a family member, confirmed being informed about the resident leaving AMA but expressed concerns about the resident's mental capacity to make such a decision. The emergency contact mentioned that the resident had a history of going off medication and wanting to leave, which had occurred in the past. Despite the verbal notification, the lack of documentation in the medical records constitutes a deficiency in maintaining complete and accurate records.
Loose Handrails on 3rd Floor
Penalty
Summary
The facility failed to ensure that handrails were securely affixed to the walls on the 3rd floor, as observed during an initial tour conducted on August 26, 2024, between 9:45 AM and 11:00 AM. The handrails were found to be loose in several locations, including next to specific rooms, near the 3rd floor elevator close to the nursing station, and across from other rooms. Photographic evidence was obtained to document these deficiencies. During an interview on August 30, 2024, at 1:00 PM, the Administrator acknowledged the issue with the loose handrails on the 3rd floor. She mentioned that a similar problem had occurred on the 2nd floor, where the handrails had been secured to the wall.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to potential safety risks. Resident #88, who had a slight cognitive impairment, fell while attempting to go to the bathroom without assistance because the call light was not within reach. Observations confirmed that the call light cord was consistently found on the floor, out of reach. Resident #88 expressed concern about not being able to call for help in the event of another fall. Staff confirmed the call light system's function but did not address the accessibility issue. Resident #11, who was cognitively intact but dependent on staff for toileting hygiene, was unable to reach the call light due to it being wrapped around the bed rail and out of reach. Resident #15, who was rarely understood and also dependent on staff, indicated through gestures that the call light was inaccessible. Resident #306, with cognitive impairment and a history of falling, was found with the call light behind the bed on the floor, unable to call for assistance. These observations highlight a consistent issue with call light accessibility for residents with varying levels of cognitive and physical impairments.
Deficiencies in Comprehensive Care Plans for Medications and Advance Directives
Penalty
Summary
The facility failed to implement comprehensive care plans for antipsychotic medications for three residents and an advance directive for one resident. Resident #56, who was admitted with Alzheimer's, Anemia, and Anxiety Disorder, was prescribed Seroquel for psychosis. However, there was no care plan developed to address the use of this antipsychotic medication. The Assistant Director of Nursing acknowledged the absence of a care plan and mentioned that the staff member responsible for care plans was not yet working full-time. Resident #94, admitted with Anxiety Disorder, Type 2 Diabetes Mellitus, and Altered Mental Status, had a severely impaired cognitive status. Despite having physician's orders for insulin and clonazepam, there was no comprehensive care plan documented except for an entry on advanced directives. The Assistant Director of Nursing confirmed the lack of a care plan and noted that only an interdisciplinary care plan conference record was available. Resident #306, diagnosed with Dementia and Depression, was prescribed Olanzapine for a psychotic disorder. The care plan did not include any entry for antipsychotic medications, despite the physician's orders requiring close observation for side effects. Additionally, Resident #100, with a cognitive response score indicating full cognitive ability, had no care plan addressing advanced directives, even though the physician's orders indicated a full code status. The Social Service Director acknowledged the oversight and entered the care plan during the surveyor's visit.
Failure to Provide Supervised Feeding for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good nutrition for a resident who was unable to eat without staff assistance. During an observation, it was noted that the resident, who was cognitively impaired and diagnosed with dysphagia, was left unsupervised with a lunch tray placed within reach. The resident was seen using her hands to scoop large portions of pureed food into her mouth, leading to coughing and regurgitation. The Director of Nursing (DON) was called to the room and confirmed the resident's need for maximum assistance with eating and honey-thick liquids, as per her care plan and physician orders. The resident's clinical record indicated a diagnosis of hemiplegia and dysphagia, with orders for a pureed diet and honey-thick liquids. The Minimum Data Set (MDS) documented that the resident required maximum assistance with eating, yet the nutritional assessment inaccurately noted independent feeding. The assigned CNA was unaware of who placed the tray in front of the resident, as she was assigned to the dining room at the time. This lack of supervision and adherence to the care plan resulted in the resident being at risk during mealtime.
Inadequate Supervision and Safety Hazards in Smoking and Laundry Areas
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by inadequate supervision of a resident who smokes, improper disposal of cigarette butts and trash, and failure to maintain dryer lint cleanliness. Specifically, Resident #59, who has a history of Chronic Obstructive Pulmonary Disease and requires supervision while smoking, was observed smoking on the patio without direct supervision. The staff member responsible for supervision was inside the facility and unable to see all residents on the patio, citing short staffing as the reason for inadequate supervision. Additionally, the smoking patio was found to have multiple cigarette butts scattered on the floor and paper trash mixed with cigarette butts in a designated bin, which was acknowledged by staff as needing to be emptied. Furthermore, the laundry area showed a lack of documentation for lint removal at scheduled times, and an observation revealed a significant accumulation of lint in one of the dryers, indicating that the lint removal process was not being followed as required.
Medication Administration Error with High-Risk Medication
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for high-risk medications. During a medication administration observation, a registered nurse (RN) was preparing morning medications for a resident diagnosed with Hemiplegia, Type 2 Diabetes Mellitus, and Hypertension. The resident, who was cognitively intact, had a physician's order for Labetalol HCL 100mg tablet, with a prescribed dose of 1.5 tablets (150 mg) to be given every 12 hours for hypertension. However, the RN prepared only one tablet of Labetalol 100 mg, which was an incorrect dose. The surveyor intervened before the incorrect dose was administered, prompting the RN to review the medication orders. Upon review, the RN acknowledged the error and corrected the dose to the prescribed 150 mg by preparing one and a half tablets. This incident highlights a lapse in the medication administration process, where the RN did not initially verify the correct dose as per the facility's policy and the medication administration record.
Failure to Provide Appropriate Food Consistency for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs, specifically for residents requiring thickened liquids and pureed diets. During an observation, a resident with cognitive impairment and a diagnosis of dysphagia was found with a lunch tray containing non-thickened water and was eating pureed food with bare hands, leading to coughing and regurgitation. The resident required honey-thick liquids and maximum assistance with eating, as documented in their care plan and physician orders. However, the resident was left unsupervised with inappropriate food and liquid consistency, indicating a lack of adherence to the prescribed dietary requirements. Additionally, during a review of the breakfast meal preparation, it was observed that regular consistency grits and scrambled eggs were being served to residents on a pureed diet. The breakfast cook admitted to not reviewing the approved menu, which led to the improper preparation of meals for residents with dysphagia. The facility's policy and procedure for thickened liquids were not followed, as evidenced by the presence of non-thickened liquids at the resident's bedside and the failure to provide the appropriate food consistency, posing a risk of choking or aspiration for residents with specific dietary needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 313 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra Lakes Nursing & Rehabilitation Center | 0.3 mi | ★★★★★ | 11 | 1 |
| Hampton Court Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Aventura Rehab And Nursing Center | 2.1 mi | ★★★★★ | 8 | 0 |
| North Beach Healthcare And Rehabilitation Center | 2.9 mi | ★★★★★ | 11 | 0 |
| Regents Park At Aventura | 2.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Gardens Nursing And Rehab Center.
100% money-back within 48 hours.
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.