Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Haven Nursing And Rehab Center during CMS and state inspections, most recent first.
Missing Personal Items Not Returned or Replaced: Two residents reported missing clothing and other personal belongings that staff had not resolved, and grievance records showed multiple complaints about missing items. Observation of the laundry area found unlabeled clothing, shoes, and blankets stored in carts and on shelves, while staff said items often accumulated without names, were not routinely delivered to residents, and were sometimes donated or redistributed.
Insufficient nursing staffing was identified when only one CNA was assigned to the East Unit and one CNA to the Reflections Unit during the overnight shift, with additional limited coverage on another unit. Three residents reported delays in care, unanswered calls for help, and needing to ask other residents for assistance because staffing was inadequate. The Staffing Coordinator confirmed the assignments, and the DON stated the NHA was notified of the shortage so bonuses could be offered to staff who might agree to work the shift.
Unsafe resident room conditions were identified when multiple rooms had nonfunctional A/C units, temperatures above 81 degrees, and unsealed openings around replacement units. A resident with paraplegia, polyneuropathy, chronic pain, and TBI reported living in a room without working A/C for weeks, while staff said several rooms had been hot for months and administration knew about the issue. Surveyors also observed biological growth inside one A/C unit and on a ceiling tile above a sink in a room occupied by a resident with respiratory concerns.
Failure to Reassess Fall Interventions After Repeated Unwitnessed Falls: A resident with encephalopathy, schizophrenia, bipolar disorder, and a history of subarachnoid hemorrhage had repeated unwitnessed falls with head bleeding. Although the care plan identified fall risk and included multiple interventions, the record did not show updates after the first fall, and staff later confirmed the earlier fall was not reviewed when the resident fell again and required 911 transfer for further evaluation.
Insufficient linen supply on resident units. An observation found the 100-unit linen closet had no towels or washcloths, and residents reported repeated delays in showers because towels were unavailable. CNAs on both the 100 and 200 units said towels, washcloths, and wipes were often not available, sometimes leading staff to use sheets to clean residents. Laundry staff said clean linen was distributed several times a day, but there was no extra supply beyond what was in circulation, and the Housekeeping Director noted one dryer was broken.
Advance directive not implemented for a resident with cirrhosis, thrombocytopenia, COPD, and hepatic encephalopathy. The chart contained a signed DNR from the surrogate, but the resident remained listed as Full Code in the orders and the DNR form was not in the nurses’ station DNR book. Staff, including an LPN, SSD, and DON, confirmed the mismatch between the medical record and the DNR documentation.
Failure to protect residents from repeated sexual abuse: A resident with dementia and ongoing sexually inappropriate behaviors was not effectively monitored after an initial allegation, and the facility later allowed him continued access to other confused male residents. Staff reported missing 1:1/15-minute monitoring documentation, the care plan was not updated after the second incident, and two alleged victims were not promptly separated or fully assessed after the events.
A resident was struck by a motor vehicle while in a wheelchair during an LOA and was transferred by EMS for evaluation. The resident later reported stabbing pain and feeling scared and frightened about falling out of the chair. Record review showed no assessments were completed for several days around the incident, no progress notes were entered that day beyond a few nursing entries, and the skin assessment was delayed. Interviews with the SSD, DON, ADON, MD, and NHA confirmed staff did not complete the expected post-hospital return assessment, including VS, pain, skin check, and order review.
Two residents with complex medical conditions did not receive weekly skin checks as required by physician orders and care plans. Documentation in the EMR was incomplete, and staff interviews revealed a lack of consistent scheduling and follow-through for skin assessments. The facility's policy for weekly skin evaluations by licensed nurses was not adhered to, resulting in a deficiency in care.
Three residents with significant wounds and pressure ulcers did not receive timely or consistent wound care as ordered by physicians. Documentation showed delays in obtaining and implementing wound care orders, incomplete treatment records, and lack of wound care for some wounds. Nursing staff and the DON confirmed that required admission assessments and prompt physician notification for wound care were not consistently performed.
A resident's Nursing Admission Screening/History was left incomplete and blank at the time of admission, with essential assessment sections missing. Over a month after the resident's discharge, an LPN completed and locked the assessment at the request of the CNO, despite not having performed the original admission. The CNO confirmed this was not appropriate and that the facility lacked a specific policy for admission documentation.
Two residents in an LTC facility did not receive therapeutic diets as ordered by their physicians. One resident, at risk for aspiration, was given a mechanical soft diet instead of the required pureed diet due to a missing dietary change form. Another resident, who needed double portions for weight management, did not receive the correct meal portions. The facility lacked a policy for following meal tickets, leading to these deficiencies.
Two residents in a facility did not receive their prescribed therapeutic diets, leading to deficiencies in dietary services. One resident, requiring a pureed diet and double protein portions, was given a mechanical soft diet due to staff's lack of awareness of dietary changes. Another resident, needing double protein portions, received only a single portion despite the meal ticket indicating otherwise. The facility lacked a policy for ensuring dietary orders were followed, resulting in residents not receiving appropriate nutrition.
A CNA was witnessed abusing two residents, slapping them during care. The incident was not reported immediately due to fear, leaving other residents at risk. Both residents were non-verbal and dependent on staff for care. The facility's abuse prevention policy was not followed, leading to a failure to protect vulnerable residents.
A facility failed to report an incident of abuse by a CNA towards two residents in a timely manner. The residents, who were non-verbal and highly dependent on staff, were physically abused by the CNA, leaving a handprint on one. The incident was not reported immediately due to fear of retaliation, and the facility's policy for immediate reporting was not followed, leading to a significant deficiency.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including not reporting rashes to the health department, not changing a blood-stained pillowcase for a resident with a bloodborne pathogen, and not sanitizing a glucometer after use. The DON/IP was unaware of scabies treatment for residents, and infection control protocols were not followed during medication administration.
The facility failed to maintain a clean and safe environment, with observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Issues included petrified worms, brown and black stains, debris accumulation, and exposed wires on bed remotes. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the deficiencies, highlighting a failure to adhere to cleaning policies. Photographic evidence supported the findings, indicating a systemic issue affecting multiple areas.
The facility failed to ensure accurate accountability and storage of controlled medications in two medication carts. Discrepancies were found in the narcotic count, including loose pills and incorrect records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. A card for a discharged resident was also found. An LPN admitted to not signing out medications due to a hectic morning, and the DON was unaware of the issue, indicating a failure to follow facility policies on controlled substances and medication storage.
A facility reported a 28.57% medication error rate, with errors including incorrect dosages and improper medication handling. An LPN administered incorrect doses via a G-tube, and an RN crushed extended-release medications, mixing them with pudding. Another LPN failed to prime an insulin pen before use. Interviews confirmed these practices did not align with guidelines.
The facility failed to provide a dignified dining experience for three residents during assisted dining. A CNA was observed standing while assisting a resident with amyotrophic lateral sclerosis, despite a chair being available. Another CNA stood while feeding a resident and later sat on a resident's bed, citing a lack of chairs. The facility's policy emphasizes a dignified existence, which was not upheld.
A resident with a moderately impaired mental status was moved to a new room without prior notice or explanation. The facility failed to document the room change or communicate the reason to the resident, contrary to its policy requiring advance notice and documentation.
A resident with a shoulder wound did not receive wound care as per physician orders, resulting in missed treatments and lack of documentation. The resident's care plan did not address the wound, and staff confirmed the absence of documented treatments. The facility's policy required treatment per physician order, which was not followed.
The facility failed to properly store respiratory equipment for two residents, leading to unsanitary conditions. One resident's oxygen tubing was found on the floor, while another's tubing had not been changed as per physician orders. Staff interviews revealed a lack of understanding and absence of a policy for storing respiratory equipment.
The facility failed to properly store and secure medications, with unlocked cabinets and carts containing resident medications, unlabeled insulin pens, and loose pills. The DON struggled to secure the narcotic box due to key access issues, and medication carts were left unattended, violating facility policy.
A resident with amyotrophic lateral sclerosis, who was cognitively intact, was served green beans and spicy sausage despite documented dislikes. The CNA did not check the meal ticket for dislikes, and the resident was not offered an alternative. The CDM, DON, and NHA acknowledged the failure to follow the process for honoring meal preferences.
A facility failed to ensure hospice services were provided according to professional standards due to poor communication and documentation for a resident with advanced dementia. Despite a physician order for hospice care, there was no documentation in the resident's progress notes or care plan. Interviews revealed communication issues between facility staff and the hospice provider, with the DON noting a lack of documentation from the hospice nurse.
Missing Personal Items Not Returned or Replaced
Penalty
Summary
The facility failed to ensure residents’ right to retain and use their personal possessions for two residents with missing belongings. One resident in room 127W reported that staff had been told on several occasions that clothing, tennis shoes, and a blanket were missing; the resident stated the items had been labeled with the resident’s name using a black marker, but they were neither returned nor replaced. Another resident in room 111P also reported missing personal items to several facility staff members and had not received any resolution regarding the missing belongings. A review of the grievance log showed six grievances filed between 12/11/2025 and 05/01/2026 related to missing personal items, and the grievances documented that the residents’ items were neither returned nor replaced. During observation of the laundry room, several collections of clothing, shoes, and blankets without names were seen in a laundry cart, on a table near the dryers, and on a shelf; Staff A verified the items did not have name labels and said staff were unsure which residents they belonged to. The Social Services Director stated most grievances were related to missing items, and the Laundry Assistant said resident clothing was not delivered because resident linens and towels were the priority and unnamed clothing continued to accumulate in the laundry room. The Nursing Home Administrator stated unnamed clothing was donated about once per month, sometimes given to residents with fewer belongings, and occasionally taken to the activities room for residents to identify missing items.
Insufficient Nursing Staffing on Overnight Shift
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide adequate supervision and prevent accidents. On the 11 PM-7 AM shift, the East Unit had one CNA assigned to Rooms 100-128, the Reflections Unit had one CNA assigned to Rooms 200-210, and the [NAME] Unit had two CNAs assigned, including one CNA for a 1:1 resident and one CNA for Rooms 213-229. The facility’s Daily Staffing Form showed a census of 85 residents for that date. During interviews, three residents reported delays in care and said they had to rely on other residents for assistance because staffing was inadequate. One resident reported concerns about residents calling out for help without receiving a response, and all three residents stated that on the shift in question, residents asked other residents for help to avoid burdening the single CNA. The Staffing Coordinator confirmed the staffing assignments and stated attempts were made to staff the shift but staff declined to work. The DON stated the NHA was notified of the staffing shortage because approval was needed to offer bonuses to staff who might agree to work the shift, and also stated the facility does not use agency staffing.
Unsafe Resident Room Conditions Due to Nonfunctional A/C and Biological Growth
Penalty
Summary
Resident rooms in units 100 and 200 were not maintained in a safe, functional, and comfortable condition because multiple air-conditioning units were not operational, some room openings around replacement units were unsealed, and environmental contaminants were present in at least one unit. On 6/29/26, Resident #2 stated the room had been without working A/C since before admission, that the facility had provided a fan, and that the resident and family had added another fan because of the heat. By the end of the interview, the room temperature measured 87.8 degrees Fahrenheit. Resident #2’s record showed diagnoses including paraplegia, polyneuropathy, chronic pain, and traumatic brain injury, and the resident had a BIMS score of 15, indicating cognitive intactness. Staff interviews and observations showed the problem extended beyond one room. A CNA stated multiple rooms in the locked unit had similar A/C issues, and another CNA stated several resident rooms had not had working A/C for a while and that administration had known about the issue for months. Observations in the 200 hall identified nonfunctional A/C units in 10 resident rooms, with temperatures above 81 degrees Fahrenheit in multiple rooms, including rooms 206, 207, 216, 221, 222, 224, 225, and 229. The NHA and DON stated they were aware of A/C issues in only two rooms and said replacement units had been ordered. The report also documented environmental concerns within the room conditions. One A/C unit had visible biological growth inside it, and a large circular black area of biological growth was observed on the ceiling tile above the sink in a room occupied by a resident with documented respiratory concerns. The DOM stated replacement A/C units were smaller than the originals, leaving unsealed openings around the units that exposed residents to outside elements. The maintenance log contained no entries documenting malfunctioning A/C units in the 200 hall, and no completed room inspection checklists were available despite a preventative maintenance checklist requiring inspection of A/C units, thermostats, and filters.
Failure to Reassess Fall Interventions After Repeated Unwitnessed Falls
Penalty
Summary
The facility failed to reevaluate and reassess fall-prevention interventions for one resident with a history of encephalopathy, nontraumatic subarachnoid hemorrhage, unspecified symbolic dysfunctions, schizophrenia, and bipolar disorder. The resident’s care plan identified a risk for falls and fall-related injuries and included interventions such as a low bed, call bell in reach, assistance with transfers and ambulation, toileting, appropriate footwear, PT evaluation, a mat by the bed, medication review, q15-minute checks, and later use of a transfer/gait belt. However, after an unwitnessed fall with a head injury and bleeding, the care plan did not show updates or added interventions following that event. The resident had another unwitnessed fall shortly afterward and was found lying on the floor with bleeding to the right side of the head. First aid was provided, vital signs were obtained, and 911 was called for further evaluation and treatment. The DON stated she was not aware of the earlier fall and confirmed there was no change of condition documentation and no records from the CT scan or return to the facility. The Regional DON and NHA confirmed the earlier fall was not reviewed in the record, that care plan updates and added interventions were not present, and that the interdisciplinary team missed the earlier fall when reviewing the later event.
Insufficient Linen Supply on Resident Units
Penalty
Summary
The facility did not ensure an adequate supply of linens for residents on the 100 and 200 units. On 6/1/26, an observation of the linen closet on the 100 unit showed there were no towels or washcloths available. Resident #8 reported that there was a problem with having towels and washcloths, said the towels were very rough when available, and stated she often had to wait to shower because towels were not available. Resident #7 also reported that towels were not available for showers on multiple occasions and said it would be nice to have towels when showering. Staff interviews confirmed ongoing concerns with linen availability. A CNA stated residents often had to wait for showers until towels were available and that some residents asked to use sheets so they would not have to wait. Another CNA on the 200 unit said towels were intermittently available and wipes were often not available to clean residents. A CNA was observed searching the 100 unit linen closet and stated there were no towels or washcloths available and that it was always a problem. Laundry staff said clean linen was delivered about five times a day and divided between units based on need, but there was no extra supply of linens or towels beyond what was in circulation. The Housekeeping Director said he was responsible for ordering linen, washcloths, and towels and noted one dryer was broken and being repaired. The DON stated the facility did not have a policy regarding linens or supplies on the units.
Advance Directive Not Implemented
Penalty
Summary
The facility failed to ensure an advance directive was implemented as requested for one resident. The resident was admitted with diagnoses including cirrhosis of the liver, thrombocytopenia, COPD, and hepatic encephalopathy. The medical record contained an active Full Code order, while the record also included a signed DNR order completed by the resident’s healthcare surrogate. The DNR form was signed by the surrogate on 5/7/26, but it was not signed by a provider until 5/26/26. The DNR form was not present in the DNR books at the nurses’ stations, and staff interviews confirmed the resident was still listed as Full Code. An LPN stated she would check the resident’s orders and the DNR book to confirm code status and verified the resident had an active Full Code order with no DNR form in the book. The SSD reviewed the signed DNR and stated hospice completed the paperwork, but she did not know why there was a 19-day gap between signatures and said the form was not clearly tracked into the medical record and DNR book. The DON confirmed the resident did not have a signed DNR form in the DNR books and that the resident’s orders should have been updated.
Failure to Protect Residents From Repeated Sexual Abuse
Penalty
Summary
The facility failed to fully implement its abuse prevention policy by not preventing Resident #11 from further accessing alleged victims and by not implementing effective interventions to protect other residents from additional abuse. Resident #11 was admitted with dementia, mood disorder, major depression, and a right femur fracture, and records documented repeated sexually inappropriate behaviors, including grabbing, touching, and exposing himself to other male residents. He had a BIMS score of 11, indicating moderate impairment, and staff described him as wandering, confused, and fixated on male residents. The abuse prevention policy required timely and thorough investigations, review of abuse incidents, and implementation of changes to prevent further occurrences. After an initial incident in which Resident #11 allegedly groped Resident #12, both residents were placed on 1:1 supervision together in the same room. The care plan initiated for Resident #11 listed 1:1 supervision as much as possible, but it was not updated after the later incident on 5/22/26. Staff and leadership reported that 1:1 supervision was later discontinued and replaced with 15-minute checks, and the record review showed multiple missing entries on the 15-minute check sheets, including entire shifts and full days. The DON stated the missing documentation meant the monitoring did not happen, and the NHA acknowledged missing and falsified check sheets and stated he expected continuous eyes-on 1:1 supervision. A second incident occurred when a CNA observed Resident #11 in the wrong room with his private area exposed toward Resident #9. Resident #9 was severely cognitively impaired, mostly non-verbal, and unable to participate in an interview; family reported he had been moved to the secured unit for safety. Resident #12 was also confused and unable to recall the incident. The facility did not separate the residents after the first incident, and Resident #12 was not moved until 16 days later due to limited space, while Resident #11 was moved later as well. The DON stated the skin assessment for Resident #9 was not completed until four days after the incident and that assessments following allegations should occur immediately. Staff and the psych ARNP stated all three residents were severely impaired and that psychosocial impact was difficult to determine.
Failure to Assess and Monitor Resident After Motor Vehicle Incident
Penalty
Summary
The facility failed to assess and monitor a resident after an off-campus incident in which the resident was struck by a motor vehicle while seated in a wheelchair in a store parking lot across from the facility. The resident reported that the car hit the side of the wheelchair while the resident was holding the wheelchair frame, and the resident was transferred by emergency services to an acute care facility for examination and testing. When later observed in the room, the resident was alert and oriented and reported having intermittent stabbing pain and feeling scared, nervous, and frightened about potentially falling out of the chair. Record review showed the resident was admitted with diagnoses including type 2 diabetes mellitus with diabetic autonomic neuropathy and intervertebral disc degeneration with lumbar discogenic back pain and lower extremity pain. Nursing documentation noted the resident signed out on leave of absence to go to the store, was struck by a motor vehicle, and later returned with a note that CT results showed no pelvic fracture. The record also showed pain medication was given on the day of the incident, but no other progress notes were completed that day by any staff member. The review further showed no assessments were completed for the resident from three days before the incident through four days after the incident, and the skin evaluation was not completed until four days after the incident. Interviews with the SSD, DON, ADON, MD, and NHA confirmed that the resident could have experienced trauma from the accident and that staff did not complete assessments after the resident returned. The DON stated staff should complete a re-admission assessment when a resident returns from the hospital, including vital signs, pain evaluation, skin assessment, verification of medical orders, and notification of family and physician, but also stated the nurses did not do a skin assessment upon the resident's return. The ADON reported there were no assessments done on the day of or the day after the incident, and the NHA stated staff should be doing an assessment when a resident comes back from the hospital after being hit by a car.
Failure to Complete and Document Weekly Skin Checks for Two Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion of weekly skin checks for two residents. For one resident with multiple diagnoses including vascular dementia, chronic kidney disease, and diabetes, physician orders required weekly skin checks. However, review of the electronic medical record revealed only one documented skin evaluation during the resident's stay, despite the presence of scratches and dried blood on the arms. Additionally, there was no care plan addressing skin integrity or weekly skin checks for this resident. Interviews with nursing staff and the acting DON confirmed that weekly skin checks were not performed or documented as required. For another resident with diagnoses such as osteomyelitis, hepatitis B, and septic pulmonary embolism, the care plan included weekly skin checks due to impaired or at-risk skin integrity. Despite this, the medical record showed only one skin evaluation, and there was no evidence of a weekly skin assessment schedule or documentation of skin checks for this resident. Staff interviews revealed that the unit did not have a weekly skin assessment schedule in place, and the DON acknowledged the missing assessment, stating that a provider's note was being counted as a skin assessment, although this did not meet the facility's policy requirements. The facility's policy required licensed nurses to complete and document weekly skin evaluations for all residents. Observations, interviews, and record reviews demonstrated that this policy was not consistently followed, resulting in a failure to provide care and treatment according to physician orders, resident care plans, and professional standards of practice for the two residents involved.
Failure to Provide Timely and Consistent Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide appropriate wound care treatment and follow physician orders for three residents who were admitted with significant skin and wound care needs. For one resident, the admission records and physician documentation indicated multiple skin tears and wounds requiring specific dressing changes and wound care regimens. However, the treatment administration record showed that wound care orders were not implemented upon admission, and wound care was only documented once during the resident's stay. The resident's responsible party also reported that wound care was not provided consistently. Another resident was admitted with multiple pressure ulcers and wounds, including stage IV pressure areas and an unstageable wound. Physician orders and wound care consults were documented, specifying daily wound care treatments for several sites. Despite this, the facility's records lacked documentation of wound care being provided until several days after admission, and initial orders did not cover all identified wounds. The nursing admission assessment confirmed the presence of multiple wounds, but corresponding treatment orders were incomplete or delayed. A third resident was admitted for wound care with several unstageable pressure ulcers documented on admission forms and nursing assessments. Despite the clear need for wound care, the facility's records did not contain any wound care orders for this resident. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required prompt skin assessments and obtaining physician orders for treatment upon admission, but this process was not followed for these residents. The Director of Nursing acknowledged that the facility's expectations for wound care assessment and treatment were not met in these cases.
Incomplete and Late Documentation of Admission Assessment
Penalty
Summary
The facility failed to ensure that medical records were completed and accurate for one resident out of three sampled. Upon review, the Nursing Admission Screening/History for a resident admitted from the hospital and later discharged was found to be blank except for auto-populated vital signs. Key sections such as admission details, neurological status, social history, physical assessments, and medication information were not documented at the time of admission. The assessment remained incomplete and unlocked in the electronic medical record system until more than a month after the resident's discharge. On the day of the survey, a staff LPN/Unit Manager completed and locked the previously blank assessment at the request of the Chief Nursing Officer (CNO) to print the document. The LPN admitted to filling out the assessment despite not having performed the original admission, and the CNO confirmed that this was not appropriate practice. The CNO also acknowledged that the facility did not have a specific policy for documentation of admission assessments, and that documentation should have been completed within 72 hours of admission, not after discharge.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet according to physician orders for two residents, leading to deficiencies in their care. Resident #1, who was admitted with medical diagnoses including cerebral infarction and dysphagia, was observed not receiving the appropriate pureed diet and thickened liquids as ordered. Despite the speech therapist's recommendation to downgrade his diet to pureed due to aspiration risk, the dietary manager was unaware of the change, resulting in Resident #1 receiving a mechanical soft diet instead. This miscommunication was attributed to a missing dietary change form, which was not properly processed in the dietary system. Resident #25, who was supposed to receive double portions of protein due to weight loss, did not receive the correct meal portions as per his dietary orders. During a lunch observation, it was noted that he received only one Salisbury steak patty instead of the double portion indicated on his meal ticket. The facility's Registered Dietician confirmed the oversight and acknowledged that the meal ticket was not followed, which should have been caught by the tray line staff. The lack of adherence to the meal ticket resulted in Resident #25 not receiving the necessary nutritional support to address his weight loss. The facility's dietary management process was found to be lacking, as there was no policy or procedure in place for following and honoring meal tickets and diets. The dietary staff, including the cook and dietary aide, were unable to explain how the errors occurred, indicating a systemic issue in the meal service process. The absence of a structured protocol for ensuring dietary orders are accurately followed contributed to the deficiencies observed in the care of both residents.
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 resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increased in decrease in SPO2 noted. No. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service (205). (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 completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order and residents receive double portions/2x entrees. Quality review completed by the DON/designee ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket and residents receive double portions/2x entrees. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee regarding ensuring residents receive snacks upon request to be completed. (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; Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice 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 then quarterly and PRN as indicated and modified based on findings.
Failure to Provide Therapeutic Diets as Prescribed
Penalty
Summary
The facility failed to provide therapeutic diets according to physician orders for two residents, leading to deficiencies in dietary services. Resident #1, who was admitted with medical diagnoses requiring a specific diet, did not receive the prescribed pureed texture and double portion protein/entrée at each meal. During an observation, Resident #1 was given a mechanical soft diet instead of the required pureed diet, and staff were unaware of the resident's dietary needs. The Dietary Manager was not informed of the diet change, resulting in the resident receiving incorrect meal portions. Resident #25 also did not receive the prescribed double portions of protein as indicated in the physician's orders. Despite the meal ticket specifying double portions, the resident received only one patty of Salisbury steak instead of two. The Registered Dietician confirmed that the resident should have received double portions due to previous weight loss and the need for increased nutritional intake. The facility's dietary staff failed to follow the meal ticket instructions, leading to the resident not receiving the necessary dietary support. The facility lacked a policy and procedure for following and honoring meal tickets and diets, contributing to the oversight in providing the correct meals to residents. The dietary staff, including the Cook and Dietary Aide, were unable to explain how the error occurred, indicating a lack of communication and oversight in the dietary service process. The absence of a structured protocol for ensuring dietary orders are followed resulted in residents not receiving the appropriate nutrition as prescribed by their physicians.
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 resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increase in or No decrease in SPO2 noted. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service. (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 completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order, and residents receive double portions/2x entrée. Quality review completed by the DON/designee r/t ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket, and residents receive double portions/2x entrée. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions, or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee r/t ensuring residents receive snacks upon request to be completed. (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: Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice 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 then quarterly and PRN as indicated and modified based on findings.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by a staff member, Staff J, CNA, towards two residents, Resident #11 and Resident #12. On December 20, 2024, Staff J was witnessed by another CNA, Staff I, slapping the residents on their legs, sides, and buttocks during care. Despite witnessing the abuse, Staff I did not report the incident until three days later, leaving other residents at risk of further abuse. The delay in reporting was attributed to Staff I's fear of being targeted due to past personal trauma. Resident #11, who was admitted with severe intellectual disabilities, quadriplegia, epilepsy, legal blindness, scoliosis, and gastrostomy status, was non-verbal and dependent on staff for all care needs. Resident #12, with a history of traumatic brain injury, psychosis, and muscle weakness, was also non-verbal and required substantial assistance for mobility and hygiene. Both residents were placed on 15-minute checks following the delayed report of abuse, as indicated by a sign observed in the facility. Interviews with facility staff revealed a culture of fear and reluctance to report abuse, as evidenced by Staff K, Door Monitor, who had previously witnessed Staff J's abusive behavior but did not report it. The Nursing Home Administrator confirmed the incident and stated that Staff J was suspended and later terminated. The facility's abuse prevention policy, which mandates immediate reporting and thorough investigation of abuse, was not adhered to, resulting in a failure to protect vulnerable residents from harm.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an incident of verbal and physical abuse by a Certified Nursing Assistant (CNA) towards two residents. The incident involved Staff J, CNA, who was reported to have been rough and abusive while assisting with the care of two residents. Staff I, CNA, who was present during the incident, reported that Staff J slapped the residents multiple times, leaving a handprint on one of them. Despite witnessing the abuse, Staff I did not report the incident immediately due to fear of retaliation, and the incident was only reported to the Nursing Home Administrator (NHA) three days later. The residents involved in the incident had significant medical conditions and were highly dependent on staff for their care. One resident had severe intellectual disabilities, quadriplegia, and was legally blind, while the other had severe cognitive impairment and required substantial assistance for mobility and hygiene. Both residents were non-verbal, making them particularly vulnerable to abuse. The delay in reporting the incident meant that the abuse was not addressed promptly, potentially compromising the residents' safety and well-being. The facility's policy required immediate reporting of any suspected abuse to management, but this protocol was not followed. Staff I, CNA, initially attempted to inform a nurse but was unsuccessful and instead reported the incident to a door monitor, who corroborated the abusive behavior of Staff J. The NHA was eventually informed of the incident, and law enforcement and state agencies were notified. However, the delay in reporting and the failure to adhere to the facility's abuse reporting policy constituted a significant deficiency in the facility's operations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to report rashes affecting four residents to the local health department and to ensure appropriate testing for a possible contagious epidermal condition. The Director of Nursing/Infection Preventionist (DON/IP) was unaware that the residents were being treated with medication for scabies, and the facility did not track these cases on their infection map. The DON/IP admitted to not reporting the rashes because they were not classified as scabies, despite the residents receiving treatment for it. Another deficiency involved a resident with a bloodborne pathogen who had a blood-stained pillowcase that was not changed promptly. Observations revealed that the pillowcase remained stained with blood for an extended period, posing an infection control concern. Interviews with the Nursing Home Administrator (NHA), DON/IP, and staff confirmed that the blood-stained linen should have been changed immediately to prevent infection risks. Additionally, the facility did not adhere to infection control practices during medication administration. A Licensed Practical Nurse (LPN) was observed placing a glucometer back into the medication cart without cleaning or sanitizing it after use. The DON/IP confirmed that glucometers should be cleaned with bleach wipes after each use, but this protocol was not followed. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Observations revealed the presence of petrified worms and lizards, brown and black stains on floors and walls, and significant debris accumulation in various locations. Bathrooms were particularly affected, with brownish stains and buildup on toilets, sinks, and floors, as well as cracked and uncleanable surfaces. The presence of exposed wires on bed remotes further highlighted the unsafe conditions. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the unsatisfactory state of cleanliness and safety in the facility. The Maintenance Director acknowledged the need for cleaning rather than just floor maintenance, while the Nursing Home Administrator admitted awareness of the need to replace non-cleanable surfaces and ensure daily cleaning of resident rooms. Despite having policies in place for cleaning procedures, the facility failed to adhere to these standards, resulting in the observed deficiencies. The report includes photographic evidence of the unsanitary conditions, reinforcing the findings. The facility's failure to provide a clean and safe environment compromised the residents' right to a homelike setting, as mandated by regulations. The observations spanned several days, indicating a systemic issue rather than isolated incidents, and involved multiple resident rooms, bathrooms, and common areas, underscoring the widespread nature of the problem.
Controlled Medication Discrepancies in Medication Carts
Penalty
Summary
The facility failed to ensure accurate accountability and storage of controlled medications in two out of three medication carts inspected. During an observation, discrepancies were found in the narcotic count of the East Wing Carts 1 and 2. Specifically, there was a loose pill in the narcotic box, and several discrepancies in the controlled substance records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. Additionally, a card containing Tramadol tablets was found for a resident who had already been discharged, indicating a failure to remove discharged narcotics from the cart. Interviews with staff revealed that the LPN responsible for the medication carts admitted to not signing out medications when administered due to a hectic morning. The LPN also stated that discharged narcotics should have been removed, but this task was overseen by the DON, who was unaware of the narcotic medication card from a discharged resident. The facility's policies on controlled substances and medication storage require compliance with laws and regulations, including immediate documentation after administration and secure storage of medications, which were not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 28.57% based on observations of medication administration. During the survey, 35 medication administration opportunities were observed, resulting in ten errors involving four residents. These errors included incorrect dosages, failure to follow proper medication administration procedures, and inappropriate handling of medications. One incident involved a Licensed Practical Nurse (LPN) administering medications to a resident with a gastric tube. The LPN dispensed 5 mL of Levetiracetam instead of the prescribed 10 mL and failed to administer Ferrous Sulfate and Calcium as ordered via the PEG-Tube. Another error was observed when a Registered Nurse (RN) failed to administer Thiamine HCl to a resident as per the medication administration record. Additionally, the RN crushed extended-release medications, which is contraindicated, and mixed them with pudding for another resident. Further errors were noted when an LPN did not prime an insulin pen before administering insulin to a resident, contrary to the manufacturer's instructions. Interviews with the Director of Nursing, Medical Director, and Pharmacist confirmed that the facility's practices did not align with proper medication administration guidelines, contributing to the high error rate.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during assisted dining. Resident #8, diagnosed with amyotrophic lateral sclerosis, required staff assistance with eating. On a specific day, a CNA was observed standing while assisting the resident with their meal, despite a chair being available in the room. The CNA acknowledged the oversight and mentioned having received education on the proper procedure, which involves sitting at eye level with the resident during meal assistance. Both the Director of Nursing and the Nursing Home Administrator confirmed that the expectation was for staff to sit at eye level when assisting residents with meals. Additionally, Resident #3 was observed being fed by a CNA who was standing, and Resident #27 was assisted by a CNA who initially stood and then sat on the resident's bed, which is against protocol. The CNA admitted to sitting on the bed and cited a lack of available chairs as the reason. The facility's policy on Resident Rights emphasizes the importance of a dignified existence and being treated with respect, which was not upheld in these instances.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to honor a resident's right to receive written notification for a room change before the change was made. Resident #51, who had a moderately impaired mental status with a BIMS score of 11, was moved from her original room to a new room without prior notice or explanation. The resident expressed confusion about the move, stating she was not given an opportunity to see the new room or understand the reason for the change. The facility's records showed no documentation regarding the move or the reason for the room change. Interviews with facility staff revealed a lack of communication and documentation regarding the room change. The Social Services Director stated that the process for a room change involves notifying the resident and their representative, but there was no documentation in the room change binder. The Director of Nursing admitted to moving the resident without informing her of the reason, as he was waiting for information from the Health Department. The facility's policy requires advance notice and documentation of room changes, which was not followed in this instance.
Failure to Provide Wound Care Per Physician Orders
Penalty
Summary
The facility failed to provide wound care according to physician orders for a resident with a wound on the right shoulder. Observations revealed blood stains on the resident's pillow, and the resident confirmed the stains were from her shoulder wound. The wound was described as red, raw, and bloody, and was open to the air. The resident had a history of chronic viral hepatitis C, anoxic brain damage, seizures, anxiety disorder, obsessive-compulsive disorder, and bipolar disorder, with a moderate cognitive impairment score. The facility's Treatment Administration Record (TAR) showed missed wound care treatments on several occasions, specifically on the 19th, 20th, and 23rd of the month. The care plan did not include any focus, goals, or interventions for the resident's shoulder wound. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the absence of documented treatments and the lack of a current care plan addressing the wound. The facility's policy required treatment per physician order with documentation in the medical record, which was not followed. The attending physician expected the nurses to adhere to the wound care orders, and the wound physician recommended covering the wound with a hydrocolloid dressing. However, the facility did not consistently apply the dressing or document the care provided, leading to the deficiency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the proper storage of respiratory equipment for two residents, leading to unsanitary conditions. Resident #34's oxygen tubing was observed on her bedside table and the floor, not stored in a sanitary manner. The resident, who uses oxygen as needed due to morbid obesity, expressed a need for oxygen during the observation. The care plan for Resident #34 indicated the need for oxygen therapy related to obesity, with specific interventions for monitoring and documenting respiratory distress. Interviews with staff revealed that the tubing and cannula should be stored in a bag when not in use, but there was no policy in place regarding the storage of respiratory equipment. Resident #39 was observed with oxygen tubing connected to an oxygen concentrator, with a piece of tape dated 9/16/2024, indicating the tubing had not been changed as per the physician's order. The facility's policy required oxygen tubing to be changed weekly or as needed when soiled. Staff interviews confirmed the tubing change process was not clearly understood, contributing to the deficiency. The lack of adherence to the facility's policy and physician orders for changing and storing respiratory equipment resulted in unsanitary conditions for both residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications in several areas, including the East medication storage room, Reflection Hallway treatment cart, and multiple medication carts. During observations, a cabinet in the Reflection Hallway was found unlocked with a resident's prescribed medication inside. Staff D, LPN/UM, acknowledged the cabinet should be locked but could not explain why the medication was there. Additionally, a PPE storage bin outside resident rooms contained an open box of Hydrocortisone Acetate 1% Cream packets. In the East Wing medication storage room, the narcotic box inside the refrigerator was unlocked, and the Director of Nursing (DON) struggled to find the correct keys to secure it, revealing that only one nurse, who works infrequently, had access to the keys. Further observations revealed issues with medication carts. The East Cart 2 had two unlabeled insulin pens and a loose pill in the narcotic box. Staff H, LPN, confirmed these items should be labeled and the loose pill destroyed. The cart's surface was also found with a liquid and white powdered substance. In the [NAME] Wing, Staff I, RN, found loose pills in the medication cart's drawer, which were not supposed to be there. Additionally, East Cart 2 was left unlocked and unattended, with numerous staff and residents passing by, until the Nursing Home Administrator intervened. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts not be left unattended, which was not adhered to in these instances.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor meal preferences for a resident with a primary diagnosis of amyotrophic lateral sclerosis, who was on a regular diet with pureed texture and nectar/mild thick consistency. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a documented dislike for green beans. Despite this, the resident was served green beans during lunch, which was confirmed by both the resident and Staff A, a Certified Nursing Assistant (CNA). The resident also expressed a dislike for the spicy sausage served and was not offered an alternative meal option. Interviews with Staff A, the Certified Dietary Manager (CDM), the Director of Nursing (DON), and the Nursing Home Administrator (NHA) revealed a breakdown in the facility's process for honoring meal preferences. Staff A admitted to not checking the resident's meal ticket for dislikes and failing to offer an alternative. The CDM acknowledged that the process to identify disliked items was not followed, resulting in the resident being served an unwanted meal. Both the DON and NHA confirmed that the resident should have been offered an alternative meal, and the dietary staff should have adhered to the resident's documented meal preferences.
Lack of Communication and Documentation in Hospice Services
Penalty
Summary
The facility failed to ensure hospice services were provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for a resident. The resident, who was re-admitted with early onset Alzheimer's disease and other co-morbidities, had a physician order for hospice care due to advanced dementia. However, there was no documentation of hospice services in the resident's progress notes or care plan, despite the Minimum Data Set indicating hospice care was being given. Interviews with facility staff revealed communication issues between the facility and the hospice provider. The Registered Nurse stated that communication with hospice only occurred if there was a change in the resident's condition. The Director of Nursing (DON) mentioned that the hospice nurse did not check out with her or leave any notes, which was a consistent problem. The facility's policy required a coordinated plan of care with hospice, including communication and documentation, which was not followed in this case.
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What surveyors actually found near you
We read the 317 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dunedin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowpark Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 8 | 0 |
| Aviata At Lakeside Oaks | 0.8 mi | ★★★★★ | 3 | 0 |
| Willowbrooke Court Skilled Care Center At Mease Li | 0.9 mi | ★★★★★ | 0 | 0 |
| Aviata At Sand Key | 2.5 mi | ★★★★★ | 0 | 0 |
| Regency Oaks Health Center | 3.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.