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 Tower Road Post Acute, Llc during CMS and state inspections, most recent first.
Food storage and dishwashing practices were deficient when multiple opened dry goods and refrigerated items were found without labels, dates, or proper expiration control, including crackers, gravy mix, mashed potatoes, cereal, cheese, ham, and dairy items. Surveyors also observed expired seasoning items, expired emergency food, and dishwashing problems including wet nesting, dirty-to-clean dish transfer, and food residue on dishware; a Dietary Aide said she had not been trained on wet nesting.
A cognitively intact resident with depression, anxiety, and significant ADL dependence reported to an LPN that she had fallen during the night, hit her head, and that a night-shift nurse told her to get the “curse-word” up. The LPN observed redness to the resident’s eye and notified a UM, who then informed the DON. The resident and a family member later reported that a high-level staff member had cursed at the resident and her sister, and the resident identified this person as the DON. Staff, including the UM, DON, and Abuse Coordinator, acknowledged that verbal abuse is reportable and that abuse allegations must be reported to the state within two hours per facility policy. However, after the resident gave differing accounts of the incident when questioned by the DON, the DON and Abuse Coordinator decided not to report the allegation to the State Agency, resulting in a failure to report a verbal abuse allegation as required.
A resident with severe cognitive impairment, gait/mobility issues, and a falls care plan requiring fall mats on both sides of the bed was observed multiple times with only one mat in place, while the other was absent or propped against the wall. Staff confirmed the right-side mat was not being used and stated the resident was only given one mat because he had a roommate and favored one side of the bed; the DON said staff were expected to know the care plan interventions.
Failure to provide bathing assistance: A cognitively intact resident with lower-extremity impairments and mobility limitations reported not receiving a bath or bed bath after admission. The resident said a CNA stated she was responsible for 14 other residents and could not help, and the next CNA never returned. The DON said showers were tied to scheduled shower days and bed baths were offered, while the CNA stated N/A was entered when no shower or bed bath occurred and that bathing was not offered as an option.
A facility failed to provide oxygen therapy as ordered for two residents. One resident with COPD, acute respiratory failure, and pneumonia was ordered 2 L via NC but was observed receiving 2.5 to 3 L, and the RN confirmed the concentrator was set at 3 L. Another resident with pneumonia, acute respiratory failure, and CHF was ordered 3 LPM continuously but was observed at 2 L; the RN confirmed the mismatch, and the DON and RT noted there was no documentation supporting the change.
Hand Hygiene Not Performed During Medication Passes. An LPN administered medications to two cognitively intact residents without performing hand hygiene before or after medication pass activities, including before entering and after exiting resident rooms. One resident had diagnoses including HIV and hepatitis C, and the other had diagnoses including diabetes and depression. The LPN also returned from the medication machine and continued the medication pass without sanitizing her hands, and later confirmed she had not used hand hygiene while passing out medications.
A resident with multiple serious diagnoses was started on IV fluids and oral antibiotics for pneumonia, but the responsible party was not notified of this change in condition as required by facility policy. Documentation did not show any notification, and staff interviews confirmed that the LPN could not recall notifying the family or responsible party. The DON acknowledged the lapse after a grievance was filed.
A resident with multiple diagnoses, including dementia, did not receive a properly documented SNF ABN regarding Medicare non-coverage. The Business Office Manager read the notice to the responsible party by phone but failed to provide or document a signed copy, and the Director of Nursing cited miscommunication about the correct process.
The facility failed to maintain a safe and homelike environment, with surveyors observing issues like peeling paint, missing vent covers, and broken fixtures across three halls. The Maintenance Director confirmed these deficiencies, noting a lack of awareness prior to the survey and indicating plans for repairs. Additional concerns included leaking toilets, slow-draining sinks, and makeshift lighting solutions, highlighting potential safety hazards.
The facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in 17 out of 22 bathrooms, with temperatures ranging from 108 to 123 degrees. Residents reported the water as very hot, though no burns occurred. The Maintenance Director set the water heater at 122 degrees and did not keep a log of temperature checks, contributing to the oversight.
A resident with severe cognitive impairment was observed with an uncovered Foley catheter bag and a shirt displaying her full name in large letters, violating the facility's policies on dignity and privacy. Staff interviews confirmed the failure to adhere to established procedures for clothing labeling and catheter dignity.
A resident was found with medication at their bedside without an assessment or physician's order for self-administration, contrary to facility policy. Staff interviews confirmed that medications should not be left at the bedside unless the resident is assessed and authorized. The DON and Administrator emphasized the importance of proper assessment and adherence to protocols.
A resident with severe cognitive impairment and requiring a wheelchair was found with the call light out of reach on two occasions, despite facility policy requiring accessibility. The DON stated that staff were expected to meet residents' needs and had received training on accommodation policies.
The facility did not have an effective system for after-hours visitation, as the phone number provided for access was not answered, preventing visitors from entering. Staff interviews revealed that the phone system was supposed to transfer calls to the nurses' station, but this did not happen, potentially causing distress for visitors unable to reach their family members.
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to two residents who remained in the facility after being discharged from Medicare Part A services. Instead, only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was given. Interviews revealed a misunderstanding of NOMNC requirements, with staff believing NOMNCs were only for residents discharged to home. The administrator expected correct notifications to prevent resident confusion.
A resident with multiple diagnoses, including dementia and Parkinson's disease, was inaccurately documented in the MDS assessment as having no dental concerns, despite being observed with missing upper teeth. A prior dental exam noted multiple missing teeth and a plan for partials. The Chief Clinical Officer confirmed the documentation error.
A facility failed to complete the PASARR Level II screening for a resident admitted with multiple diagnoses, including depression and PTSD. The facility's policy mandates a Level II screening for individuals with mental disorders or intellectual disabilities, but this was not done for the resident. The Social Services Director confirmed that Level II screenings are usually done by the hospital before admission, and acknowledged the oversight.
The facility failed to implement baseline care plans within 48 hours for several residents, as required by policy. This deficiency affected residents with various health conditions, including a resident with a urinary tract infection and another with high fall risk due to amputations. Staff interviews confirmed the oversight, and one resident experienced a fall due to delayed assistance.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific medical conditions such as UTIs, oxygen therapy, and PTSD. Despite clear expectations for baseline care plans within 48 hours of admission, these deficiencies were confirmed through staff interviews and record reviews.
A facility failed to include a resident's family in care plan meetings, contrary to its policy requiring family involvement. The resident's family was unaware of any care plan, and staff interviews revealed inconsistent communication practices. The facility's policy mandates active participation of residents and their representatives in care plan development, which was not followed, resulting in a deficiency.
A resident was discharged without proper instructions being provided to the responsible party, as required by the facility's discharge planning policy. The resident's son, who was the responsible party, was not present to receive the discharge instructions, which were reportedly discussed over the phone. The instructions lacked details on dietary/nutrition, therapy, and medications, and there was no signature from the resident or responsible party. Interviews with staff revealed that the expected discharge process was not followed.
A resident with severe cognitive impairment and dependency on staff for personal hygiene was found to have long, sharp, and dirty fingernails, indicating a failure in providing adequate fingernail care. Despite the facility's policy requiring morning ADL care, including nail care, staff interviews revealed that nail care was performed on an as-needed basis, which was insufficient for the resident's needs.
A facility failed to arrange follow-up appointments and transportation for a resident with multiple health conditions after hospital discharge. The resident required follow-up with specialists, but the facility did not document these arrangements, as confirmed by the resident's responsible party and the administrator.
A resident with a history of chest pain and heart disease was observed receiving oxygen at 1 LPM instead of the prescribed 2 LPM, as per physician orders. Despite the facility's policy requiring verification of physician orders, the discrepancy was not identified until observed by staff. The resident, who was cognitively intact, reported the incorrect oxygen level, and the LPN confirmed the error. The DON and Administrator emphasized the importance of adhering to physician orders to prevent respiratory complications.
The facility failed to discard expired medications and biologicals in two of three medication rooms, contrary to its Medication Storage policy. An observation revealed an emergency kit with expired medications, including insulin and suppositories, in a medication room refrigerator. The Unit Manager confirmed the expiration, and the DON stated that medications should not be expired.
A facility failed to ensure a resident receiving hospice care had a physician's order for hospice services. The facility's policy requires the Interdisciplinary Team to coordinate care and ensure hospice physician orders. Despite documentation in the MDS and care plan, the current physician's orders lacked hospice services. Interviews with an RN and the DON confirmed the need for a physician's order.
The facility failed to follow proper infection control practices during medication administration via a G-tube, perineal care, and tracheostomy care. An LPN did not wear a gown for a resident on Enhanced Barrier Precautions, and a CNA did not sanitize a blood pressure machine between residents. Another CNA reused a cleaning wipe during perineal care, and an LPN did not maintain sterile technique during tracheostomy care. Additionally, hand sanitizer dispensers were found empty in several areas.
The facility's call light system in the West Hall was found to be deficient, with four call lights flashing without sound, and a call device in a resident's room failing to activate the hallway light. A CNA and an RN confirmed these malfunctions during observations.
Food Storage and Dishwashing Deficiencies
Penalty
Summary
The facility failed to ensure opened food items in the walk-in refrigerator and dry storage area were labeled, dated, and discarded by expiration date, as required by its Food Storage policies. During the initial tour, the District Manager observed multiple dry storage items without labels or dates, including single-count packages of saltine crackers and graham crackers, an opened package of homestyle old-fashioned biscuit gravy mix, an opened package of mashed potatoes with vitamin C, an opened bag of cereal, and packages of goldfish crackers and name brand crackers. In the kitchen near the prepping table, seasoning and spice items with expired dates were also observed, including two bouillon cubes with an expiration date of October 2024 and an opened beef flavor base without labeling. The District Manager confirmed the items were missing required dating and labeling. In the walk-in cooler/refrigerator, surveyors observed 13 bottles of lactose free dairy with an expiration date of 12/7/2025, unthawed meat marked with a date of 1/3/2026 that the District Manager could not confirm as an open date or expiration date, an opened 80 oz mozzarella cheese without proper labeling or any open or expiration date, and an opened 4 lb ham without proper labeling or dating. In emergency food storage, five bags of 80 oz grits were found with an expiration date of 12/20/2025, and the District Manager stated the previous Dietary Manager had been responsible for monitoring expiration dates in that area. The survey also identified sanitation issues in the dishwashing area: dirty dishes were transferred to clean dishes, wet nesting was observed on the storage rack, a Dietary Aide confirmed she was unaware of wet nesting and had not received training on it, and random dishware had water and food residue on it.
Failure to Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own abuse policy and federal and state law. The facility’s policy on Abuse, Neglect and Misappropriations, revised 1/1/2025, states that all alleged violations involving abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property must be investigated and reported immediately, defined as no later than two hours after the allegation is made, to the Facility Administrator, the State Survey Agency, and other appropriate agencies. Verbal abuse is defined in the policy as the use of oral, written, or gestured language that includes any threat or frightening, disparaging, or derogatory language to residents or their families, or within their hearing distance. Staff interviews confirmed their understanding that verbal abuse allegations are reportable and must be reported within two hours. The resident involved, R11, had diagnoses including metabolic encephalopathy, depression, generalized muscle weakness, and anxiety disorder, and was care planned for fall risk and behavior related to refusing care. A recent MDS showed a BIMS score of 15, indicating she was cognitively intact, with documented depression symptoms and significant functional dependence for multiple ADLs, including toileting, bathing, and transfers. On the morning after a reported fall, an LPN documented that the resident stated she had fallen overnight, hit her side table and then the floor, and that a nurse found her on the floor and instructed her to get up. The LPN observed redness to the resident’s left eye and reported these observations to management. Subsequent progress notes documented that the DON and Unit Manager spoke with the resident and her sister about the incident, and that the resident gave differing accounts of what happened and refused further evaluation and interventions. Interviews and documentation showed that R11 alleged that a night-shift nurse cursed at her in connection with the fall. LPN GG reported that during shift change rounds, the resident stated she had fallen off the bed, hit her head, and that the night nurse told her to get the “curse-word” up. UM FF confirmed that she was notified by LPN GG that the resident reported being cursed at by the night nurse and that she then notified the DON. UM FF defined verbal abuse as being spoken to harshly and acknowledged knowing that abuse allegations must be reported to the state within two hours. The DON stated that when he spoke with the resident, she initially said the staff told her to get the “curse word” off the floor, then changed her account to say the staff only told her to get out of bed after he informed her he would have to report the incident, and then returned to her original statement. The DON and the Abuse Coordinator/AIT both confirmed that the allegation was not reported to the State Agency because the resident changed her story, despite the facility policy requiring immediate reporting of all abuse allegations and staff acknowledging that verbal abuse is reportable. Further interviews with the resident and her family corroborated that the resident reported being cursed at by staff. The resident described the alleged perpetrator as a tall, slender Black man in a high position at the facility and identified him as the DON, and she told the surveyor that this person had cursed her and her sister because he wanted her to leave. A family member stated that the resident told her she had fallen and that the nurse had cursed at her. The Abuse Coordinator confirmed that the administrator was aware of the incident and that, although he was the abuse coordinator, the administrator determined what would be reported to the state. Despite multiple staff being aware of the allegation of verbal abuse and the facility’s written requirement to immediately report all such allegations to the State Survey Agency, the facility did not report this allegation, resulting in the cited deficiency.
Failure to Follow Fall Mat Care Plan
Penalty
Summary
The facility failed to implement the care plan for one sampled resident, R19, by not using bilateral fall mats as identified in the resident’s care plan. R19 was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease stage 3a, cognitive communication deficit, and other abnormalities of gait and mobility. The quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and Section GG showed the resident required extensive assistance with bed mobility and was dependent for multiple transfers and personal care tasks. R19’s care plan included a falls problem with interventions that specified fall mats on both sides of the bed and keeping the resident in a highly visible area when out of bed. During observations, the resident was seen in bed on multiple occasions with only one fall mat present, while the other mat was either absent or propped against the wall. Staff interviews confirmed that the right-side mat was not in place and that the resident was being managed with only one mat because he had a roommate and favored one side of the bed. The DON stated that staff were expected to review the care plan and know the interventions.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living, specifically bathing, for a resident who was cognitively intact with a BIMS score of 15 and had diagnoses including muscle weakness, gait and mobility abnormalities, and irritable bowel syndrome with diarrhea. The resident’s admission MDS documented impairments on both sides of the lower extremities and the need for a wheelchair/walker for mobility. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene. Review of the bathing/shower system showed N/A entries for the resident for several consecutive days. During observation and interview, the resident stated that since admission no one had been available to assist with a bath or bed bath, and that when she asked a CNA for help, she was told the CNA was responsible for 14 other residents and could not assist during that shift. The resident said she asked the next shift’s CNA for bathing assistance, but the CNA never returned, and the resident confirmed she had not declined care. The DON later stated the resident’s scheduled shower days were Tuesday and Friday, that showers were not conducted upon admission but bed baths were offered, and that the resident refused a shower because her sister had provided one. CNA BB stated that if a resident did not receive a shower or bed bath, she marked N/A in the EHR, did not have any conversation with the resident about bathing, and did not offer bathing as an option.
Oxygen Therapy Not Provided per Physician Orders
Penalty
Summary
The facility failed to ensure that two residents received oxygen therapy in accordance with physician orders. One resident had diagnoses including COPD with acute exacerbation, acute respiratory failure with hypoxia, atrial fibrillation, and pneumonia, and the record showed an order for oxygen at 2 L via nasal cannula every day and night shift. During observation, the resident’s oxygen concentrator was found set between 2.5 and 3 L, and the Unit Manager RN confirmed the setting was 3 L even though the order specified 2 L. The DON stated the resident had stubborn behaviors and may have adjusted the concentrator, but no such behaviors were documented in the care plan, and the resident later stated he had not changed the oxygen setting. A second resident had diagnoses including pneumonia, acute respiratory failure with hypoxia, congestive heart failure, and atrial fibrillation, with an order for oxygen at 3 LPM via nasal cannula continuously and to maintain oxygen saturation at 92% or above. The skilled charting documented oxygen at 3 L via nasal cannula, but during observation the concentrator was set at 2 L. The Unit Manager RN confirmed the setting was 2 L despite the order for 3 L. The DON stated the oxygen had been reduced because it was being phased out, but there was no documentation or assessment identifying the reduction, and the Respiratory Therapist also stated there was no documentation of the change.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for two residents. The facility’s Infection Prevention and Control Policy stated that hand hygiene should be used after touching blood, body fluids, secretions, contaminated items, immediately after removing gloves, and between patient contacts. During observation, an LPN administered medications without using hand hygiene before or after medication pass activities, including before entering and after exiting resident rooms. R35 was admitted with diagnoses including contracture of the right hand, HIV, congenital cerebral cysts, and chronic hepatitis C. The resident’s quarterly MDS showed a BIMS score of 15, indicating cognitive intactness, and Section GG showed the resident required or was set up/clean-up assistance for ADLs. During medication administration, the LPN passed medication packets at the cart, realized a new medication was not on the cart, returned to the medication machine without sanitizing her hands, then prepared the medications with applesauce and water. She entered R35’s room, administered the medications, exited without washing or sanitizing her hands, and went to the next room to begin setting up medications. R38 was admitted with diagnoses including unilateral primary osteoarthritis of the left knee, cardiomegaly, type 2 diabetes mellitus, and depression, and had a BIMS score of 15. During observation and interview, the LPN administered medications to R38 without using hand hygiene before setting up medications, upon room entrance, or upon room exit. When questioned, the LPN confirmed she had not used hand hygiene while passing out medications and then removed a small sanitizer bottle from her pocket. Staff interviews later confirmed that hand hygiene was expected before and after resident care, when entering and exiting rooms, and when touching contaminated surfaces.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition involving the initiation of intravenous fluids and antibiotics. According to the facility's policy, the interdisciplinary team is required to communicate with residents and/or families or responsible parties when there is a change in clinical condition, including changes in medication. For one resident with diagnoses including acute respiratory failure with hypoxia, pneumonitis due to inhalation, and dementia, physician orders were initiated for IV sodium chloride and oral levofloxacin for pneumonia. Documentation in the electronic medical record confirmed the administration of these treatments, but there was no evidence that the responsible party was notified of these changes. Staff interviews revealed that the LPN responsible for the resident's care could not recall if the family or responsible party had been notified and did not believe any such notification was documented. The unit manager confirmed that changes in medication or clinical condition should prompt family notification. The Director of Nursing acknowledged that the responsible party had not been notified and that a grievance had been filed by the family. The lack of notification was not in accordance with facility policy and resulted in the responsible party not being informed of the resident's change in condition.
Failure to Provide Proper SNF ABN and Documentation to Resident's Responsible Party
Penalty
Summary
The facility failed to provide an accurate and properly documented Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for one resident who was reviewed for beneficiary notices. The resident, who had diagnoses including hypertension, dementia, and hyperlipidemia, was admitted to the facility and had a responsible party (RP) managing their affairs due to cognitive deficits. The facility's records showed that the Notice of Medicare Non-Coverage (NOMNC) and SNF ABN were not properly signed or dated, and there was no evidence that the required notice was physically provided to the RP. Instead, the Business Office Manager (BOM) stated that the information was read to the RP over the phone, but there was no documentation to confirm this communication or to indicate that the RP was informed of the resident's financial responsibility for continued services. Interviews with the BOM confirmed the lack of documentation and the absence of a signed SNF ABN form. The BOM acknowledged that the notice was not provided in accordance with requirements and that the resident remained in the facility after the notice was given. The Director of Nursing (DON) indicated there was a miscommunication regarding the proper use of the SNF ABN form and expected the BOM to follow the correct procedure.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents across three halls, as observed by surveyors. Specific deficiencies included peeling paint, missing air vent covers, holes in walls, bent or broken blinds, a broken light fixture pull cord, a loose electrical wall socket, and cracked floors. These issues were identified in multiple rooms, affecting a sample size of 59 residents. The Maintenance Director confirmed these observations during an interview, acknowledging the need for repairs but indicating a lack of awareness of the specific concerns prior to the survey. The Maintenance Director also mentioned that maintenance concerns are reported directly to him or entered into a logbook at each nurse's station, which he checks regularly. Additional observations revealed further deficiencies, such as a leaking toilet, slow-draining sink, and a water temperature of 125 degrees Fahrenheit in one room, which could pose safety risks. Makeshift solutions, like using grocery bags to extend a broken string light, were noted, indicating inadequate lighting solutions. Structural issues, such as uneven and raised bathroom floors, exposed wiring from a wall socket, and gaps between the floor and baseboard, were also observed, highlighting potential safety hazards. The Maintenance Director stated that repairs were planned, starting with painting resident rooms and bathrooms, but he was operating as a one-man team and would request assistance for more extensive repairs.
Unsafe Water Temperatures in Facility Bathrooms
Penalty
Summary
The facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in 17 out of 22 bathrooms sampled across three halls. This deficiency was identified during an initial observation on 9/16/2024, where the water from bathroom sinks was found to be too hot to touch. Specific temperature readings ranged from 108 to 123 degrees Fahrenheit, with several rooms recording temperatures at or above the 120-degree threshold. Interviews with residents revealed that they perceived the water as very hot, although no burns were reported. The Maintenance Director (MD) acknowledged setting the water heater at 122 degrees Fahrenheit to supply hot water to various facility areas, including the kitchen and laundry, and admitted to not maintaining a log of water temperature checks. The MD stated that he conducted random weekly checks of water temperatures but had not received any complaints or reports of burns. Despite this, the lack of a formal policy on water temperatures and the absence of a documented monitoring process contributed to the oversight. The review of facility records, including the Grievance Log, Resident Council Minutes, and Incident Reports, showed no prior concerns related to hot water. This oversight had the potential to cause serious injury to residents due to the excessively high water temperatures in the bathrooms.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident with a Foley catheter. The resident was observed sitting in the hallway in a wheelchair with a urinary catheter bag left uncovered and visible, which is against the facility's policy that requires the use of a dignity bag or leg bag for Foley catheters, especially when the resident is out of their room. Additionally, the resident was wearing a shirt with her full name written in large black marker across the front, which is contrary to the facility's clothing labeling policy that requires labeling to be done inside the clothing near the label to maintain privacy. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 00, and required partial/moderate assistance for activities of daily living. The resident's care plan included interventions to encourage social interaction and participation in activities. Interviews with staff, including the Unit Manager LPNs and the Director of Nursing, confirmed the facility's policies on clothing labeling and catheter dignity, and acknowledged the failure to adhere to these policies in this instance.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication before leaving medications at the bedside. The facility's policy requires that residents who wish to self-administer medications must be assessed by a Licensed Nurse and have a physician's order confirming the safety of this practice. However, in the case of the resident in question, there was no assessment or physician's order found in the electronic health record to authorize self-administration of medication. During an observation, a tube of diclofenac sodium topical gel was found on the resident's bedside table. The resident's electronic health record did not contain any documentation of an assessment or physician's order for self-administration of medication. Interviews with staff, including a CNA and an LPN, confirmed that medications should not be left at the bedside unless the resident has been assessed and deemed capable of self-administration. The staff also confirmed that they had received in-service training regarding the protocol for medications at the bedside. The Director of Nursing and the Administrator both emphasized that medications should not be stored at the bedside unless the resident has been properly assessed and authorized to self-administer. The DON highlighted the importance of assessing residents' ability to self-administer medications and noted the potential negative outcomes if residents take medications outside the prescribed times. The Administrator reiterated the expectation that residents should not have any medications by their bedside table.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R112, by not ensuring that the call light was within reach, which is a requirement under the facility's policy titled 'Residents Rights Accommodation of Needs and Preference and Homelike Environment.' The policy, effective from February 1, 2024, mandates that call lights should be accessible to residents both in their rooms and bathrooms. R112, who has a severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of five, requires a manual wheelchair and two-person assistance. On September 16, 2024, at 12:00 pm, R112 was observed sitting in her wheelchair, screaming for help with the door closed, and her call light device was found wrapped around her bed rail, out of reach. A subsequent observation on September 18, 2024, at 3:00 pm, revealed R112 sitting in her wheelchair watching television, again with the call light device out of reach. During an interview on September 19, 2024, the Director of Nursing (DON) stated that her expectation was for staff to ensure residents' needs and preferences are met and to provide a homelike environment, noting that in-service education on resident accommodation and policy had been provided to the nursing staff.
Failure to Facilitate After-Hours Visitation
Penalty
Summary
The facility failed to have a system in place that allows visitors to enter after hours, which is a violation of the residents' rights to receive visitors of their choosing at any time. Observations revealed that the entrance to the facility was very dark, with only security lights on, and a small sign instructed visitors to call a number for after-hours access. However, when the number was called multiple times, the phone rang continuously without being answered or redirected to voicemail. Surveyors had to walk around to a side entrance to gain access to the building. Interviews with staff, including LPNs and the Director of Nursing (DON), indicated that the phone system was supposed to transfer calls to the nurses' station after hours, but this did not occur. The DON and the Administrator both stated that while visiting hours were from 8:00 am to 8:00 pm, visitors were not stopped from coming after hours if they called ahead. However, the phone system's failure to transfer calls as expected could lead to visitors being unable to contact their family members, potentially causing upset or worry.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents who remained in the facility after being discharged from Medicare Part A services. The facility's policy requires that if a resident is unable to sign, the NOMNC can be issued by telephone, with written confirmation sent the same day. However, for both residents, only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided, indicating their discharge from Medicare Part A services. The records for one resident showed a Medicare stay from July 19, 2024, to August 30, 2024, while the other resident's stay was from June 25, 2024, to August 7, 2024. Interviews with the Business Office Manager and therapy staff revealed a misunderstanding of the NOMNC requirements. The Business Office Manager believed NOMNCs were only for residents discharged to home, while SNF ABNs were for those remaining in the facility. Therapy staff confirmed the discharge of the residents from therapy services, noting they had met their maximal potential. The facility administrator expected staff to provide the correct notification at the time of discharge from Medicare Part A, acknowledging that failure to do so could lead to resident confusion or incorrect information.
Inaccurate Dental Status Documentation in MDS Assessment
Penalty
Summary
The facility failed to accurately document the dental status of a resident in the annual Minimal Data Set (MDS) assessment. The resident, who was admitted with diagnoses including cognitive communication deficit, unspecified dementia, unspecified neurocognitive disorder with Lewy bodies, depression, and Parkinson's disease, was observed to be missing all but one of her upper teeth. However, the MDS assessment inaccurately recorded that there were no dental concerns. A dental exam conducted earlier documented multiple missing teeth and a plan for upper and lower partials. The Chief Clinical Officer confirmed the inaccuracy in the MDS assessment and acknowledged the expectation for the MDS Coordinator to perform accurate assessments.
Failure to Complete PASARR Level II Screening for Resident
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level II was completed for one of the residents, identified as R92. The facility's policy requires that all potential admissions undergo a PASARR Level I screening to determine if a Level II screening is necessary for individuals with mental disorders or intellectual disabilities. However, for R92, who was admitted with diagnoses including encephalopathy, depression, altered mental status, cognitive communication deficit, alcohol dependence, cannabis abuse, and PTSD, the Level II screening was not completed. This oversight was identified during a review of the facility's records and staff interviews. The electronic medical record for R92 showed a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, yet the care plan highlighted dependencies on staff for emotional, intellectual, physical, and social needs. Despite being seen by psychiatric services for depression, there was no documentation of a PTSD diagnosis in the psychiatric progress notes. An interview with the Social Services Director revealed that Level II screenings are typically completed by the hospital prior to admission, and she acknowledged the absence of a Level II screening for R92, indicating a lapse in the facility's adherence to its own policy.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for five residents, which is a requirement according to their policy. The policy mandates that an individualized interdisciplinary plan of care be in place within 48 hours of admission, but this was not completed for the residents in question. Interviews with staff, including the MDS Coordinator and the Director of Nursing, confirmed that the baseline care plans were not completed as expected, which could potentially affect the level of care and services provided to these residents. For instance, one resident was admitted with a urinary tract infection and other health issues but did not have a baseline care plan in place. The resident and their family expressed concerns about the resident's slow healing process. Another resident, who had been at the facility for six weeks, also did not have a baseline care plan, and the family was unaware of any care plan being in place. The MDS Coordinator acknowledged the oversight and stated that the comprehensive assessment should be completed by day 14, but the baseline care plan was expected within 48 hours. Additionally, a resident with a high risk for falls due to bilateral below-the-knee amputations and other health conditions did not have a baseline care plan completed within the required timeframe. This resident experienced a fall after using the call light without receiving timely assistance. The fall assessment was only completed after the incident, highlighting the lack of a proactive care plan to address the resident's needs and risks. Interviews with nursing staff and the DON revealed that the expected procedures for fall risk assessment and care planning were not followed, contributing to the deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. For one resident, identified as R49, the facility did not create a baseline care plan or address the resident's urinary tract infection (UTI) in the care plan. Despite the resident being alert and oriented, the absence of a care plan for the UTI was confirmed by both the Registered Nurse and the MDS Coordinator. The Director of Nursing acknowledged that baseline care plans should be completed within 48 hours of admission. Another resident, R111, was receiving oxygen therapy for hypoxia, with specific physician orders to maintain oxygen saturation levels. However, the care plan lacked specific interventions for the oxygen therapy. Interviews with the Director of Nursing and the Administrator confirmed that residents on oxygen therapy should have corresponding care plans, and it was expected that baseline care plans be completed within 48 hours of admission. For resident R92, who had diagnoses including depression and PTSD, the care plan did not address PTSD, despite the resident being seen by psychiatric services for depression. The care plan noted the resident's dependence on staff for emotional and social needs but failed to include interventions for PTSD. Progress notes from psychiatric services did not mention PTSD, indicating a gap in addressing this aspect of the resident's care needs.
Failure to Include Family in Care Plan Meetings
Penalty
Summary
The facility failed to include a resident, their family, or family representative in baseline care plan meetings and care plan meetings, as required by their policy. The policy mandates that the Interdisciplinary Team (IDT) develop the care plan in conjunction with the Resident Assessment Instrument (RAI) and conduct a Comprehensive Care Plan meeting by Day 21 post-admission. However, a review of the electronic medical record for the resident revealed no documentation of who attended the care plan meeting. Interviews with staff, including the MDS RN and Social Services Director, indicated that typically only the resident attends these meetings, and there was a lack of consistent communication with families regarding care plan meetings. The resident's family was unaware of any care plan, highlighting a communication breakdown. The Director of Medical Records and the Director of Nursing provided insights into the processes for scheduling and documenting care plans, but there was no clear timeframe for when care plans should be uploaded into the system. The facility's policy states that residents and their representatives should play an active role in care plan development, but this was not adhered to in this case, leading to the deficiency.
Failure to Provide Adequate Discharge Instructions
Penalty
Summary
The facility failed to provide adequate discharge instructions to the responsible party of a resident, identified as R366, upon discharge. The facility's policy on discharge planning, revised on 7/19/2024, mandates that discharge plans include the location of discharge, anticipated referrals, and durable medical equipment, and that a copy of the discharge plan be given to the resident or their representative. However, the responsible party, R366's son, reported that he was not provided with necessary information regarding medications and therapy needs for his mother, who was discharged with diagnoses including cerebral infarction, atrial fibrillation, cognitive communication deficit, type 2 diabetes, and hypertension. The son was informed of the discharge after receiving the Notice of Medicare Non-Coverage and was not present at the facility to receive discharge instructions, which were reportedly discussed over the phone. The discharge instructions lacked dietary/nutrition and therapy special instructions, and the medications the resident was to receive at home were not listed. Additionally, there was no signature from the resident or the responsible party on the discharge summary. Interviews with facility staff, including an LPN and the Director of Nurses, revealed that the discharge process involves obtaining a discharge order from the physician, notifying the family, and ensuring the resident is clean and stable for transport. The Director of Nurses expected that discharge instructions would be reviewed with the resident and/or family, and documented to ensure understanding, but this was not adequately done in this case.
Failure to Provide Adequate Fingernail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident, identified as R80, who was unable to perform activities of daily living independently. R80 was admitted with diagnoses including type 2 diabetes and cerebral infarction, and had a severely impaired cognition with a BIMS score of 2. The resident's care plan indicated a need for full staff assistance with self-care ADLs. Despite this, observations on multiple occasions revealed that R80 had long, sharp, and dirty fingernails, which were not being properly maintained as per the facility's policy titled AM Care. Interviews with facility staff, including a CNA and the Unit Manager, indicated that nail care was provided on an as-needed basis, which was not sufficient for R80's needs. The CNA confirmed that R80's nails were too long, and the DON expressed an expectation for all residents' nails to be clean and groomed. However, the observations and interviews demonstrated a failure to adhere to these expectations, resulting in the deficiency noted in the report.
Failure to Arrange Follow-Up Appointments and Transportation
Penalty
Summary
The facility failed to arrange follow-up appointments and transportation for a resident after discharge from the hospital, which was a deficiency identified by surveyors. The resident, who was admitted with conditions including cerebral infarction, atrial fibrillation, cognitive communication deficit, type 2 diabetes, and hypertension, had a BIMS score indicating moderate cognitive impairment and was dependent on staff for ADLs. Hospital discharge instructions required follow-up with a hematologist, neurologist, and cardiologist. However, the facility did not provide documentation of appointments or transportation for these follow-ups, as confirmed by the resident's responsible party and the facility administrator.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for a resident, identified as R111, who was on oxygen therapy. The facility's policy on oxygen administration required verification of a physician's order and adjustment of the oxygen delivery device to ensure the proper flow of oxygen. However, observations and interviews revealed that R111's oxygen was set at 1 liter per minute (LPM) instead of the prescribed 2 LPM. This discrepancy was noted during an observation on September 16, 2024, and confirmed again on September 18, 2024, despite the resident's electronic health record indicating a physician's order for 2 LPM to manage hypoxia and maintain oxygen saturation at 90% or above. The resident, R111, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported that her oxygen level was supposed to be at 2 LPM. Licensed Practical Nurse (LPN) CC confirmed the physician's order for 2 LPM but was unaware that the oxygen level was set below the prescribed amount. The Director of Nursing (DON) and the Administrator both expressed expectations that nursing staff adhere strictly to physician orders for oxygen therapy, acknowledging that failure to do so could lead to respiratory complications for the resident.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that medications and biologicals were discarded on or after their expiration date in two of three medication rooms, as observed during a survey. The facility's policy on Medication Storage mandates that outdated, contaminated, discontinued, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, an observation revealed an emergency kit in one medication room refrigerator containing expired medications, including insulin vials, insulin pens, Tylenol suppositories, aspirin suppositories, Phenergan, and lorazepam. The Unit Manager confirmed the expiration date during the observation. An interview with the Director of Nursing indicated that her expectations were that medications should not be expired.
Lack of Physician's Order for Hospice Services
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had a physician's order for hospice services. The facility's policy, last reviewed on 9/15/2023, requires that the Interdisciplinary Team (IDT) coordinate care and ensure hospice physician and applicable attending physician orders for residents. A review of the clinical record for a resident with diagnoses including peripheral vascular disease and Alzheimer's disease indicated that hospice care was documented in the Quarterly Minimum Data Set (MDS) and the care plan. However, the current physician's orders did not include orders for hospice services, despite the facility having a hospice contract with the agency providing services to the resident. Interviews with a Registered Nurse and the Director of Nursing confirmed that the resident should have had a physician's order for hospice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices during several procedures, including medication administration via a gastrostomy tube (G-tube), perineal care, and tracheostomy care. For one resident with a G-tube, a Licensed Practical Nurse (LPN) did not wear a gown during medication administration, despite the resident being on Enhanced Barrier Precautions (EBP). The LPN admitted to not receiving education on the necessity of wearing a gown for this procedure. Additionally, a Certified Nursing Assistant (CNA) was observed using an electronic blood pressure machine on multiple residents without cleaning or sanitizing it between uses, which she acknowledged should have been done. Another deficiency was noted during perineal care for a resident with an indwelling catheter, where a CNA reused a cleaning wipe instead of using a clean one for each swipe. This was confirmed by both the CNA and an LPN. Furthermore, during tracheostomy care for a resident, an LPN failed to maintain sterile technique by contaminating the sterile field and not wearing sterile gloves properly. The facility also had empty hand sanitizer dispensers in several locations, which were confirmed by a floor technician responsible for refilling them, and a CNA who attempted to use an empty dispenser.
Deficient Call Light System in West Hall
Penalty
Summary
The facility failed to maintain a working resident call light system in one of its hallways, specifically the West Hall. During an observation, it was noted that four call lights on the nursing unit call light board were flashing without any accompanying sound, which is necessary for alerting staff to resident needs. A Certified Nursing Assistant (CNA) confirmed the malfunction, stating that the call lights should both light up and make a sound when activated, and that a flashing light indicates a high alert. Additionally, in a separate incident, the call device in a specific resident's room failed to activate the hallway light when used by the resident. This was verified by a Registered Nurse (RN) during an observation and interview.
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What surveyors actually found near you
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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 Marietta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roselane Health Center By Harborview | 0.4 mi | ★★★★★ | 14 | 0 |
| Marietta Center For Nursing And Healing | 1.3 mi | ★★★★★ | 1 | 0 |
| Autumn Breeze Health And Rehab | 3.7 mi | ★★★★★ | 6 | 0 |
| A.g. Rhodes Home, Inc - Cobb | 3.8 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Marietta | 3.8 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.