Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crossings At East Lake Of Journey Llc, The during CMS and state inspections, most recent first.
The facility failed to implement an effective infection prevention and control program, including Enhanced Barrier Precautions (EBP). A CNA provided hygiene care and a brief change to a resident with multiple wounds and a feeding tube without donning a gown, despite posted EBP signage and available PPE, stating she did not believe EBP was required. The IP could not provide evidence of ongoing infection surveillance audits beyond a few peri care/hand washing audits from a single month and was unaware that routine surveillance auditing was required. The DON reported that only informal walk‑throughs occurred, with no formal, documented infection control audits, and could not produce any CNA infection control competency checkoffs for practices such as hand hygiene and PPE use, contrary to facility policies requiring surveillance, staff training, and demonstrated competency.
A resident with multiple chronic conditions, intact cognition, and high ADL dependence was found using a deflated specialized air mattress while lying directly on the metal bed frame. Staff were aware the mattress had been broken and attempted to fix it, but the resident reported ongoing pain and said she was not offered another mattress or bed while waiting for repair parts. The DON acknowledged the resident should have been offered another mattress, and the issue persisted across multiple observations.
PASARR Level II reviews were not submitted for two residents with qualifying mental health diagnoses. One resident had PTSD, depression, suicidal ideations, anxiety, and psychotropic medication use, while the other had PTSD and major depressive disorder with mood symptoms and antidepressant use. SS stated both residents were not on the PASARR list and later confirmed each had diagnoses that qualified for PASARR Level II, but the reviews had not been submitted.
Failure to Provide Needed Grooming and Nail Care: A resident with multiple chronic conditions and moderate cognitive decline required maximal ADL assistance, including personal hygiene and nail care. Surveyors observed the resident’s fingernails repeatedly remained long, unkempt, and dirty with black/dark brown buildup underneath, and the resident stated the nails had not been cleaned or cut for over a month. The DON confirmed the condition, and a CNA said she had not recently provided nail care and did not report the issue to the nurse.
Accessible Clothes Iron Found in Resident Room: Surveyors found a plugged-in clothes iron on a windowsill next to a resident’s bed in a room on a unit with wandering residents. The resident had hemiplegia, epilepsy, weakness, and other diagnoses, and his care plan identified risks related to mobility, seizures, and unsafe hazards. The resident said he used the iron to press clothes on his bed and that staff knew about it, while an LPN and the DON said they were unaware of the iron in the room.
A resident who required mechanical lift transfers with two staff, as documented in their care plan, was transferred by a CNA without the lift or a second staff member, resulting in the resident sliding to the floor. The resident was not injured and attributed the incident to wearing socks. Review of records and staff interviews confirmed the care plan was not followed at the time of the event.
Staff did not follow the RD's order for continuous tube feeding for a resident with severe dysphagia and cognitive impairment, instead holding the feeding for four hours daily without a current order to do so. This practice was confirmed by staff interviews and observation, despite the current order specifying continuous feeding with only a one-hour stop for residual checks.
Two residents with severe cognitive impairment and feeding tubes did not receive care under Enhanced Barrier Precautions as required by their care plans. Staff provided care without using appropriate PPE or posting necessary signage, and some staff were unaware of the EBP requirements.
The facility failed to maintain an effective pest control program, resulting in a roach infestation in several resident rooms. Observations and resident interviews confirmed the presence of roaches, with pest sighting logs documenting numerous reports. Pest control technician reports highlighted sanitation issues, noting that areas such as nurses' desks and resident dresser drawers were not adequately cleaned, contributing to the persistence of the problem.
The facility failed to ensure call lights were accessible for two residents, leading to potential delays in assistance. One resident with aphasia and muscle weakness had the call light on the floor, while another with Parkinson's and contractures was unable to reach the call light due to its improper placement. Staff interviews confirmed the call lights should have been accessible, but inconsistencies in staff understanding and a lack of policy contributed to the deficiency.
A resident with a history of cerebrovascular accident and other medical conditions was not assisted back to bed for a nap despite expressing the desire to do so. The CNA preferred to wait until after lunch to avoid multiple transfers, which contradicted the resident's right to make personal choices as outlined in the facility's guidelines. Interviews with staff confirmed the resident's right to decide when to lie down was not honored.
A facility failed to accurately code a fall with major injury on the MDS for a resident who had a history of fractures. The resident sustained a fall while attempting to get out of bed without assistance, resulting in a proximal fracture to the left tibia, which required hospitalization. The fall was not documented in the quarterly MDS assessments, as confirmed by the MDS Coordinator.
A facility failed to revise a care plan for a resident with a history of CVA and contractures, as it did not address refusals of restorative care, including splint use, nor document alternative interventions. Observations showed the resident not wearing prescribed splints, and staff interviews confirmed the lack of documentation of refusals in the care plan prior to the survey.
The facility failed to provide adequate ADL care for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with diabetes and vision impairment had long, dirty fingernails causing discomfort, while another with Parkinson's disease had unkempt nails despite expressing discomfort. A third resident did not receive regular showers, leading to dry, scaly skin. Staff interviews revealed inconsistencies in care and documentation, contributing to unmet hygiene needs.
A facility failed to provide consistent restorative services for a resident with moderate cognitive impairment who required substantial assistance with daily activities. Despite physician orders for splints to increase range of motion and prevent contractures, there was no documentation of the resident receiving these services. Observations confirmed the resident was not wearing the prescribed splints, and staff interviews revealed a lack of awareness or documentation regarding the resident's restorative care needs. The Director of Nursing acknowledged the oversight but could not provide documentation due to system issues.
The facility failed to lock medication carts on the 100-Hall and 200-Hall during administration, leaving them unattended and accessible. Additionally, expired medications were found in carts on the 100-Hall and 500-Hall, including iron tablets and aspirin. Staff interviews confirmed these practices violated facility policies, potentially leading to medication errors and adverse resident outcomes.
A facility failed to document restorative nursing services for a resident with a history of CVA and contractures, as required by their policy. Despite physician orders and therapy recommendations for passive ROM exercises and splint application, no documentation was found in the resident's medical records. Interviews with staff confirmed the absence of records, citing system acquisition issues during a transition from previous ownership as a contributing factor.
A facility failed to adhere to its hand hygiene policy during wound care for a resident with a stage 4 pressure ulcer. The Wound Care Nurse did not sanitize her hands between glove changes, contrary to the facility's guidelines. The resident, who had intact cognition, was at risk of infection due to this oversight. Interviews with the Unit Manager and DON confirmed the breach in protocol.
Failure to Implement Effective Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program as required by its own policies. The facility’s Infection Prevention and Control Program policy required a system of surveillance for prevention, identification, reporting, investigation, and control of infections for residents, staff, volunteers, visitors, and others, with the Infection Preventionist (IP) responsible for leading surveillance activities, maintaining documentation, and reporting findings to the Quality Assessment and Assurance Committee. The policy also required that all staff receive training on the infection prevention and control program and demonstrate competence in relevant infection control practices. The Infection Preventionist policy required development and implementation of an ongoing infection prevention and control program and oversight of resident care activities. The Enhanced Barrier Precautions (EBP) policy required staff training on EBP, high‑risk activities, and organisms requiring EBP; obtaining EBP orders for residents with wounds and/or indwelling medical devices such as feeding tubes; making gowns and gloves available outside resident rooms; and periodic monitoring of adherence. Despite these policies, the IP was unable to provide documentation of ongoing infection surveillance audits or staff competency validations for the previous 12 months, producing only nine peri care/hand washing audit tools from a single month and stating she had not been auditing staff or was aware that routine surveillance auditing was required. The DON similarly reported that no formal infection control audits were conducted and could not produce any CNA infection control competency checkoffs. In addition to the lack of surveillance and competency documentation, staff failed to follow EBP requirements during direct resident care. A CNA provided hygiene care, including a brief change, to a resident who had multiple wounds and was receiving tube feeding, conditions that met the facility’s criteria for EBP, without donning a gown despite posted signage on the resident’s door and PPE available outside the room. The CNA confirmed she did not wear the required gown and stated she believed the resident did not have a condition requiring EBP precautions. The IP later stated she expected staff to wear PPE when providing direct contact with a resident on EBP, and the DON stated his expectation was that staff follow established protocols and use PPE as required, but acknowledged that leadership only conducted informal walk‑throughs without formal, documented infection control audits. These observations, interviews, and record reviews showed failures in consistent PPE use under EBP, failure to conduct required infection surveillance audits, and absence of documented staff infection control competency validation.
Deflated Specialized Mattress Not Replaced or Temporarily Substituted
Penalty
Summary
The facility failed to ensure that one of 16 residents, R39, had a properly functioning air mattress while using a specialized mattress. R39’s diagnoses included schizoaffective disorder, bipolar type, chronic respiratory failure with hypoxia, morbid obesity with alveolar hypoventilation, obstructive sleep apnea, chronic pain syndrome, dependence on supplemental oxygen, depression, insomnia, PTSD, and chronic pain. Her quarterly MDS showed a BIMS score of 15, maximum assistance needed for all ADLs, and risk for pressure ulcers/injuries. Her care plan addressed assistance with ADLs, pressure reducing cushion to wheelchair, and weekly skin assessments. R39 told surveyors that her air mattress had been broken since 1/9/2026 and that staff could not fix it. She stated she was in a lot of pain because the mattress was deflated and she was resting on the metal base of the bed. She said staff were aware immediately, that recreation staff had tried to fix it without success, and that she was told no one could look at it until Monday. She denied being offered another bed or mattress while the mattress remained broken. Observations on 1/12/2026 and 1/13/2026 showed R39 still lying on the deflated air mattress with no barrier between her and the metal frame. She again said she had not been offered a temporary mattress and reported back pain, requesting pain medication. The Activities Director said she had been informed on 1/9/2026 and had tried to fix the mattress without success, then informed nursing staff again when R39 complained of pain. The DON stated he was made aware on 1/11/2026, had been in communication with the rental company, and admitted R39 should have been offered another mattress. The Administrator and DON later stated the part did not arrive and the company had something similar available, and the DON said they convinced R39 to use the rental until her regular mattress became available.
PASARR Level II Reviews Not Submitted for Two Residents
Penalty
Summary
The facility failed to ensure PASARR Level II reviews were submitted for two residents, R3 and R69, who had diagnoses that qualified them for PASARR review. The facility policy stated that residents with a mental disorder, intellectual disability, or related condition are to be screened in accordance with Medicaid screening rules, and that a positive Level I screen requires a PASARR Level II evaluation prior to admission. For residents not screened due to an approved exception and remaining in the facility longer than 30 days, the Level II resident review must be completed within 40 calendar days of admission. R3’s record showed diagnoses including PTSD, depression, persistent mood disorder, suicidal ideations, and generalized anxiety disorder. His quarterly MDS showed a BIMS score of 13 and active diagnoses including anxiety disorder, malnutrition, and PTSD. His care plan documented behaviors related to suicidal ideations, depressed mood, sadness about being away from family, and thoughts of suicide without a plan. Physician orders included mirtazapine for generalized anxiety and insomnia and hydroxyzine for anxiety. Social Services stated R3 was not on the PASARR list, and after reviewing the record confirmed that he had diagnoses that qualified for PASARR Level II, but it had not been submitted. R69’s record showed diagnoses including PTSD and major depressive disorder. His quarterly MDS showed a BIMS score of 15, mood symptoms including little interest or pleasure, feeling down or hopeless, sleep disturbance, and low energy, with no behaviors exhibited. His active diagnoses included depression and PTSD, and his medication orders included trazodone for insomnia/depression and escitalopram for depression. Social Services stated there was no PASARR Level II for R69 because she was not aware of his PTSD diagnosis, and later confirmed that he did have a diagnosis that qualified for PASARR Level II, but it had not been submitted. R69 stated he would benefit from additional services.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to ensure that R13, a resident unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. R13’s diagnoses included peripheral vascular disease, longstanding persistent atrial fibrillation, chronic kidney disease stage 3, type 2 diabetes mellitus without complications, heart failure, acquired absence of the left leg below knee, chronic obstructive pulmonary disease, cognitive communication deficit, depression, and need for assistance with personal care. The quarterly MDS showed a BIMS score of 9, indicating moderate cognitive decline, and documented that R13 required maximal assistance with all ADL care needs. The care plan identified that he required assistance with ADLs, including personal hygiene, nail care PRN, and staff assistance with completion of ADLs on a daily basis. During observation, R13 was noted to have fingernails with a buildup of black/dark brown substance under each nail, and the nails were long and unkempt. R13 stated it had been over a month since the nails were cleaned or cut and that they needed cutting. Subsequent observations on the following days showed the fingernails had not been addressed and remained dirty, long, and uneven with black/dark brown substance packed underneath each nail on both hands. The DON observed the condition and confirmed the findings, stating there was no reason for it to be like this and that he would take care of it immediately. A CNA later stated that R13 had occasionally requested nail cleaning and cutting, that she had done it in the past but not recently, and that she did not report the issue to the nurse.
Accessible Clothes Iron Found in Resident Room
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards when a plugged-in clothes iron was found in R85’s room on a windowsill next to his bed. R85 was admitted with diagnoses including right-sided hemiplegia and hemiparesis following cerebral infarction, epilepsy with unspecified convulsions, aphasia and fluency disorder following cerebral infarction, generalized muscle weakness, and major depressive disorder. His quarterly MDS showed a BIMS score of 15, indicating he was cognitively intact, and Section GG showed he was impaired to one side and required supervision or touching assistance with ADLs. R85’s care plan identified risks related to decreased mobility, need for staff assistance with ADLs, seizure disorder, communication impairment, fall risk, and smoking-related hazards, with interventions including assistance with ADLs, seizure precautions, and maintaining a safe environment. Despite this, survey observations confirmed the iron remained in the room and was accessible to the resident. R85 stated that the iron was functional and that he used it to iron clothes on top of his bed, and he also stated that staff were aware of the iron. An LPN denied awareness of the iron in the room, and the DON stated he was not aware that R85 had a clothes iron in his room.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident requiring mechanical lift transfers with assistance from two staff members. According to the resident's care plan, mechanical lift transfers with two staff were required for all transfers. However, during a transfer from wheelchair to bed, a certified nurse aide (CNA) did not use the mechanical lift or a second staff member, resulting in the resident sliding to the floor. The resident attributed the incident to wearing socks and reported no pain or injury, denying hitting their head. Review of facility records and staff interviews confirmed that the care plan intervention for mechanical lift with two staff was in place at the time of admission and not followed during the incident.
Failure to Follow Tube Feeding Orders for Resident with Severe Dysphagia
Penalty
Summary
Staff failed to follow the registered dietician's (RD) nutrition orders for a resident with spastic quadriplegia cerebral palsy who was receiving nutrition via both a gastrostomy and jejunostomy tube due to severe dysphagia and cognitive impairment. The RD's order specified that the resident should receive Osmolyte 1.5 continuously at 32ml/hour via the jejunostomy tube, with a one-hour stop time for residual checks. However, observations revealed that the tube feeding pump was turned off and disconnected from 10:00 AM to 2:00 PM daily, contrary to the RD's continuous feeding order. Staff interviews confirmed this practice, with an LPN stating the feeding was held for four hours each day, and the VP for Nutrition and DON both acknowledging that the only current order was for continuous feeding with a one-hour hold for residual checks. Record review showed that previous orders for intermittent feeding had been discontinued, and the current order was for continuous feeding to address the resident's history of vomiting. Despite this, staff continued to implement a prolonged feeding hold not supported by the current physician or RD orders. This deviation from prescribed nutrition orders placed the resident at risk for health complications and weight loss.
Failure to Implement Enhanced Barrier Precautions for Residents with Feeding Tubes
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who shared a room and both had feeding tubes for nutrition. Both residents were admitted with cerebral palsy and were assessed as severely cognitively impaired, requiring tube feeding due to dysphagia. Their care plans included interventions for EBP, but these precautions were not followed during care activities. Specifically, a registered nurse provided oral care to one resident without wearing a gown, and a certified nursing assistant was unaware of the need for EBP when providing care to both residents. Observations and interviews confirmed that staff did not utilize the required personal protective equipment (PPE) or post appropriate signage indicating the need for EBP. The Director of Nursing acknowledged that EBP should have been implemented, including the use of PPE and signage, but these measures were not in place at the time of the survey. This lapse was identified through direct observation, staff interviews, and review of medical records and care plans.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in five out of eight resident rooms. Observations confirmed sightings of live and dead roaches in various locations within the rooms, including dresser drawers, cabinets, sink counters, floors, and walls. Resident interviews corroborated these findings, with one resident reporting daily sightings of roaches and the need to shake out her clothes. Pest sighting logs documented numerous reports of ants, gnats, roaches, and spiders over several years, with recent reports indicating multiple sightings of ants and roaches. The facility's pest control program, as outlined in their policy, was not effectively implemented. Pest control technician reports highlighted sanitation issues, noting that areas such as nurses' desks and resident dresser drawers were not adequately cleaned, contributing to the persistence of the roach problem. Despite pest control treatments, the technician observed that the lack of sanitation allowed roaches to return. Interviews with staff and the administrator revealed awareness of the infestation issue, but the facility's operational reports did not comprehensively address pest control concerns in all affected rooms.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents, R51 and R38, which could lead to delayed assistance and medical attention. R51, who has a history of aphasia, hemiplegia, and muscle weakness, was observed multiple times with the call light on the floor beside the bed, out of reach. Staff interviews confirmed that the call light should have been placed on the bed or pillow for accessibility, but this was not done, indicating a lapse in ensuring the resident's needs were met. R38, diagnosed with Parkinson's disease and muscle contractures, was found in bed with food on his mouth and clothes, unable to reach the call light due to his contracted condition. Although staff claimed R38 could use his voice to call for help, observations showed he was unable to press the call light. Interviews with staff revealed inconsistencies in their understanding of R38's ability to use the call light, with some staff members admitting the call light was not positioned correctly for the resident's use. The Director of Nursing and other staff members acknowledged the importance of having call lights accessible to residents, yet the facility lacked a specific policy on call light placement. This deficiency in ensuring call light accessibility for residents R51 and R38 highlights a failure in the facility's responsibility to accommodate the needs and preferences of its residents, potentially leading to delayed care and dissatisfaction with the level of care provided.
Failure to Honor Resident's Right to Choose Nap Time
Penalty
Summary
The facility failed to honor a resident's right to make personal choices, specifically regarding the desire to return to bed for a nap. The resident, identified as R8, has a medical history that includes a cerebrovascular accident with right-sided hemiparesis, hypertension, type 2 diabetes mellitus, depression, anxiety, dementia, insomnia, and muscle weakness. Despite having a Brief Interview for Mental Status (BIMS) score indicating little to no cognitive impairment and a care plan that emphasized the importance of making personal choices, R8's request to return to bed was not honored by the facility staff. On the day of the incident, R8 was observed sitting in a wheelchair and expressed a desire to return to bed for a nap before lunch. However, the Certified Nursing Assistant (CNA) II did not assist R8 back to bed, preferring to wait until after lunch to avoid multiple transfers. Interviews with the CNA, a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that the resident's request should have been honored, as it is their right to decide when to lie down. This inaction by the staff led to a deficiency in honoring the resident's right to self-determination and choice, as outlined in the facility's document titled 'Your Rights and Protections as a Nursing Home Resident.'
Failure to Accurately Code Fall with Major Injury on MDS
Penalty
Summary
The facility failed to accurately code a fall with major injury on the Minimum Data Set (MDS) for a resident, identified as R14, who was reviewed for accidents. R14's medical history included fractures of the left tibia and fibula, which were noted as subsequent encounters for closed fractures with routine healing. On 8/13/2024, R14 sustained a fall while attempting to get out of bed without assistance, resulting in a proximal fracture to the left tibia. This incident required hospitalization and treatment without surgical intervention. However, the quarterly MDS assessments dated 8/19/2024, 10/23/2024, and 11/25/2024 failed to document this fall. The MDS Coordinator confirmed during an interview that the fall was not captured in the assessments and acknowledged the oversight.
Failure to Revise Care Plan for Restorative Services
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R8, who had a history of cerebrovascular accident (CVA) with right-sided weakness and contractures in the right upper and lower extremities. The care plan did not address the resident's refusals of restorative care, including the use of splints, nor did it document any alternative interventions or strategies to encourage participation. Observations over several days revealed that the resident was not wearing the prescribed splints, and interviews with staff confirmed that the refusals were not documented in the care plan prior to the survey. The facility's policy on Restorative Nursing Programs required that a resident's plan include specific details such as the problem, type of activities, frequency, duration, measurable goals, and target dates. However, the care plan for R8 lacked documentation of refusals and alternative interventions. Interviews with the RN, Restorative Aide, and MDS Coordinator revealed that the care plan had not been updated to reflect the resident's refusals and the necessary strategies to encourage compliance until after the survey. This oversight led to inconsistencies in the provision of restorative services for the resident.
Deficiencies in ADL Care and Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, leading to deficiencies in personal hygiene and grooming. Resident 8, who has a history of cerebrovascular accident, diabetes, and vision impairment, was observed with long, dirty fingernails that were causing discomfort. Despite the resident's cognitive awareness and ability to communicate, the staff did not address the issue until it was brought to their attention by surveyors. The Director of Nursing (DON) acknowledged that nail care should be part of the routine grooming process, especially for diabetic residents, to prevent health risks. Resident 38, diagnosed with Parkinson's disease and moderate cognitive impairment, was also found with long, unkempt nails. Although the resident was dependent on staff for ADL care, the nails were not clipped despite being cleaned. The staff mentioned that the resident often refused nail care, but upon inquiry, the resident expressed discomfort and a willingness to have the nails clipped. The DON and other staff members recognized the need for better monitoring and care to prevent the nails from becoming a health hazard. Resident 16, with a history of hemiplegia and mild cognitive impairment, did not receive regular showers as per the facility's schedule. The resident's skin was observed to be dry and scaly, indicating a lack of proper hygiene care. The facility's records showed inconsistencies in the documentation of showers, and staff interviews revealed that missed or refused showers were not consistently reported or documented. The lack of adherence to the shower schedule and inadequate documentation contributed to the resident's unmet hygiene needs.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide consistent restorative services for a resident identified as needing such care. The resident, who has moderate cognitive impairment and requires substantial assistance with daily activities, had physician orders for a right knee contracture splint and a right wrist/hand contracture splint to increase range of motion and prevent contractures. Despite these orders and a discharge recommendation from physical therapy for a restorative splint and brace program, there was no documentation of the resident receiving these restorative services. Observations over several days confirmed that the resident was not wearing the prescribed splints, and interviews with the resident revealed that he was unaware of ever having worn a splint and expressed a desire for assistance. Interviews with facility staff, including a registered nurse and a restorative aide, indicated a lack of awareness or documentation regarding the resident's restorative care needs. The Director of Nursing acknowledged that the resident was supposed to receive restorative services but could not provide documentation due to system acquisition issues. The facility's failure to document and provide the necessary restorative services for the resident was not rectified before the survey exit, indicating a deficiency in the facility's adherence to its restorative nursing program policy.
Medication Storage and Expired Medication Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in two significant deficiencies. Observations revealed that medication carts on the 100-Hall and 200-Hall were left unlocked and unattended during medication administration. Registered Nurse (RN) JJ was observed removing medications from the carts and entering residents' rooms without securing the carts. Interviews with RN JJ, the Director of Nursing (DON), and Unit Manager (UM) MM confirmed that the carts should have been locked when not in use to prevent unauthorized access, which could lead to adverse outcomes if residents accessed the medications. Additionally, the facility did not remove expired medications from the medication carts on the 100-Hall and 500-Hall. Observations identified several expired medications, including iron tablets, aspirin, and ferrous sulfate, which had not been removed from the carts. Interviews with RN JJ, Licensed Practical Nurse (LPN) LL, and UM HH confirmed the presence of expired medications and acknowledged that administering these could result in medication errors and adverse reactions. The DON and UM MM stated that expired medications should be promptly removed by licensed nurses to prevent potential harm to residents.
Deficiency in Restorative Nursing Documentation
Penalty
Summary
The facility failed to maintain and document accurate medical records for a resident receiving restorative nursing services. The resident, who had a history of cerebrovascular accident (CVA) with right-sided weakness and contractures, was supposed to receive restorative services, including passive range of motion (ROM) exercises and splint application, as per physician orders and physical therapy recommendations. However, a review of the resident's medical records revealed no documentation of these services being provided, despite the facility's policy requiring such documentation. Interviews with the Director of Nursing and the Restorative Aide confirmed the absence of documentation for the restorative services. The Director of Nursing acknowledged the lack of records and attributed it to system acquisition issues following a transition from previous ownership. The Administrator also confirmed the documentation gaps and noted challenges in accessing the electronic medical record (EMR) system due to the transition, which hindered the retrieval of historical medical records.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control protocols during wound care for a resident with a stage 4 pressure ulcer. The facility's policy on hand hygiene, dated February 1, 2024, mandates that all staff perform hand hygiene procedures to prevent the spread of infection. This includes sanitizing hands before donning gloves and immediately after removing them. However, during an observation on January 8, 2025, the Wound Care Nurse (WCN) was seen changing gloves without sanitizing her hands in between, which is a violation of the facility's hand hygiene policy. The resident involved, identified as having intact cognition and a stage 4 pressure ulcer, was receiving wound care as per physician's orders. The WCN admitted to not sanitizing her hands between glove changes, acknowledging the risk of infection to the resident. Interviews with the Unit Manager and Director of Nursing confirmed that the expected protocol was not followed, emphasizing the importance of hand hygiene in preventing infections and ensuring proper wound care.
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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 Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Virginia Park | 3 mi | ★★★★★ | 0 | 0 |
| Decatur Center For Nursing And Healing Llc | 3 mi | ★★★★★ | 7 | 0 |
| Harborview Decatur | 3.1 mi | ★★★★★ | 0 | 0 |
| Glenwood Health Center By Harborview | 3.3 mi | ★★★★★ | 10 | 0 |
| Parkside At Budd Terrace Operating Company Llc | 3.7 mi | ★★★★★ | 22 | 0 |
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