Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Hawthorne Center For Rehabilitation And Healing Of during CMS and state inspections, most recent first.
Oxygen was not provided according to physician orders for two residents, and one resident had no documented oxygen order. An LPN and the DON confirmed that one resident’s oxygen was running above the ordered rate, another resident was receiving oxygen at 4 L/min despite an order for 2 L/min PRN, and a third resident was on oxygen without an order specifying the flow rate. The facility policy required oxygen to be started at the prescribed rate and adjusted so the proper flow was administered.
Food Storage and Meal Service Sanitation Deficiency: The walk-in freezer did not have a stand-alone thermometer, and the CDM confirmed it was missing. During meal service, a cook was observed handling food with a gloved hand, touching the countertop, placing a cheese slice on a hamburger bun with the same glove, touching the food contact surface of multiple plates, and changing gloves without washing hands first. The CDM stated staff should not touch food or plate surfaces with their hands and should wash hands after removing gloves and before putting on clean gloves.
PASARR assessments were not updated for four residents after new mental health diagnoses were documented. Records showed residents with diagnoses including MI, dementia, major depressive disorder, and PTSD, but the Level I PASARRs did not reflect those conditions. The Administrator confirmed one PASARR had not been updated, and the DON stated she saw the issues with the PASARRs.
PASARR assessments were not accurately completed for three residents. One resident had depression and anxiety documented in the chart and psychiatry notes, but the PASARR did not list those diagnoses; another had anxiety documented with psych meds and a psych consult, but anxiety was omitted from the PASARR; and a third had bipolar disorder, major depressive disorder, and anxiety documented in the record, while the PASARR did not fully reflect the psychiatric diagnoses. The DON and NHA stated the PASARRs were incorrect and not being updated when new psych diagnoses were added.
A facility failed to develop and implement comprehensive care plans for two residents. One resident had diagnoses including depression, anxiety, and bipolar disorder and was receiving multiple antianxiety medications, but the care plan did not include anxiety or antianxiety medication as a focus. Another resident had multiple respiratory and cardiac diagnoses and an order for continuous oxygen via nasal cannula, but the care plan did not include oxygen use or respiratory care. Staff stated the care plans should have been revised or implemented.
A resident with a PICC line receiving antibiotics had an overdue dressing change, and the chart lacked flush orders for the line. Another resident with a surgical incision did not have the ordered weekly skin checks documented. A resident with CHF/CKD had multiple missed daily weights despite a physician order, and a resident with HTN and dementia had repeated elevated BPs without receiving ordered PRN clonidine. Staff and the DON acknowledged the ordered care was not completed as written.
A resident’s midodrine was administered multiple times despite MAR-documented BPs above the prescriber’s hold parameter of SBP > 120. The RN stated a check mark means the med was given and was unsure why the resident’s midodrine was marked that way, while the DON confirmed the med should not have been administered when BP was outside parameters and that the MAR check mark indicates administration.
Incomplete documentation was found for two residents’ skin-related treatments. One resident had a PICC line dressing that was dated beyond the expected change interval, while another resident’s ordered sacral wound care was not documented on multiple shifts even though an LPN stated the care had been done. The facility’s policy required accurate documentation of care provided, and the DON and Administrator confirmed that dressing changes and wound care should be documented.
An LPN failed to perform hand hygiene during multiple medication passes, including before handling medications, before donning gloves, after resident contact, and after touching resident equipment and personal items. The LPNs were observed unlocking the med cart, using the computer, handling medications improperly, entering resident rooms without sanitizing hands, and administering meds without hand hygiene. The DON confirmed nurses should follow infection control policies during med pass, and facility policy required hand hygiene before and after resident contact and medication handling.
Several residents with a history of Alprazolam use missed multiple doses of their prescribed medication because staff did not know the medication was available in the automated dispensing system and failed to notify the physician or document the missed doses. This resulted in withdrawal symptoms for at least one resident and demonstrated a breakdown in medication administration and communication procedures.
Facility staff failed to administer prescribed Alprazolam to three residents as ordered, resulting in multiple missed doses and withdrawal symptoms for one resident. LPNs were unaware that the medication was available in the automated dispensing system and did not notify providers when medications were unavailable. The DON and Administrator acknowledged gaps in staff training and oversight, and there was no documentation of physician notification or intervention regarding the missed doses.
Three residents with complex medical histories did not receive prescribed Alprazolam for anxiety on multiple occasions, and staff failed to document the reasons for non-administration or notify the physician as required by facility policy. MARs indicated a need for explanatory notes, but no such documentation was found in the residents' records, resulting in incomplete and inaccurate medical records.
A facility failed to ensure an accurate assessment for a resident who was documented as discharged to a hospital, while progress notes indicated a transfer to another nursing home. The MDS Director confirmed the assessment was inaccurate, as the resident was transferred to a skilled nursing facility, not a hospital.
The facility failed to develop comprehensive care plans for residents requiring oxygen therapy, as evidenced by the lack of documented respiratory services focus in the care plans of four residents. A resident with heart failure and COPD had a physician's order for oxygen therapy, but their care plan did not include a focus on respiratory services. Similarly, another resident with respiratory failure and pneumonia had multiple physician orders for oxygen therapy, yet their care plan also lacked a focus on respiratory services. Additionally, the facility did not address the issue of residents self-adjusting their oxygen concentrator settings in their care plans, despite staff acknowledging this behavior.
A facility failed to document medication parameters and provider conversations for a resident. Insulin was administered despite blood glucose levels being below the prescribed threshold, and Midodrine was given when systolic blood pressure was above the limit. Staff followed provider instructions but did not document these interactions, violating the facility's documentation policy.
The facility failed to follow infection control standards during medication administration and oxygen therapy. An RN did not use alcohol wipes on vial stoppers before needle insertion, and two residents had unbagged nebulizer masks on bedside tables, contrary to facility policy. The DON confirmed these practices were not in line with infection control guidelines.
Oxygen administered at incorrect flow rates and without a physician order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by administering oxygen at flow rates that did not match physician orders for two residents and by not having a physician order documenting the prescribed oxygen flow rate for one resident. Resident #58 had diagnoses including congestive heart failure, morbid obesity, protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, asthma, cardiomegaly, atherosclerotic heart disease, osteoporosis, anxiety, hyperlipidemia, insomnia, hypertension, and major depressive disorder. During observations on 5/26/2026 and 5/27/2026, Resident #58 was observed receiving oxygen at 3 liters via nasal cannula, while the physician order dated 3/16/2026 specified oxygen at 2 L/min continuous via nasal cannula. An LPN stated the resident’s oxygen should be at 2 liters and that staff should follow the ordered rate, and the DON stated oxygen should be running at the ordered rate and doctors’ orders should be followed. Resident #116 was observed multiple times receiving oxygen at 4 liters per minute via nasal cannula, including while sitting at bedside and while eating breakfast, but the physician order dated 5/14/2026 specified oxygen at 2 L/min via nasal cannula as needed. The DON confirmed the resident’s oxygen was being administered at 4 liters per minute and stated nurses are to check orders prior to administering oxygen. Resident #130 was observed receiving oxygen at 1.5 liters per minute via nasal cannula, later at 2 liters per minute, but review of the physician orders did not document any oxygen order. An LPN stated there was no oxygen order in place and that one would be needed for the nasal cannula and liters of oxygen, and the DON stated doctors’ orders need to be in place for oxygen. The facility policy titled Oxygen Administration stated oxygen should be started at the prescribed rate and adjusted so the proper flow of oxygen is being administered.
Food Storage and Meal Service Sanitation Deficiency
Penalty
Summary
Food was not stored and served in a sanitary manner. During observation of the walk-in freezer on 5/26/2026 at 9:34 AM, there was no stand-alone thermometer in the freezer. During interview at 9:35 AM, the Certified Dietary Manager confirmed that the walk-in freezer did not have a stand-alone thermometer. Review of the policy titled Storage of Perishable Goods, last reviewed 1/22/2026, stated that freezer temperatures are maintained at a level to keep frozen food solid and that stored frozen foods shall be maintained frozen. During observation of midday meal service on 5/29/2026 beginning at 11:20 AM, the cook was observed using a gloved hand to scoop and place meal items onto plates and touching the countertop. The cook was then observed lifting a cheese slice from a stack with the same gloved hand and placing it on a hamburger bun for a resident. Throughout meal service, while plating food for residents, the cook was observed placing her hand on the food contact surface of 4 plates. The cook was also observed removing used gloves and putting on new gloves without washing her hands after removing the gloves. During interview beginning at 11:30 AM, the Certified Dietary Manager agreed dietary staff should not touch food items or food contact surfaces with their hands and stated staff were expected to wash their hands after removing gloves and before putting on clean gloves. Review of the policy titled Food Handling, last reviewed 1/22/2026, stated that food shall be handled in a proper method to ensure retention of flavor, appearance, quality, nutrients, and to safeguard against contamination, and that when it is necessary for staff to touch food during preparation, they must wash their hands immediately before beginning the process and use disposable gloves.
PASARR Assessments Not Updated for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure assessments were updated after new diagnoses were documented for 4 residents sampled for PASARR review. Resident #119’s record showed diagnoses of altered mental status, depression, anxiety disorder, brief psychotic disorder, and major depressive disorder, but the Level I PASARR dated 4/2/2026 had no entry in section A for MI or suspected MI. During interview, the Administrator confirmed the PASARR had not been updated to include the mental health diagnoses. Resident #70’s admission record showed a diagnosis of dementia with other diseases classified elsewhere, mild, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety, but the PASARR dated 1/8/2026 was not revised to document dementia. Resident #2’s record showed vascular dementia and major depressive disorder, but the Level I PASARR dated 5/08/2025 was not revised to reflect major depressive disorder. Resident #5’s admission record showed PTSD, but the Level I PASARR dated 2/16/2026 did not document PTSD. During interviews, the Social Services Director stated the DON was responsible for PASARRs when a resident is first admitted, the Administrator stated the PASARR process should be an IDT approach and previously the DON was responsible, and the DON stated she saw the issues with the PASARRs.
PASARR assessments were incomplete and did not match residents' psychiatric diagnoses
Penalty
Summary
The facility failed to ensure PASARR assessments were accurately and completely documented for 3 residents reviewed for preadmission screening and resident review. For one resident, the admission record listed multiple medical diagnoses, a physician order for a psych consult was present, and a psychiatric note documented depression, anxiety, and nicotine dependence disorder, but the PASARR did not document anxiety disorder or depressive disorder in Section 1A. For another resident, the admission record included depression and anxiety disorder, and physician orders included Risperidone, Hydroxyzine, Xanax, and a psych consult for anxiety, but the PASARR did not include anxiety disorder as a diagnosis. For the third resident, the PASARR documented bipolar disorder as a mental illness or suspected mental illness, while the medical admission record listed major depressive disorder recurrent, other specified anxiety disorders, and other bipolar disorder, and physician orders included Clonazepam for severe anxiety and Bupropion for major depressive disorder. During interviews, the DON stated the PASARRs did not include the appropriate diagnoses and should have, and the NHA stated the PASARRs were not correct and that the interdisciplinary team was not updating them when new psychiatric diagnoses were added. The facility policy stated that if a Level I PASARR is incomplete or inaccurate, a corrected Level I PASARR must be completed.
Failure to Care Plan Anxiety Medication and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #14 and Resident #58. Resident #14 was admitted with diagnoses including major depressive disorder, anxiety disorders, and bipolar disorder. The medical record showed physician orders for Clonazepam for severe anxiety, then Clonazepam for anxiety, a later Clonazepam order with a hold for sedation, and Hydroxyzine as needed for anxiety/agitation. Review of the care plan did not document a focus for anxiety or antianxiety medication. During interview, the MDS Lead stated the care plan should have been revised because the resident was on medication for anxiety. The facility also failed to document a focus for oxygen use or respiratory care for Resident #58. The admission record listed diagnoses including unspecified diastolic congestive heart failure, morbid severe obesity, protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, asthma, cardiomegaly, atherosclerotic heart disease, anxiety disorder, insomnia, hypertension, and major depressive disorder. A physician order dated 3/16/2026 directed oxygen at 2 L/min continuous via nasal cannula. During interview, the DON stated the care plan should have been implemented, and the MDS Lead stated there was no care plan related to oxygen use. The facility policy stated the RAI process is used to assess resident needs, develop individualized care plans, and revise them to reflect condition changes.
Failure to Follow Orders for IV Care, Skin Checks, Weights, and PRN BP Medication
Penalty
Summary
The facility failed to provide ordered care for a resident with a PICC line receiving antibiotics for a back wound infection. During observation, the PICC dressing was dated 5/6/2026 and remained intact, but the dressing had not been changed within the ordered 7-day interval. The resident stated she could not recall when the dressing was last changed. The physician order required transparent dressing changes every 7 days and as needed, and the record did not contain orders for flushing the PICC line for patency. Staff and the DON stated that IV dressings should be changed every 7 days and that flush orders should be present for a resident with a PICC line. The facility also failed to complete weekly skin observations for a resident with diagnoses including a surgical incision noted on the skin sweep. The physician order required weekly skin observation every Friday, and the skin sweep documented that the skin was impaired with a surgical incision on the chest. However, the resident’s evaluations did not document the weekly skin observations. Staff stated that nurses were responsible for completing the weekly skin assessments and documenting them on the evaluation form, and the DON stated that nurses should follow the order and complete the weekly skin assessments. In addition, the facility failed to obtain daily weights for a resident with pleural effusion, chronic kidney disease stage 3B, and hypertensive heart disease with heart failure, despite a physician order for daily weights. The TAR showed multiple dates with missing, NA, or otherwise undocumented weights, and the resident stated that staff had not been checking the weight every day. The facility also failed to administer clonidine as ordered for a resident with dementia, diabetes, hypertension, and other diagnoses. The order required clonidine every 8 hours as needed for elevated blood pressure, but the MAR showed multiple blood pressure readings above the ordered parameters without documentation that clonidine was given. An LPN stated the medication should have been administered, and the DON stated that all orders should be followed.
Medication Administered Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure Resident #108’s medication regimen remained free from unnecessary drugs by administering midodrine outside of the prescriber’s ordered parameters. The physician orders dated 03/13/2026 and 05/20/2026 directed midodrine 5 mg by mouth three times daily for hypotension and to hold the medication for systolic blood pressure greater than 120. Review of the May 2026 MAR showed multiple administrations of midodrine when the resident’s documented blood pressure was above the hold parameter, including readings such as 132/84, 130/81, 130/72, 140/72, 132/70, 121/61, 126/74, 122/70, 129/68, 122/75, 131/73, 136/69, 134/72, 130/70, 145/78, 145/65, 126/62, 121/66, and 124/62. During interview, Staff K, RN stated that a check mark on the MAR means a medication was administered and that if a medication is held, a number should be documented in the MAR along with a nursing note, but she was not sure what happened with the resident’s midodrine. The DON stated that the check mark means the medication was given and that nurses should not have administered midodrine if the blood pressure was outside of parameters. The facility policy required medications to be administered as prescribed in accordance with written prescriber orders.
Incomplete Documentation of PICC Dressing and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation for resident care related to skin and wound treatment for 2 residents reviewed. For Resident #32, the resident was observed in bed with a PICC line dressing dated 5/6/2026, and there was no redness or swelling at the site. The resident stated she was receiving antibiotics for a wound infection in her back and could not recall when the dressing was last changed. Staff C, LPN stated IV dressings are to be changed every 7 days and later confirmed the dressing was dated 5/6/2026 and needed to be changed. The physician order required the PICC line transparent dressing to be changed every 7 days, and the TAR documented dressing changes on 5/13/2026 and 5/20/2026, initialed by Staff D, LPN. For Resident #8, the physician order required sacral wound care every shift and as needed, including wound cleanser, zinc to the peri-wound, collagen/silver alginate, and a silicone bordered gauze dressing. The TAR for May 2026 did not document wound care on 5/16/2026, 5/22/2026, and 5/26/2026 on the 7 AM to 7 PM shift. Staff I, LPN stated she had done the wound care on her shift but forgot to check it off, and the Administrator stated that when a nurse is doing wound care, it should be documented as completed. The facility policy stated clinical staff will document care according to nursing standards and regulatory requirements, and documentation will accurately reflect the care provided.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to perform hand hygiene during medication administration in 6 of 9 observed medication passes. During observations on 5/27/2026, Staff D, LPN did not sanitize hands before retrieving keys, unlocking the medication cart, activating and typing on the computer, or before donning gloves. Staff D then handled medication cups and medications, placed a thumb inside the medication cup touching the medications, entered residents' rooms without hand hygiene, and administered medications without changing gloves or sanitizing hands after contact with residents or resident equipment. During additional observations, Staff D also prepared medications for another resident without hand hygiene, entered the room without hand hygiene, and administered medications after touching bed controls and assisting the resident reposition in bed without sanitizing hands. Staff M, LPN was observed beginning medication preparation without hand hygiene, retrieving keys from a uniform pocket, unlocking the medication cart, opening and typing on the computer, and preparing medications without sanitizing hands. Staff M also poured medications into a cap, placed an ungloved thumb over medications, returned two tablets to the bottle, donned gloves without hand hygiene, touched a stethoscope and hair with gloved hands, entered a resident room, and administered medications without hand hygiene. Staff M later returned to the cart and resident room multiple times without sanitizing hands, including after touching the bedside table and after exiting the room. Staff M was also observed preparing medications for another resident without hand hygiene, placing an ungloved hand over medications, returning tablets to the bottle, entering the room without hand hygiene, and administering the medication. During interview, Staff D stated hand sanitizer should have been used before pouring medications and when entering the room or touching the resident. Staff M stated hand sanitizer should have been used before and after putting on gloves and that hands should not have touched medications before returning them to the bottle. The DON stated all nurses should follow infection control policies during medication pass. Facility policy required hand hygiene before beginning a medication pass, before handling medications, before and after direct resident contact, after contact with intact skin, and after removing gloves, and stated that glove use does not replace hand hygiene.
Failure to Administer Prescribed Controlled Medications Due to Staff Unawareness and Communication Breakdown
Penalty
Summary
The facility failed to ensure that residents with prescribed controlled medications, specifically Alprazolam, were administered their medications according to physician orders. Three residents with a history of Alprazolam use experienced multiple missed doses upon admission or during their stay. In each case, staff did not contact the physician when prescriptions were needed, and the medication was not administered as ordered. For example, one resident missed nine doses over several days, resulting in withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident missed three doses, and a third resident, a long-term facility resident, also missed three doses of Alprazolam. The investigation revealed that staff were unaware that Alprazolam was available in the facility's automated medication dispensing system. Multiple interviews with LPNs and the DON confirmed that nurses did not know they could access the medication from the dispensing system and did not notify the physician or document the missed doses as required. Progress notes for the affected residents did not include any documentation of the missed medication or physician notification. Staff interviews indicated a lack of training and awareness regarding the availability of controlled substances in the dispensing system and the proper procedures to follow when medications were unavailable. The facility's policy required that if a medication with a current, active order could not be located, staff should search all possible locations, contact the pharmacy, or remove the medication from the emergency kit. If a dose of a vital medication was withheld, refused, or not available, the physician was to be notified, and the notification documented. However, these procedures were not followed, and the lack of communication and documentation led to residents not receiving their prescribed medications, resulting in adverse symptoms for at least one resident.
Failure to Administer Prescribed Controlled Medications Due to Policy and Communication Breakdowns
Penalty
Summary
Facility administration failed to implement and enforce policies and procedures for medication administration, resulting in residents not receiving prescribed controlled medications, specifically Alprazolam, as ordered by their physicians. Three residents with histories of Alprazolam use were affected: one was admitted with a prescription for Alprazolam four times daily but experienced a delay of nine missed doses, leading to withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident, prescribed Alprazolam once daily, did not receive the medication for three days after admission, and a third long-term resident missed three doses of their twice-daily Alprazolam prescription. In each case, there was no documentation of physician notification regarding the unavailability of the medication, and progress notes did not reflect any communication or intervention related to the missed doses. Interviews with nursing staff revealed a lack of awareness about the availability of Alprazolam in the facility's automated medication dispensing system. Several LPNs stated they were unaware that the medication could be accessed from the system and did not know the procedures for obtaining it in the absence of a pharmacy delivery. Staff also failed to notify physicians or nurse practitioners when medications could not be administered, as required by professional standards and facility policy. The DON acknowledged that staff should have called the provider and documented the situation but confirmed that this was not done. The facility's policy required staff to search for medications, contact the pharmacy, and notify the physician if a vital medication was unavailable, but these steps were not followed. The deficiency was further compounded by inadequate staff training and oversight. The DON and Administrator admitted that staff were not properly oriented to the medication distribution system, and there was no regular auditing of medication administration or staff competency regarding the use of the automated dispensing system. The Medical Director and pharmacist confirmed that Alprazolam was available in the emergency drug kit and could have been administered if staff had followed proper procedures. The lack of communication, documentation, and adherence to policy resulted in residents experiencing unnecessary discomfort and withdrawal symptoms due to missed doses of essential medication.
Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting the reasons why prescribed medications were not administered. For each resident, Alprazolam was ordered by the physician to address anxiety, but the medication was not given on multiple occasions. The Medication Administration Record (MAR) indicated a chart code requiring further explanation in the nurses' notes, but no such documentation was found in the progress notes for any of the residents. Additionally, there was no evidence that the physician was notified about the unavailability of the medication. Resident #9, with multiple diagnoses including anxiety disorder, depression, hypertension, and chronic obstructive pulmonary disease, did not receive Alprazolam as ordered on several days. Staff interviews confirmed that the medication was not available and that staff did not document the reason for non-administration or notify the physician. Similarly, Resident #10, who had chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder, also did not receive Alprazolam as ordered, and staff again failed to document the reason or notify the physician. Resident #7, with a complex medical history including multiple fractures, chronic heart failure, and anxiety disorder, experienced the same issue, with multiple missed doses of Alprazolam and no corresponding documentation or physician notification. The facility's policy required that any withheld, refused, or unavailable medication be documented in the nurses' notes with an explanatory note and that the physician be notified, with the notification and response documented. Despite this policy, staff interviews and record reviews confirmed that these steps were not followed for the three residents, resulting in incomplete and inaccurate medical records regarding medication administration.
Inaccurate Assessment of Resident Discharge
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident who was reviewed for discharge. The resident, who had been admitted with diagnoses including pneumonia, sepsis, acute respiratory failure, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, was documented in the Minimum Data Set (MDS) as being discharged to a hospital. However, progress notes indicated that the resident and their family had decided on a transfer to another nursing home, which was the originally preferred facility but had no available beds at the time of the initial discharge from the hospital. Once a bed became available, the resident was transferred to the chosen nursing home, and all necessary documentation was sent. The MDS Director confirmed that the assessment was inaccurate as the resident was transferred to a skilled nursing facility, not a hospital.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop comprehensive care plans for residents requiring oxygen therapy, as evidenced by the lack of documented respiratory services focus in the care plans of four residents. Resident #79, diagnosed with heart failure, hypertensive heart disease, and COPD, had a physician's order for oxygen therapy, but their care plan did not include a focus on respiratory services. Similarly, Resident #77, with acute and chronic respiratory failure and pneumonia, had multiple physician orders for oxygen therapy, yet their care plan also lacked a focus on respiratory services. Interviews with staff confirmed the absence of respiratory focus in the care plans, despite the presence of oxygen orders. Additionally, the facility did not address the issue of residents self-adjusting their oxygen concentrator settings in their care plans. Resident #4's oxygen concentrator settings were observed to be inconsistent with the physician's order, and staff acknowledged that residents sometimes change their settings. However, this behavior was not documented in the care plan. Similarly, Resident #49's oxygen concentrator settings were frequently changed by the resident, but this was not reflected in their care plan. Interviews with staff, including the Director of Nursing and MDS Coordinator, revealed a lack of awareness and documentation regarding residents manipulating their oxygen settings, indicating a failure to revise care plans to address this behavior.
Failure to Document Medication Parameters and Provider Conversations
Penalty
Summary
The facility failed to accurately document notifications of medication parameters for a resident reviewed for medication administration. The resident had a physician's order for Insulin NPH Isophane & Regular Subcutaneous Suspension to be held if blood glucose was less than 150. However, the Medication Administration Record (MAR) showed that the insulin was administered multiple times in December 2024 and January 2025 when the resident's blood glucose levels were below 150. Additionally, the resident had a physician's order for Midodrine to be held if systolic blood pressure was greater than 135, but the MAR documented administration of the medication on several occasions when the resident's systolic blood pressure exceeded this threshold. Interviews with the attending provider and the Director of Nursing revealed that while the staff contacted the provider and acted according to instructions, they failed to document these conversations. The facility's policy on documentation required clinical staff to document the provision of care and services according to nursing standards and regulatory requirements, ensuring that appropriate information is available to all interdisciplinary team members. The lack of documentation of provider conversations and adherence to medication parameters led to the deficiency in maintaining accurate medical records for the resident.
Infection Control Lapses in Medication Administration and Oxygen Therapy
Penalty
Summary
The facility failed to adhere to infection control standards during a medication administration observation involving a registered nurse (RN) and a resident. The RN did not follow proper aseptic techniques when preparing a Ceftriaxone sodium injection. Specifically, the RN did not wipe the rubber stoppers of the vials with an alcohol wipe before inserting a needle, which is a standard practice to prevent contamination. Despite the RN's belief that the vial tops were clean upon cap removal, this practice contradicts established guidelines, as confirmed by the Director of Nursing (DON) and the National Library of Medicine's safety practices for injections. Additionally, the facility did not comply with infection control protocols for oxygen therapy equipment for two residents. Observations revealed that nebulizer masks were left unbagged on bedside tables, contrary to the facility's policy, which requires such equipment to be stored in a plastic bag when not in use. The DON acknowledged that the nebulizer masks should not have been left exposed, as this practice increases the risk of nosocomial infections. These lapses in infection control practices were identified during observations and interviews with facility staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Ocala | 0.2 mi | ★★★★★ | 8 | 0 |
| Palm Garden Of Ocala | 0.6 mi | ★★★★★ | 1 | 0 |
| Avante At Ocala, Inc | 2.7 mi | ★★★★★ | 27 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Ocala Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 10 | 0 |
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