Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pruitthealth - Palmyra during CMS and state inspections, most recent first.
A facility failed to follow the puree menu for all residents receiving a puree diet, with dietary staff preparing Chicken and [NAME] Casserole by pureeing a large pan of the item and adjusting consistency during meal prep. The facility also failed to follow one resident’s ordered NAS/renal diet with no potatoes or bananas; the resident reported receiving restricted foods and not getting large portions, and an observed breakfast tray included one-half banana despite the diet order.
Failure to report an injury of unknown origin: A resident with severe cognitive impairment and multiple chronic conditions sustained an unwitnessed fall with eye discoloration and swelling. Staff documented the fall, notified the provider and family, and discussed it in clinical meeting, but the Administrator confirmed the injury was not reported to the state as required by policy.
Fall mats were not consistently placed as ordered for four residents with fall histories and significant cognitive or mobility impairments. Surveyors observed mats missing, rolled up, folded against a wall, or positioned incorrectly rather than on both sides of the bed or next to the bed as directed in the care plans. The DON confirmed the missing or improper placement and stated staff were expected to monitor mat placement during rounds.
A resident with COPD, chronic respiratory failure with hypoxia, and dependence on supplemental O2 was ordered O2 at 2 LPM via NC, but observations showed the resident receiving 4 liters with no humidifier bottle attached. The Administrator confirmed the O2 flow was set above the ordered rate and stated that licensed nursing staff were expected to monitor and ensure O2 settings matched the physician order.
A resident with dysphagia, aphasia, vascular dementia, and a puree diet order was given a peanut butter sandwich instead of a puree snack. The resident choked, and the CNA stated she did not know the resident was on a special puree diet when she passed out snacks. The dietician confirmed that puree snacks were available and that staff used diet lists on the floors.
Care plans were not fully developed or followed for several residents. One resident with COPD and chronic respiratory failure was receiving O2 at a higher flow than ordered, and another resident on O2 had no care plan for oxygen use. Multiple residents with fall risk did not have fall mats placed at the bedside as planned, and one resident with dysphagia was given the wrong food consistency, with a choking incident documented. The DON, Administrator, and ADON confirmed the mismatches between the care plans, orders, and what was observed.
The facility did not develop or implement care plan interventions for routine weekly skin assessments for multiple residents at risk for pressure ulcers, resulting in missed assessments and delayed identification of new or worsening wounds. Several residents with significant risk factors, including those with existing pressure ulcers and severe cognitive or physical impairments, did not receive the required weekly skin inspections as outlined in facility policy.
Multiple high-risk residents did not receive consistent weekly skin assessments or timely wound care treatments as ordered, resulting in delayed identification and management of pressure ulcers. Gaps in documentation, missed treatments, and unclear staff responsibilities contributed to the deficiency, with several residents developing new or worsening wounds that were only discovered during a facility-wide skin sweep.
Administration did not ensure that licensed nurses consistently performed and documented weekly skin assessments and wound treatments as ordered, impacting six residents at risk for or with existing wounds. The facility also lacked effective oversight and a QAPI process for its skin integrity program, and did not develop a Performance Improvement Plan despite identified issues. Staffing instability further contributed to lapses in wound care and documentation.
The facility's QAPI committee did not provide effective oversight to ensure staff performed weekly skin assessments, resulting in missed identification and treatment of pressure ulcers. Despite wound care issues being identified and recommendations for a Performance Improvement Plan, the facility did not implement timely corrective actions or conduct required audits, leading to a situation with the likelihood to cause serious harm to residents.
The facility did not have a Certified Dietary Manager (CDM) overseeing the kitchen after the previous CDM left, and the Registered Dietitian did not fully assume responsibility for the Dietary Services Department. Staff interviews and observations showed that cleaning schedules and duty assignments were not maintained, and dietary staff operated without clear direction, impacting the provision of oral meals to most residents.
Surveyors identified multiple deficiencies in food service operations, including unsanitary conditions in the ice machine, improper dishwashing procedures, inadequate food storage and labeling, and unclean kitchen floors. Staff failed to follow proper sanitation protocols for both equipment and food handling, and the dishwasher did not consistently reach required temperatures for effective sanitation.
The facility did not ensure that grievances raised by residents during council meetings were tracked, resolved, or communicated back to the residents, as required by policy. Staff interviews confirmed that while complaints were documented and forwarded to department heads, there was no consistent follow-up or resolution process in place.
The facility experienced repeated delays in meal service, with observations showing backlogs of dirty dishes and late delivery of meals, including the use of Styrofoam containers when plates were unavailable. An LPN and a CNA confirmed late meal deliveries, and a resident reported consistently late dinners. The Dietary Supervisor cited dishwashing issues and a shortage of dry plates as causes for the delays, affecting the majority of residents receiving oral diets.
Three cognitively intact residents who wished to vote in the November 2024 election were not assisted by staff with obtaining absentee ballots or renewing necessary identification, despite available resources and a visit from voter registrars. Staff interviews confirmed a lack of follow-up and awareness regarding which residents wanted to vote.
The facility did not promptly notify a physician about a resident's repeated episodes of low blood pressure and fainting, nor did it inform a responsible party about another resident's diagnostic test results and a new leg wound. These failures involved residents with complex medical conditions and resulted in missed communication regarding significant changes in condition and care.
A resident admitted with an indwelling Foley catheter, and with multiple complex diagnoses, did not have a physician's order for the catheter documented in their medical record. Facility policy required verification of such orders, but this was not completed, and staff confirmed the ongoing use of the catheter without a physician's order.
A resident with intact cognition and a documented dislike for broccoli was served broccoli at lunch, despite the facility's policy to honor food preferences. The resident reported not being asked about menu choices and regularly receiving unwanted foods.
A resident with multiple complex medical conditions developed a Stage 2 pressure ulcer that was not consistently or thoroughly assessed and documented according to facility policy. After the initial identification and measurement, no further weekly wound assessments were recorded until the resident was seen by an outside wound care clinic, and no subsequent documentation was found before the resident's discharge.
A resident with an unsteady gait and intermittent confusion slipped and fell in the memory care unit after water leaked from the ceiling, with trash cans placed to collect the water. The roof had a history of leaks, and although temporary fixes and repair quotes were documented, no permanent repairs had been completed, resulting in a persistent hazard.
A resident with multiple complex medical conditions experienced significant, unmonitored weight loss over several months. The facility did not follow its own policy for re-weighing, weekly weight monitoring, or timely referral to a Registered Dietician. Additionally, a Speech Therapy evaluation for swallowing difficulties was not ordered until prompted by a surveyor, despite earlier indications it was needed.
A resident with multiple sclerosis and other conditions did not receive scheduled doses of Kesimpta for several months due to late or missing pharmacy deliveries and lack of timely ordering. Medication administration records and staff interviews confirmed that the medication was not available on the scheduled dates, resulting in missed doses.
Puree Menu Not Followed and Diet Order Errors
Penalty
Summary
The facility failed to ensure that the puree menu was followed for 18 of 18 residents receiving a puree diet. During observation of lunch meal preparation, Dietary PP was seen preparing Chicken and [NAME] Casserole and Broccoli for the puree meal. She placed a large pan of the casserole into the food processor, pureed the contents, and stated that she added 18 spoonfuls or more of the casserole to the recipe. She also stated that density was checked with additions of chicken broth and alternating processing until the desired consistency was reached. The Regional Registered Dietician stated that the recipe provided to the surveyor was generic and configured for a serving size of 210, and that the number of servings had been reduced to match the number of residents on puree consistency, with a serving size equal to 18 residents plus a few extra portions. The facility also failed to follow the diet ordered for one resident with diagnoses including hydronephrosis bilaterally, end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, obstructive and reflux uropathy, malignant neoplasm of colon, secondary malignant neoplasm of lung, and anxiety disorder. The resident had an active order for a NAS diet with special instructions for no potatoes or bananas, and the care plan addressed nutrition risk related to dialysis dependence and other diagnoses with interventions to provide diet as ordered and a therapeutic diet liberalized renal diet as ordered/tolerated. The resident stated he was not supposed to eat potatoes, bananas, or tomatoes because he was on a liberalized renal diet, said he constantly gets potatoes, and said he was supposed to get large portions but did not. He provided photographs of meal tickets showing food he stated he received, including potatoes, bananas, and tomatoes. Observation of the breakfast tray showed one-half banana served to the resident. The RRD verified that dietary staff had been educated to check meal slip tickets to ensure meals were plated correctly according to the diet ordered and stated it was the responsibility of all staff to make sure the food served was what was ordered.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one of four residents reviewed for accidents. The facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property stated that injuries of unknown source must be immediately reported to the Administrator and that the Administrator or designee must notify the appropriate state agency, the attending physician, and the resident’s representative according to applicable timeframes. Review of the resident’s record showed a Quarterly MDS with a BIMS score of 0, indicating severe cognitive impairment, and diagnoses including aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and depression. The resident sustained an injury from an unwitnessed fall and was found lying on a fall mat with discoloration to the eye. Staff completed an assessment, notified the provider and family, and performed neuro checks and a post-fall assessment. The fall was discussed in the next morning’s clinical meeting, and the DON confirmed awareness of the injury and that the resident was later sent to the emergency room because of eye swelling, anticoagulant use, and a high lactic acid level. The Administrator stated she did not remember the fall but confirmed that unwitnessed falls with injury should be reported to the state and that this resident’s injury was not reported.
Fall Mats Not Positioned as Ordered for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure fall mats were placed at the bedside for four residents who had documented fall histories and care plan interventions requiring mats on both sides of the bed or at bedside. The report identified residents with significant medical conditions and cognitive impairment, including hemiplegia and hemiparesis, vascular dementia, aphasia following cerebral infarction, amyotrophic lateral sclerosis, epilepsy, and severe or moderate cognitive impairment based on BIMS scores. Each resident’s care plan included fall precautions with fall mats as an intervention, and each had a history of falls or unwitnessed falls documented in the record. For one resident, observations showed the resident lying in bed without fall mats on either side, while two mats were folded and leaning against the wall. For another resident, observations showed only one mat on the left side of the bed, no mat on the right side, and later the left mat was rolled up on the floor. For a third resident, the mats were observed rolled up next to the sink rather than placed on both sides of the bed, and later only one mat was present on the right side of the bed. For the fourth resident, no mat was next to the resident’s bed during repeated observations, although the roommate’s mat was positioned more centrally between both beds. During observations and interviews, the DON confirmed the missing or improperly placed mats for each resident and stated that staff were expected to monitor mat placement in residents’ rooms. The DON also confirmed that fall mats should have been placed for residents who required them and acknowledged that the mats were not positioned as expected at the time of survey observations.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility failed to ensure that one of 16 sampled residents, R109, received oxygen therapy in accordance with the physician order. R109 had diagnoses including COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and shortness of breath. The admission MDS showed a BIMS score of 5, indicating severely impaired cognition, and also documented that the resident received oxygen therapy. The physician order form included an order for oxygen at 2 LPM via nasal cannula. Observations on 9/23/2025 at 10:19 AM and 1:01 PM showed R109 lying in bed receiving oxygen by concentrator and nasal cannula at a flow rate of 4 liters with no humidifier bottle attached. During an observation with the Administrator at 4:30 PM in R109's room, the Administrator confirmed that the resident was receiving oxygen at 4 liters instead of 2 liters without a humidifier bottle. The Administrator stated that licensed nursing staff were expected to monitor and ensure that oxygen flow rates were set per physician orders.
Wrong-Consistency Snack Given to Resident on Puree Diet
Penalty
Summary
The facility failed to ensure that a snack provided to R5 was consistent with the resident’s prescribed puree diet. R5’s medical record showed diagnoses including dysphasia and aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus without complications, vascular dementia, and depression. The physician order dated 9/26/2024 specified a regular diet with puree consistency, and the care plan identified R5 as being at nutrition and hydration risk related to multiple chronic conditions, with a history of cerebral infarction resulting in dysphagia and a need for both pureed diet and enteral feedings to meet nutritional needs. A progress note dated 4/5/2025 documented that R5 had a choking incident after being given a snack of the wrong consistency compared to the physician’s order. During interview, the Corporate Dietician Consultant stated that nurses and CNAs pass out snacks and that puree consistency snacks such as pudding, applesauce, and ice cream were available, with diet lists kept on each floor. A CNA who had started in March 2025 stated that 4/5/2025 was her first time passing out snacks, that she gave R5 a peanut butter sandwich without knowing he was on a special puree diet, and that R5 choked until she turned him on his side and he coughed up the food.
Care plans not developed or implemented for fall mats, oxygen, and diet
Penalty
Summary
The facility failed to develop and implement complete care plans for six residents, including failures related to fall mats, oxygen use, and diet. The report states that the facility did not implement the care plans for R111, R5, R135, and R155 related to fall mats, for R18 related to oxygen, and for R5 related to diet. It also states that the facility did not develop a care plan for R18 related to oxygen use. The facility policy titled Care Plans required the comprehensive person-centered care plan to include measurable goals and timeframes to meet the resident’s medical, nursing, and psychosocial needs. R111 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, unsteadiness on feet, and a lumbar compression fracture. The quarterly MDS showed a BIMS of 8, indicating moderate cognitive impairment. R111’s care plan included fall mats at the bedside, but on multiple observations the resident was lying in bed without fall mats on either side, and the two mats were folded and leaning against the wall. The DON confirmed during observation that R111 was in bed without the fall mats in place. R109 had COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and shortness of breath. The care plan addressed oxygen use at 2 L/NC, but observations showed the resident receiving oxygen at 4 LPM via NC, and the Administrator confirmed the higher flow rate and that no humidifier water bottle was attached. R18 had heart failure, acute respiratory disease, acute respiratory failure with hypercapnia, cerebral infarction, and COPD; the MDS showed a BIMS of 8 and shortness of breath. R18 was observed receiving oxygen at 4 LPM via NC, but the care plan did not include oxygen use, and the ADON confirmed that R18 did not have a care plan for oxygen. R5 had aphasia following cerebral infarction, chronic systolic heart failure, diabetes, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and depression. The resident had a physician order for a regular diet, puree consistency, and a progress note documented a choking incident after the resident was given a snack of the wrong consistency. R5’s care plan addressed fall risk and nutrition/hydration risk, including a fall mat on both sides of the bed, but observations showed only one mat on the left side, with the right side missing and the left mat later rolled up. The CNA confirmed she gave R5 a peanut butter sandwich without knowing the resident was on a puree diet, and the DON confirmed the fall mats were not positioned as expected. R135 had diagnoses including sequelae of cerebral infarction, muscle weakness, anxiety disorder, vascular dementia, and hemiplegia/hemiparesis, with a BIMS of 0. The care plan included fall mats on both sides of the bed, but observations showed the mats rolled up by the sink, later only one mat present by the right side of the bed, and none on the left. R155 had ALS, schizophrenia, epilepsy, and diabetes, with a BIMS of 3. The care plan called for a fall mat beside the bed, but repeated observations showed no mat next to the resident’s bed, while a roommate’s mat was centered between both beds. The DON and MDS Coordinator confirmed the expected bedside placement of the mats and that staff were responsible for ensuring they were positioned correctly.
Failure to Develop and Implement Weekly Skin Assessment Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable interventions and timetables for residents at risk for skin breakdown, as required by its own policy. Specifically, the care plans for several residents did not include interventions for routine weekly skin assessments, and for some residents, the existing care plan interventions for weekly skin inspections were not implemented. This deficiency was identified through observation, record review, and interviews, revealing that multiple residents with significant risk factors for pressure ulcers did not receive timely or documented weekly skin assessments. For example, one resident with end stage renal disease, diabetes, and a history of pressure ulcers had a care plan that lacked interventions for routine weekly skin assessments, and documentation showed missed weekly assessments over several months. Another resident with multiple Stage III and IV pressure ulcers and severe cognitive impairment also had a care plan without weekly skin assessment interventions, and only two assessments were documented over a two-month period. Additional residents with high or moderate risk for skin breakdown, as indicated by Braden Scale scores and other medical conditions, similarly lacked appropriate care plan interventions or did not receive weekly skin assessments as required. In several cases, new or worsening pressure ulcers were only identified during a facility-wide skin sweep, rather than through ongoing, routine monitoring. The surveyors determined that the facility's noncompliance with care planning and implementation requirements had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The deficiency was found to have existed for several months prior to the survey, affecting multiple residents with complex medical histories and significant risk factors for skin breakdown. The facility's own policy required person-centered care plans with measurable goals and regular updates, but these requirements were not met for the residents reviewed.
Failure to Consistently Assess and Treat Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown, resulting in delayed identification of pressure ulcers and inadequate documentation. Multiple residents with significant risk factors, such as immobility, cognitive impairment, and existing wounds, did not receive the required weekly skin assessments as outlined in the facility's own policy. For example, one resident with a history of Stage IV sacral pressure ulcer and multiple comorbidities did not have weekly skin assessments documented for several months, and new or recurrent wounds were only identified during a facility-wide skin sweep prompted by concerns about another resident. Other residents at high risk, including those with severe cognitive impairment, paraplegia, and malnutrition, also had significant gaps in their skin assessment documentation, with some going weeks or months without any recorded assessment. In addition to the lack of timely skin assessments, the facility failed to perform wound treatments as ordered by physicians or recommended by the wound care nurse practitioner for several residents. Medication Administration Records (MARs) revealed missed wound care treatments on multiple occasions, and in some cases, treatments were not initiated until days after wounds were identified. For instance, one resident with multiple Stage III and IV pressure ulcers had several missed wound care treatments, and another resident with an unstageable pressure ulcer to the left heel did not receive a physician's order or treatment until two days after the wound was first identified. There were also instances where wound care orders were not restarted after a resident returned from the hospital, resulting in a lack of wound care for over a month. Interviews with staff and review of facility records indicated systemic issues with the implementation and oversight of the skin integrity and wound care program. Staff responsible for weekly skin assessments were not consistently performing them, and there was confusion or lack of accountability regarding who was responsible for monitoring the program. High turnover among treatment nurses contributed to inconsistent documentation and missed treatments. The facility's own leadership acknowledged gaps in the completion of Braden Scale assessments and weekly skin audits, as well as difficulties in maintaining adequate staffing for wound care. These failures led to the delayed identification and treatment of pressure ulcers in multiple high-risk residents.
Failure to Ensure Weekly Skin Assessments and Oversight of Wound Management
Penalty
Summary
Administration failed to ensure that staff performed weekly skin assessments and wound treatments as ordered, and did not provide adequate oversight and monitoring of the skin integrity program. This deficiency affected six residents who were either at risk for skin breakdown or had existing wounds. Specifically, weekly skin inspections were not implemented for two residents, and interventions for routine weekly skin assessments were not developed for four other residents at risk for skin breakdown. Additionally, licensed nursing staff did not consistently perform or document weekly skin assessments and treatment orders for several residents. The facility also did not utilize an effective Quality Assurance and Performance Improvement (QAPI) process to identify and address concerns related to the wound management system. Despite recommendations from the Regional Nurse Consultant to develop a Performance Improvement Plan after identifying problems with the skin management program, there was no indication that such a plan was created. Staffing instability was noted, with five treatment nurses employed over several months and periods when only one treatment nurse was available, making documentation and wound care challenging.
Failure of QAPI Oversight for Weekly Skin Assessments
Penalty
Summary
The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) committee that provided oversight and monitoring to ensure staff were performing weekly skin assessments for timely identification and treatment of pressure ulcers. Review of the QAPI committee meeting agendas and minutes for two meetings showed no indication that the committee identified the staff's failure to perform these assessments. The facility's policy required a comprehensive, data-driven QAPI program with regular review and prioritization of performance improvement projects (PIPs), but there was no evidence that a PIP addressing wound care or skin assessments was implemented in a timely manner, despite identified problems. Interviews revealed that the Regional Nurse Consultant had identified wound care issues and recommended a PIP, but the facility did not act on this recommendation. Additionally, required monthly audits for residents with wounds were not completed. The Administrator acknowledged that a PIP was not implemented until after the survey team arrived, and attributed missed actions to ongoing leadership changes. The noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Employ Certified Dietary Manager and Ensure Dietitian Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) to oversee the kitchen and did not ensure that the Registered Dietitian assumed full responsibility and accountability for the Dietary Services Department. Observations revealed that after the former CDM's last day, there was no CDM present in the kitchen, and the duties were not being properly managed. The facility's job descriptions for both the Dietitian and Dietary Manager outlined responsibilities for oversight, quality assurance, and staff direction, but these were not being fulfilled due to the absence of a CDM. On one occasion, a CDM from an affiliated facility was observed overseeing the kitchen, but this was not a consistent arrangement. Interviews with staff indicated that the Registered Dietitian attempted to assist the dietary supervisor but was not able to fully assume the required responsibilities. The Dietary Supervisor admitted to not making cleaning schedules or duty assignments, resulting in staff cleaning as they saw fit without assigned responsibilities. The staff list provided by the facility confirmed the absence of a CDM, and the Administrator acknowledged that the former CDM had left and had not been replaced. The deficiency affected the provision of oral meals to 184 of 203 residents.
Widespread Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Multiple deficiencies were identified in the facility's food service operations, including improper sanitation and maintenance of kitchen equipment and surfaces. Observations revealed that the ice machine contained visible black and pink substances on the chute, and the ice bin was dirty and left open to air. Staff interviews confirmed that the ice machine had never been sanitized with the appropriate cleaning solution since its purchase, as the cleaning solution had never been ordered. Additionally, the kitchen floors were found to have food debris, dirt, and dried spills, and blankets were used on the floor to absorb water from a leaking dishwasher sprayer. The facility failed to ensure proper dishwashing procedures, as the dishwasher did not consistently reach the required water temperatures for effective sanitation, and the three-compartment sink was not used according to manufacturer recommendations. Staff were observed washing pots and pans without using the rinse or sanitizer steps, and sometimes dried cookware with cloth towels instead of allowing them to air dry. Instructional posters for proper sink use were present, but staff did not consistently follow them. The dishwasher was temporarily converted to use chlorine sanitizer due to ongoing hot water issues, but water temperatures remained below recommended levels during multiple cycles. Food storage and handling practices were also deficient. Opened food items in the walk-in refrigerator, such as turkey breast slices, cheddar cheese, liquid eggs, and cornbread, were not properly dated or labeled. Food on the steam table was observed at temperatures below 135°F, and clean dishes were stored on surfaces with visible food particles. Scoops were stored inside dry goods bins instead of in designated holders, and a no-touch trash can was not available near the sink, leading staff to use a large trash can with a lid that was manually opened. These practices had the potential to increase the spread of foodborne illness among residents receiving oral diets.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during council meetings for four out of seven months reviewed. Record review showed that issues such as lack of tea, late meals, inability to eat in the dining room on weekends, timing of evening meals, absence of coffee, and broken kitchen equipment were documented in the Patient/Resident Council Minutes/Report Forms. However, there was no evidence that these grievances were tracked, resolved, or that written decisions were issued to the individuals who filed them, as required by the facility's grievance policy. Interviews with staff revealed that while the Activity Director documented complaints and forwarded them to the relevant department heads, there was no follow-up with residents regarding the outcomes of their grievances. The Social Worker (BSW) confirmed that grievances were discussed in morning meetings but was not involved in resolving them, and the Social Worker (MSW) had not previously reviewed grievances from the council minutes. The Administrator acknowledged that staff should be educated on the grievance process and that any staff member could write a grievance, but the process for tracking and resolving grievances was not consistently followed.
Delayed Meal Service Due to Dishwashing Backlog and Plate Shortage
Penalty
Summary
The facility failed to ensure that resident meals were served in a timely manner, as required by posted mealtimes and resident needs. Multiple observations during kitchen visits revealed significant delays in dishwashing, with breakfast dishes remaining unwashed late into the morning and a backlog of dirty dishes waiting to be cleaned. These delays contributed to late meal service, as evidenced by lunch trays being delivered well after the scheduled lunch time on several occasions, including meals being served in Styrofoam containers due to a shortage of clean plates. Staff interviews confirmed that meal delivery was consistently late, with one resident reporting that dinner often arrived between 6:30 pm and 8:00 pm, despite the posted supper time of 4:30 pm. The Dietary Supervisor acknowledged responsibility for ensuring timely meal service and attributed the delays to issues with the dishwasher and insufficient dry plates for the next meal. The facility had recently purchased additional dinner plates, but this measure had not resolved the ongoing delays. The deficiency had the potential to affect 184 of 203 residents who received an oral diet, as timely meal service was not consistently maintained according to residents' needs, preferences, and posted schedules.
Failure to Assist Residents with Voting Rights
Penalty
Summary
The facility failed to assist three residents with the process of voting in the November 2024 election, despite their expressed wishes and cognitive ability to do so. Resident 14, who had intact cognition and significant physical disabilities, reported needing help to renew his state identification card in order to vote, but did not receive any assistance. Resident 28, also cognitively intact, had the necessary identification but was not provided with an absentee ballot or assistance to obtain one, despite her desire to vote. Resident 29, a registered voter, similarly did not receive an absentee ballot and expressed that he wanted to vote. Interviews with facility staff revealed a lack of follow-up and organization regarding residents' voting needs. The social worker with a master's degree stated she would survey residents with a BIMS score greater than 10 to determine voting interest and assist with identification, but was not employed during the relevant election period. The social worker with a bachelor's degree acknowledged that voter registrars had visited the facility but did not know which residents wanted to vote or provide follow-up assistance. The county voter registrar confirmed that resources were available online for assisting with voter registration and absentee ballots, but these were not utilized by the facility for the residents in question.
Failure to Notify Physician and Responsible Party of Significant Changes and Test Results
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal vital signs for one resident and did not notify the responsible party about diagnostic test results and a new skin impairment for another resident. For one resident with multiple diagnoses including heart disease, hypertension, and hypotension, therapy staff documented several episodes of low blood pressure and fainting during therapy sessions. Despite these significant changes in condition, there was no documentation that the physician or nurse practitioner was notified of the abnormal blood pressure readings until several days later, even though the therapy staff requested physician input regarding blood pressure parameters and medication regimen. For another resident with dementia, diabetes, and a gastrostomy, the facility failed to notify the responsible party of a diagnostic procedure to verify gastrostomy tube placement and did not communicate the results. Additionally, the responsible party was not informed about a new wound on the resident's leg, which was discovered during an observation with nursing staff. The nurse responsible for skin integrity was unaware of the wound prior to the observation, and there was no evidence that appropriate orders were obtained for the dressing applied to the wound.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A resident with multiple complex medical conditions, including malignant neoplasm of the prostate, Stage IV pressure ulcer, multiple myeloma not in remission, paraplegia, and a colostomy, was admitted to the facility from a hospital with an indwelling Foley catheter in place. Review of the resident's admission orders and all subsequent orders up to several months after admission revealed there was no physician's order for the continued use of the indwelling urinary catheter. Facility policy for indwelling urinary catheters required verification of orders, but this step was not followed. Nursing progress notes documented the presence and replacement of the Foley catheter, and staff interviews confirmed the ongoing use of the catheter without a physician's order.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences as required by its policy and regulatory standards. According to the resident's medical record, the individual had intact cognition and had clearly indicated a dislike for broccoli on the Diet Review/Food & Beverage Preference List. Despite this, an observation of the resident's lunch meal tray revealed that broccoli was served. The resident reported never being asked about menu choices and consistently receiving foods he did not like, such as broccoli. The facility's policy states that food preferences and choices should be honored within reason according to the resident's diet order and available menu selections, but this was not followed in this instance.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly and consistently assess and document a pressure ulcer for one resident, as required by its own policy. The policy mandates weekly wound observations and comprehensive nursing assessments, including detailed measurements and descriptions of the wound and surrounding tissue. For the resident in question, who had multiple diagnoses including hemiplegia, vascular dementia, and was dependent on staff for all activities of daily living, a Stage 2 pressure ulcer was identified and measured on the sacrum. However, after the initial assessment, there were no further wound assessments or measurements documented for over a month, until the resident was evaluated by an external wound care clinic. Following the wound care clinic's evaluation, there continued to be no further assessments of the sacral pressure ulcer documented in the clinical record. The resident was later discharged to the hospital. The Director of Health Services confirmed that there was no weekly descriptive documentation of the resident's pressure ulcer, as required by facility policy.
Resident Fall Due to Ongoing Ceiling Leak
Penalty
Summary
A deficiency occurred when a resident slipped and fell due to water leaking from the ceiling in the memory care unit. Observations revealed that water was actively leaking from the ceiling, with trash cans placed on the floor and a table to collect the dripping water. The incident involved a resident who was ambulatory with an unsteady gait, used a cane, and was sometimes confused. The fall happened in the dayroom, and there was no documented injury as a result of the incident. Review of facility records and staff interviews indicated that the roof had a history of leaking, particularly during heavy rain, and that temporary measures such as applying tar had been used. Multiple invoices and proposals for roof repairs were present, but none specified the exact section needing repair, and no repairs had been completed in 2024. The Maintenance Director confirmed the ongoing nature of the leak and the lack of permanent repairs, contributing to the continued presence of the hazard.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident, who had multiple diagnoses including hemiplegia, dysphagia, diabetes, and major depressive disorder. Despite the facility's policy requiring weekly weights and re-weighs for significant weight changes, the resident experienced an 8.2% weight loss in one month, a 16.4% loss in three months, and a 23.6% loss in six months. There was no evidence that the resident was re-weighed after the initial significant weight loss, nor was the Registered Dietician consulted in a timely manner. The resident was not placed on weekly weights as required by policy, and the Weight Loss/Gain Checklist and other interventions were not documented as completed. Additionally, the resident reported coughing and choking with eating, which prompted a Nurse Practitioner to order a Speech Therapy (ST) evaluation. However, the ST evaluation was not ordered until after the state surveyor's inquiry, despite the earlier recommendation. The Director of Health Services confirmed that the required re-weigh and dietician notification did not occur, and the ST evaluation order was delayed.
Failure to Ensure Timely Ordering and Administration of Specialty Medication
Penalty
Summary
The facility failed to ensure timely ordering and administration of Kesimpta, an injectable medication used to treat multiple sclerosis, for one resident. Observations revealed that the medication was present in the refrigerator on one date but missing on a subsequent date when the next dose was due. Review of the resident's records showed that Kesimpta was not administered for several months, specifically in April, May, June, and July, due to the medication being unavailable or not delivered on time. Pharmacy delivery records confirmed late deliveries in April, May, and July, and no evidence of delivery in June. Medication administration records also indicated that the medication was not given because it was not available on the scheduled dates. The resident involved had multiple diagnoses, including multiple sclerosis, cognitive communication deficit, seizures, and hypertension. Staff interviews confirmed that the medication was not administered when it was not available, and the Director of Health Services acknowledged that specialty medications due monthly should be ordered prior to the due date. There was no evidence that the resident received Kesimpta for the months in question, resulting in a failure to comply with requirements for timely medication ordering and administration.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wynfield Park Health And Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Lee County Health And Rehabilitation | 8.9 mi | ★★★★★ | 0 | 0 |
| Dawson Health And Rehabilitation | 19.2 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Sylvester | 20.9 mi | ★★★★★ | 0 | 0 |
| Archbold Living Camilla | 25.9 mi | ★★★★★ | 6 | 2 |
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