Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Islands Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to obtain and document AHCDs and capacity determinations: The facility did not have copies of several residents’ AHCDs on file, did not document that one resident was informed of the right to develop an AHCD, and could not provide physician documentation of lack of capacity for a resident with a surrogate decision-making form. In one case, the record showed an existing AHCD, but no copy was found in the EHR and no attempts to obtain it were documented.
Improper Food Labeling, Expired Food Storage, and Missed Temperature Checks: The facility failed to properly label refrigerated and frozen food, discard items past their used-by dates, and consistently document food temperatures before service. During kitchen observation, unlabeled meat, seafood, and papaya were found in the freezer, expired items remained in the refrigerator, and an HCA used hard-boiled eggs past their used-by date for breakfast. The DM acknowledged missing oversight and repeated failures to check and record hot and cold food temps.
A facility failed to maintain infection control in a supply room and during wound care for a resident with a stage 4 sacral PU. Clean ice for resident use was stored near a sink used for handwashing and resident water, staff food and fluid items were kept in the same area, and the ice cooler blocked access to the paper towel dispenser while staff washed hands. During wound care, an RN cleaned the wound area but did not change gloves or perform hand hygiene before applying the foam dressing, and the DON confirmed the lapse.
A resident’s choice to eat lunch before therapy was not honored when rehab treatment occurred during the lunch period and meal trays remained untouched at the bedside. Staff observed PTA and COTA treatment while the resident’s lunch was still present, and RT later had to prepare the resident to eat safely, but lunch was held when the resident could not manage secretions and catch her breath. The resident stated therapy after lunch was preferred because therapy made her tired and caused coughing, and the DON confirmed rehab should not be providing treatment during meals.
Two residents were affected by missed follow-up on psychotropic medication reviews. One resident had PRN lorazepam continued past the 14-day period without documented physician follow-up, and a routine Seroquel order lacked documentation of follow-up on a recommended GDR. Another resident had citalopram without documented side effect monitoring and PRN quetiapine that remained active beyond the 14-day limit without documentation that the resident was directly assessed.
Failure to Notify Resident Representatives and Ombudsman of Hospital Transfers: The facility failed to provide discharge/transfer notice to a resident representative for one resident and failed to notify the LTC Ombudsman for two residents transferred to the hospital. Records showed one resident had hospitalizations for sepsis and a GI bleed requiring blood transfusion, while another resident had multiple hospital transfers for pulmonary edema, pneumonia, GI bleeding, and N/V. The SW could not produce the required notices or evidence that the Ombudsman was notified.
Failure to develop and implement person-centered care plans for dialysis and mobility needs. A resident on dialysis had a fistula pressure dressing left on after treatment, with no care plan intervention to remove it within 2 hours of return. Several residents with contractures and limited ROM did not receive ordered or planned interventions such as hand rolls or PROM, and task records were repeatedly marked not applicable even though staff confirmed the care was not being done.
A facility failed to include and carry out individualized activity preferences for two residents. One resident preferred reading, TV, and outdoor strolls but was observed staying in bed, while the AC said outdoor strolls were not being done and refusals were not documented. Another resident with a stroke history, VAP, and morbid obesity said he did not get out of bed for activities and wanted to go outside for fresh air, but his care plan did not reflect that preference even though his MDS rated it very important.
Failure to provide ROM and functional maintenance services: A resident with ventilator dependence and quadriplegia had a therapy-established functional maintenance program, but it was not in the care plan or orders and there was no EHR documentation that it was performed. Other residents with severe neurologic and mobility impairments had PROM or hand-roll interventions not carried out, with task records marked not applicable, and CNA/DON interviews confirmed the care was not being done.
Pressure dressing left on after HD treatment. A resident with ESRD and a right upper arm fistula returned from dialysis and the pressure dressing remained in place for more than nine hours instead of being removed after two hours. An RN stated staff sometimes left the dressing on because of access bleeding, but no documentation was found to support bleeding that would justify keeping it on. The DON confirmed the dressing should have been removed after two hours, and the facility policy required monitoring and documenting the access site for bleeding or other complications.
A resident with depression, anxiety, insomnia, and PTSD was not adequately assessed for past trauma or trauma triggers. The SW said no specific TIC screening tool was used, the psychosocial assessment was completed late, the trauma/PTSD item was marked NA, and prior TIC documentation could not be found; the SW also had no completion date on the TIC training log.
Failure to act on pharmacist MRR recommendations for a resident receiving metformin, apixaban, and insulin. The pharmacist twice recommended A1c and CMP testing, but the EHR showed no lab results. The DON confirmed the recommendations were missed and stated he had only recently become aware of the MRR process.
Unlocked medications and chemicals were found on the third-floor resident unit in both the supply room and the DON's office. Bacitracin zinc ointment packets, hydrocortisone packets, skin integrity wound cleanser, and liquid-loc plus bottles were observed in unlocked storage, and the DON confirmed these items should have been locked. The DON also acknowledged that medications left on an open shelf in his office should be locked.
The facility did not submit required direct care staffing information, including payroll data for agency and contract staff, to CMS for a fiscal quarter. Review of the PBJ Staffing Data Report showed no data was submitted, and the Administrator confirmed missed deadlines for submission.
The facility did not keep records of dryer lint removal and cleaning as required by policy. Observation revealed lint present in the dryer lint traps, and the Environmental Services Director confirmed that record-keeping for this task had recently stopped.
Staff were observed standing over multiple residents while assisting with meals, rather than sitting or being at eye level, and a resident's urinary catheter bag was left uncovered and visible from the hallway despite an order for a privacy cover. Facility policies did not address these dignity concerns, and the DON confirmed that staff typically stand during meal assistance.
Two residents did not have comprehensive care plans addressing their specific needs. One resident lacked a care plan for bed rail use despite documented consent and observed use, while another resident's care plan did not address declining ROM, even though assessments showed impairments. These omissions were confirmed by the IDON and staff during interviews and record reviews.
A buildup of dust was observed on the backs of ceiling-mounted televisions and their wires in several rooms, including those occupied by residents with tracheostomies. Housekeeping staff had not performed high dusting recently due to a lack of proper equipment, and facility leadership acknowledged the issue after being shown photographic evidence.
A resident was not accurately assessed for range of motion limitations, as discrepancies were found in MDS documentation compared to the resident's actual abilities. Staff interviews and record reviews revealed that the resident could assist with movement, but the MDS was incorrectly coded as having impairments on both sides, leading to an inaccurate assessment.
A resident was admitted with orders for insulin to manage hyperglycemia, but did not have a documented diagnosis of diabetes or hyperglycemia in the medical record. Despite ongoing insulin administration and physician documentation of hyperglycemia, no baseline care plan was developed to address the resident's condition or insulin use. The absence of both a diagnosis and a care plan was confirmed by the IDON.
A resident with a facility-acquired stage 3 pressure ulcer, which later progressed to stage 4, was not consistently repositioned according to the care plan and facility protocols. Review of turning logs showed the resident was documented as being on the same side for consecutive intervals, and the Interim DON confirmed staff should have turned the resident as required.
A resident with significant mobility impairments and a history of brain cancer was found resting in bed without an upper right bed rail, which staff were unaware had been removed. The missing bed rail, later found in the resident's bathroom, was not identified or addressed by staff until prompted by a surveyor, indicating a lack of adequate supervision and failure to maintain an environment free from accident hazards.
A resident with multiple diagnoses and on several medications did not have a pharmacist's recommended lab work communicated to the physician, as required by facility policy. The Interim DON confirmed the omission was due to a vacant DON position, resulting in the facility's failure to act on the Medication Regimen Review recommendation.
Surveyors found that medication cart keys, including those for controlled drugs, were left unattended on the cart rather than kept with nursing staff as required by policy. Required signatures for narcotic count reconciliation were missing on two shifts. Additionally, expired insulin was not disposed of and was administered to a resident, and blood glucose testing supplies lacked required labeling for open and discard dates, making it impossible for staff to determine their usability.
A grayish-green residue was found under the ice dispenser during a kitchen inspection, and the Kitchen Manager acknowledged the buildup had not been previously noticed despite recent servicing and monthly inspection logs.
A resident with multiple medical conditions did not have an Advanced Health Care Directive or a designated healthcare POA, yet the POLST form incorrectly listed the spouse as the agent. The facility lacked documentation and a process for naming a surrogate decision-maker, resulting in an inaccurately completed POLST.
Staff did not follow infection prevention protocols, including failing to keep a urinary catheter bag off the floor for a dependent resident, not performing hand hygiene between glove changes, and not wearing required PPE such as gowns during care of residents with gastrostomy tubes. These actions were inconsistent with facility policies and staff training.
A resident with complex medical needs suffered harm due to the nursing staff's failure to demonstrate appropriate competencies and skills. The staff did not follow protocol to obtain emergency physician services when needed and applied a scopolamine patch without a physician's order, leading to adverse symptoms. The facility's records lacked documentation of the patch application, and the staff failed to follow the chain of command when the on-call provider was unreachable.
A resident with complex medical needs was inappropriately discharged from an LTC facility without proper documentation or notification. Despite the facility's capability to provide necessary care, the resident was not allowed to return post-hospitalization due to issues with the parents' behavior. The facility failed to follow its transfer/discharge policy and did not provide the required notice to the resident's representative or Ombudsman.
A resident was transferred to a hospital for higher care, and the facility decided not to readmit him. The facility failed to notify the resident's representative and the ombudsman of this decision, preventing the representative from appealing. The social worker misunderstood the process, assuming a transfer was a discharge, and did not send a formal notice of the decision not to readmit.
A facility failed to follow its discharge policy and did not provide the required notice to a resident's representative or Ombudsman. After a resident was hospitalized, the facility refused to readmit him despite having an open bed and the capability to care for him, citing concerns about the mother's behavior. The decision was made without involving the family or addressing the concerns, and the refusal was not based on the resident's behavior or medical condition.
A resident's care plan was not updated to include specific care preferences requested by the POA, despite being documented in the medical records. The resident, with a history of cerebral hemorrhage and quadriplegia, had special instructions such as the use of pressure boots and temperature control measures that were not reflected in the care plan. The DON acknowledged the oversight, noting that these instructions were visible to staff but should have been included in the care plan.
A resident with a complex medical history experienced an increased heart rate and behavioral changes, requiring emergency physician services. Despite multiple attempts, the nursing staff was unable to reach the on-call APRN, resulting in a delay before the resident was transferred to the Emergency Department. The facility's policy mandates prompt physician consultation, but there was no documentation of the attempts to contact the provider.
The facility did not post complete daily Nursing Staffing Information, omitting the hours worked by RNs and CNAs and the resident census. The Daily Assignment sheet only listed staff names, assigned areas, and shifts. The DON confirmed the missing information during an interview.
The facility failed to maintain an accurate and up-to-date facility-wide assessment, inaccurately reporting zero residents requiring respiratory treatments or mechanical ventilation. However, the facility matrix showed 24 residents with tracheostomies and 15 on mechanical ventilators. This discrepancy indicates reliance on a template rather than a comprehensive assessment, increasing the risk of harm to residents.
The facility failed to implement comprehensive care plans for three residents prescribed psychotropic medications, omitting non-pharmacological interventions and behavior monitoring. A resident with major depressive disorder and insomnia, another with dementia and anxiety, and a third with PTSD and adjustment disorder were affected, as identified during record reviews and RN interviews.
A facility failed to update the care plan for a resident with a tracheostomy, omitting the representative's decision against a tracheostomy cap trial. The care plan lacked documentation on the use of a Passy Muir valve for communication and the representative's wishes, despite these being discussed in an interdisciplinary team meeting. This oversight potentially disregards the resident's rights.
A resident with multiple health issues did not receive care according to physician orders, as the facility failed to withhold a stool softener despite documented loose stools. This oversight, confirmed by an RN, increased the risk of skin breakdown and discomfort, contrary to the facility's bowel elimination policy.
The facility failed to ensure that physicians documented the review of pharmacist recommendations for three residents. One resident's trazodone PRN continuation lacked a rationale, another's acetaminophen limit was not adjusted, and a third resident's behavioral monitoring and tests were not implemented. Documentation of physician review was missing in all cases.
The facility failed to monitor behaviors related to psychotropic medication use for three residents, including those with major depressive disorder, anxiety, and PTSD. Records lacked documentation of monitored behaviors and physician rationale for extended PRN use, as confirmed by an RN.
A facility experienced a high medication error rate of 38.36% due to improper administration practices. Errors included administering medications via the wrong route and not adhering to physician orders regarding hold parameters. One resident received medications through a G-tube that were ordered to be given by mouth, and another resident's medication was not held despite low blood pressure. Additionally, a nurse administered multiple medications together via a G-tube, contrary to policy.
The facility failed to maintain an effective infection control program, with unclean resident rooms, reused disposable equipment, and incomplete policies. Observations included soiled floors, reused G-Tube tips, and peeling paint in the kitchen. Staff interviews revealed confusion over cleaning responsibilities and a lack of comprehensive oversight in the infection control program.
The facility failed to maintain privacy and dignity for three residents. A resident on a ventilator was exposed during personal care due to an inadequate privacy curtain. Two residents with urinary catheters had their bags uncovered and visible in the hallway. The facility's policy on dignity was not effectively implemented.
A resident's rights were violated when a tracheostomy cap was placed without the legal guardian's consent, causing distress to the resident. Despite the guardian's disagreement, a Speech Therapist obtained a doctor's order, and a Respiratory Therapist placed the cap, leading to the resident's upset reaction. The incident was reported to the Director of Rehabilitation, who acknowledged the need for guardian consent.
The facility failed to ensure that three residents or their representatives received and acknowledged the Notice of Medicare Non-Coverage (NOMNC) forms as required. The forms were left at the bedside for two residents and not emailed to the representative of a third resident with severe cognitive impairment. The facility lacked a policy for NOMNC form delivery, and staff misunderstood the requirement for obtaining signatures.
The facility failed to report allegations of abuse and an injury of unknown origin involving two residents to the State Survey Agency within the required time frame. In one case, a resident was reportedly mistreated by a CNA, and the incident was not reported within the mandated two-hour window. In another case, a resident had a bruise on his forearm from a dialysis session, with no documentation or timely reporting of the injury. These failures constitute a deficiency in regulatory compliance.
A facility failed to remove a CNA accused of abuse from the premises during an investigation, allowing her continued access to a resident who reported feeling harassed. Despite the facility's policy requiring immediate suspension of accused employees, the CNA continued working, and the investigation was not completed until two days later. The allegations were ultimately unsubstantiated, but the failure to follow protocol led to a deficiency.
A facility failed to provide written transfer/discharge notifications to a resident, their representative, and the LTCO for three hospitalizations due to medical conditions. The Social Services Director cited the resident's VA insurance status as the reason for not issuing the notifications, despite facility policy requiring such notices.
A facility failed to conduct a quarterly fall assessment for a resident, as required by their Fall Prevention Program. The last assessment was done in December, and the next one due in March was missed. A new RN was unaware of the assessment schedule, and the DON confirmed the oversight.
A facility failed to include a resident's daily preferences in her baseline care plan within 48 hours of admission. The resident, who has a tracheostomy and uses a ventilator, was admitted without her preferences documented, despite her daughters being involved in her care decisions. The DON confirmed that all areas of the baseline care plan should be completed within 48 hours, which was not done in this case.
Failure to Obtain and Document Advance Directives and Capacity Determinations
Penalty
Summary
The facility failed to obtain copies of residents’ Advance Health Care Directives (AHCDs), failed to inform a resident of the right to develop an AHCD and/or provide assistance in doing so, and was unable to provide documentation of physician determination that certain residents lacked capacity for decision making in relation to the Declaration of Authority to act as Surrogate for a Patient. For one resident, the Declaration of Authority form was present in the electronic health record, but the section for the physician’s lack-of-capacity determination was not completed, and the Social Worker stated that physician confirmation should be present when the form is initiated. A facility document also confirmed that a physician note of capacity for that resident could not be found in the EHR. For other residents reviewed, the EHR showed no AHCD on file, no copy of an existing AHCD, or no documentation that the resident and/or responsible party had been informed of the right to develop an AHCD. In one case, the resident’s record indicated an existing AHCD, but no copy was located in the EHR, and no documentation of attempts to obtain the AHCD was found. The facility policy stated that upon admission, if a resident has an advance directive, copies will be made and placed on the chart and that the facility will periodically assess decision-making ability and approach the health care proxy or legal representative if the resident is determined not to have decision-making capacity.
Improper Food Labeling, Expired Food Storage, and Missed Temperature Checks
Penalty
Summary
The facility failed to ensure that food items stored in the refrigerator and freezer were properly labeled and that food past its used-by date was discarded. During the initial kitchen walkthrough, multiple meat and seafood items and a box of papaya were observed in the freezer without proper labeling. In the refrigerator, hummus and spinach artichoke dip had a date of 04/15/26 but no discard date, and sliced cucumber and hard-boiled eggs with a used-by date of 04/24/26 were still present. The Dietary Manager stated the facility was short-staffed and he was out on emergency leave, resulting in no oversight of labeling and discarding food items, and acknowledged the importance of labeling and discarding food on or before the used-by date to prevent foodborne illness. The facility also failed to consistently check and document food temperatures before service, and hard-boiled eggs that were past their used-by date were served for breakfast. During breakfast preparation, Kitchen Help 1 was observed assembling the tray line, and the daily temperature log showed no documented temperature check for the hot foods. Review of the April temperature log showed missing temperature checks for both hot and cold foods for breakfast on 04/05/26 and for dinner on 04/25/26. The Dietary Manager confirmed that staff had missed checking and documenting food temperatures at least two to three times a month over the prior six months and acknowledged the importance of serving foods at the required temperature. Kitchen Help 1 used hard-boiled eggs from the refrigerator without checking the label, and those eggs had a used-by date of 04/24/26.
Infection Control Lapses in Supply Room Storage and Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in the third-floor supply room and during wound care for a resident with a stage 4 sacral pressure ulcer. On 04/28/26, RN17 stated that a small red cooler in the supply room contained clean ice for resident use, while the same sink in that room was used for both handwashing and filling water for residents. Staff food items were observed stored on top of a cabinet near the sink, and fluid storage containers were kept inside the cabinet. The cooler was positioned in front of the paper towel dispenser, and on multiple observations RT19, CNA21, RT4, and CNA2 washed their hands at the sink and reached toward the paper towel dispenser with wet hands while the cooler remained in front of it. The DON confirmed the sink was used for both handwashing and resident water, and stated the ice and staff food/fluid items should not have been stored next to the sink. On 04/29/26, the EHR showed that R20 had a stage 4 pressure ulcer to the sacrum requiring daily wound care and dressing changes. During observed wound care, RN6 cleaned the sacral area with skin prep but did not change gloves or perform hand hygiene before applying the foam dressing. RN6 stated she forgot to remove the dirty gloves, perform hand hygiene, and put on new gloves before applying the dressing. The DON later confirmed that RN6 should have changed gloves and performed hand hygiene prior to applying the foam dressing, and acknowledged that this was important for infection prevention.
Therapy Provided During Lunch Despite Resident Preference
Penalty
Summary
The facility failed to honor one resident’s choice to eat lunch before receiving therapy. On 04/28/26, CNA 20 and CNA21 were observed delivering meal trays to resident rooms on the third floor, and later that day PTA 1 was observed finishing treatment to the resident while an uneaten lunch tray remained on the bedside table. At 01:00 PM, RT 19 was suctioning the resident in preparation to deflate the tracheostomy cannula and attach the speaking valve so the resident could eat safely, but the resident could not manage secretions and catch her breath, so lunch was held. On 04/30/26, COTA 1 was observed providing treatment to the resident with the uneaten lunch tray still on the bedside table, and stated there was no set schedule for therapy for residents. COTA 1 also stated she tries to avoid providing treatment during lunchtime unless eating is related to the treatment, and confirmed eating was not part of the resident’s goals. The resident stated that rehab therapy after lunch was her preference because therapy makes her tired and causes coughing, leaving her too tired to eat. The DON stated nursing was not aware of rehab therapy’s schedule, confirmed rehab was aware of the lunch period and should not be providing treatment during meals, and said discussion with therapy was needed to coordinate schedules for residents receiving rehab therapy.
Failure to Follow Up on Psychotropic Medication Reviews
Penalty
Summary
The facility failed to ensure that two residents sampled for unnecessary medications were free from chemical restraints. For one resident, a medication regimen review by the consultant pharmacist recommended providing a specific stop date or time period and a clinical rationale to continue lorazepam 0.5 mg every 6 hours as needed past 14 days, but no nursing progress note was found showing that the recommendation was followed up with the physician. The same resident also had a consultant pharmacist recommendation to consider a gradual dose reduction for Seroquel 12.5 mg at bedtime, and no nursing progress note was found showing that this recommendation was followed up with the physician. For another resident, medication regimen reviews recommended documenting side effects for citalopram hydrobromide 20 mg via G-tube daily, but the current orders and April 2026 MAR did not list any monitoring for side effects. The resident also had quetiapine ordered as needed on 04/02/26 and it remained active beyond the 14-day time limit, with no nursing progress notes or prescribing practitioner notes showing the resident was directly examined and assessed to determine whether the PRN antipsychotic was still needed.
Failure to Notify Resident Representatives and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident representative of a discharge/transfer for one resident and failed to notify the Ombudsman for two residents who were transferred to the hospital. For one resident, the electronic health record showed hospitalizations for sepsis and for a gastrointestinal bleed with a hemoglobin level of 6.6 requiring a blood transfusion, but the facility could not provide documentation of discharge/transfer notification to the family representative or evidence that the Ombudsman was notified for those transfers. For another resident, the record showed three hospital transfers within the last 90 days, including admissions for pulmonary edema and pneumonia, gastrointestinal bleeding, and nausea and vomiting. When surveyors requested the discharge/transfer notifications, the Social Worker could not provide the notification to the family representative for one of the transfers and could not provide any notification made to the Ombudsman. The Social Worker stated they were still trying to find the missing transfer notification to the family representative and could not find any notification to the Ombudsman made by the previous Social Worker. The facility’s Transfer and Discharge policy stated that the notice must be provided to the resident, resident representative if appropriate, and LTC Ombudsman as soon as practicable before transfer or discharge, and that the facility will maintain evidence that the notice was sent to the Ombudsman.
Failure to Develop and Implement Person-Centered Care Plans for Dialysis and Mobility Needs
Penalty
Summary
The facility failed to develop and implement person-centered care plans for a resident receiving dialysis and for residents with decreased mobility and range of motion. For the resident on dialysis, a right upper arm fistula dressing was observed still in place the morning after dialysis treatment, and RN 6 stated the dressing is supposed to be removed two hours after the resident returns from dialysis, although it is sometimes left on because of bleeding. No documentation was found to support keeping the pressure dressing on, and RN 6 acknowledged the dressing should have been removed to prevent occlusion of the fistula. The resident’s care plan did not include an intervention to remove the pressure dressing within two hours of return from dialysis. For residents with contractures and limited mobility, the care plans and task documentation did not reflect the interventions being provided. One resident was observed repeatedly with a right hand contracture and no hand roll in place, and the care plan did not include application of a hand roll to the right hand. CNA 17 confirmed that the hand roll had not been applied, and the DON stated the CNAs should have been applying a specific hand roll made for that resident. The resident’s PROM task documentation for upper and lower extremities was marked not applicable for most of the month, and CNA 17 confirmed that not applicable meant the task was not done because staff did not have time. The same pattern was identified for two other residents with limited mobility. One resident’s care plan included gentle PROM with daily care, but the PROM task documentation was marked not applicable for most of the month, and CNA 17 confirmed PROM was not being done. Another resident’s care plan did not include PROM in the mobility problem, and the PROM task documentation was also marked not applicable for most of the month. The DON confirmed that not applicable meant the task was not done and acknowledged that PROM should have been included in the resident’s care plan despite the resident’s inability to communicate.
Failure to Individualize and Provide Resident Activity Preferences
Penalty
Summary
The facility failed to put individual activity preferences into the care plan and failed to implement those preferences for 2 sampled residents, R4 and R33. On 04/28/26, R4 was observed in bed watching television and stated that there were no activities he was interested in, and that other than going to physical therapy he had stayed in bed. His Activities-Initial Review completed on admission noted that he preferred independent activities such as reading and watching TV, and also wanted opportunities for outdoor strolls with wheelchair and porter assistance. The Event Calendar Report showed that R4 was invited to outdoor strolls multiple times in March and April, but the Activities Coordinator stated that the resident was offered the activity and declined, and also stated that refusals were not documented. The coordinator further stated that outdoor strolls were not currently being done because she was being pulled to CNA duties. R33, a [AGE]-year-old male admitted with diagnoses including left basal ganglia intraparenchymal hemorrhage, ventilator associated pneumonia, and morbid obesity, was interviewed in his room and indicated that he did not get out of bed during the day for activities. He also indicated that if there were an opportunity to go outside for fresh air, he would want to go outside. The Activities Coordinator stated that resident activities were being provided one on one because it was difficult to coordinate and get staff cooperation to get residents out of bed, and that outdoor strolls listed on the activities calendar were not currently being done. R33's MDS coded going outside for fresh air when the weather is good as very important, but his Activities care plan did not include this preference.
Failure to Provide ROM and Functional Maintenance Services
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment, equipment, and services to maintain or prevent decline in ROM, and failed to ensure a facility procedure was in place to implement functional maintenance programs. For one resident with chronic respiratory failure, ventilator dependence, and quadriplegia, therapy had established a functional maintenance program that included lower and upper extremity exercises and training for facility staff, but the program was not found in the care plan or physician orders and there was no documentation in the EHR that it was performed. The DON stated there was no formal restorative program, that the AC was the staff member educated on resident functional maintenance programs, and that there was no set documentation to show the programs were being done. For another resident with chronic respiratory failure, cerebral infarction, limited mobility, neurological deficit, weakness, and right-hand contracture, the resident was observed multiple times with no hand roll in place. CNA staff confirmed they had not been applying anything to the resident's right hand contracture, and the DON stated the CNAs should have been applying the hand roll that had been made for the resident. The resident's care plan included gentle ROM as tolerated with daily care, but the PROM task documentation for the upper and lower extremities was marked not applicable for the majority of the month, which staff confirmed meant the task was not done. Two additional residents with severe neurologic and mobility impairments also had PROM task documentation marked not applicable for most of the month. One resident with amyotrophic lateral sclerosis, functional quadriplegia, and bilateral lower extremity contractures had a care plan directing gentle PROM with daily care, but family reported staff had stopped doing PROM about a year earlier when in-house PT left. Another resident with chronic respiratory failure, cerebral infarction, and persistent vegetative state had no PROM included in the mobility problem on the care plan, and the PROM task documentation was also marked not applicable. The DON acknowledged that not applicable meant the task was not done and stated the importance of residents receiving PROM with daily care to prevent further decline in mobility.
Pressure dressing left on after hemodialysis
Penalty
Summary
The facility failed to ensure that dialysis care was consistent with professional standards of practice for a resident who required hemodialysis services. Resident 12, a male admitted with diagnoses including acute respiratory failure, gastrointestinal hemorrhage, and end stage renal disease, was on a Tuesday/Thursday/Saturday dialysis schedule. On 04/29/26 at 07:00 AM, he was observed in bed with the right upper arm fistula dressing still in place after completing dialysis the prior day. Registered Nurse 6 stated that the resident returned from dialysis around 09:30 PM on 04/28/26 and that the pressure dressing was left on for more than nine hours. RN 6 said the dressing was supposed to be removed two hours after the resident returned from dialysis, but staff sometimes left it on because of access bleeding. When asked for documentation showing bleeding that would justify leaving the dressing on, none could be found. The Director of Nursing confirmed that staff should have removed the pressure dressing after two hours to prevent access complications and occlusion. The facility’s Dialysis Treatment policy stated that the nurse will monitor and document the status of the resident’s access site to observe for bleeding, signs of infection, or other complications.
Failure to Identify Resident Trauma History
Penalty
Summary
The facility failed to adequately assess for and identify past trauma experienced by one resident with diagnoses including depression, anxiety, insomnia, and PTSD. The resident stated that he experienced trauma as a child, including violence by his father toward his mother and sisters, and reported that he had nightmares about it in the past. He also stated that the SW had not talked with him about his past trauma. The SW stated that no specific trauma assessment or screening form was used for the resident’s most recent readmission. A psychosocial assessment completed for the readmission included one question about trauma, but it was completed late and the History of Trauma/PTSD item was marked as NA. The SW also stated he was not aware of the resident’s PTSD diagnosis and could not find prior psychosocial assessment or TIC assessment documentation before the late assessment. The facility’s TIC training log did not show a completion date for the SW.
Failure to Act on Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to review and act upon the pharmacist’s recommendations from the monthly Medication Regimen Review for one sampled resident, R2. On 04/30/26, review of R2’s MRR from 11/30/25 showed pharmacist recommendations to consider A1C and CMP testing, and the MRR from 03/30/26 again recommended checking A1c and CMP because R2 was receiving metformin, apixaban, and insulin. Review of the electronic health record found no results for these blood tests. During interview on 04/30/26, the DON confirmed there were no lab results and stated the recommendations were not carried out. The DON said he had only recently become aware of the MRR process and that the recommendations for R2 were missed. The facility’s Medication Regimen Review policy, revised 03/25/26, stated that for residents experiencing a change in condition, the facility would notify the pharmacy provider using the Medication Regimen Review Communication form and would act upon all recommendations according to procedures for addressing medication regimen review irregularities.
Unlocked Medications and Chemicals Found on Third-Floor Unit
Penalty
Summary
The facility failed to ensure that medications and chemicals were stored in locked compartments on the third-floor resident unit. During an observation on 04/28/26 at 06:15 AM, a box of individual bacitracin zinc ointment packets, a box of individual hydrocortisone packets, skin integrity wound cleanser, and liquid-loc plus medical fluid waste encapsulation and treatment bottles were seen in unlocked storage cabinets on the left side of the supply room as entered. These items were identified in the report as medications and chemicals that should have been in locked storage. On 04/30/26 at 08:20 AM, unlocked medications were also observed on an open shelf in the DON's office on the third-floor resident unit, with the office door open and the medications left unattended. During an interview on 04/30/26 at 11:04 AM in the supply room, the DON confirmed that the bacitracin zinc ointment packets, hydrocortisone packets, skin integrity wound cleanser, and liquid-loc plus bottles should be in locked storage, and stated that the medication stored on the shelf in his office should also be locked. The facility policy titled Medication Storage, revised 03/25/26, stated that all drugs and biologicals will be stored in locked compartments.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, to the Centers for Medicare and Medicaid Services (CMS) for fiscal quarter 3 of 2024. Review of the CMS Payroll-Based Journal (PBJ) Staffing Data Report indicated that no staffing data was submitted for the specified quarter. During an interview, the Administrator confirmed that there were two instances when the facility did not submit the required PBJ information on time and stated that once the deadline is missed, submission is no longer allowed. This deficiency was identified through record review and staff interview.
Failure to Maintain Records of Dryer Lint Removal and Cleaning
Penalty
Summary
The facility failed to maintain records of dryer lint removal and cleaning as required by its own policy. During an observation of the dryer lint traps, a thin layer of lint was noted mid-cycle, indicating that lint removal may not have been performed as needed. In an interview, the Environmental Services Director stated that the facility had recently stopped keeping records of dryer lint removal and cleaning, but later indicated that record-keeping would resume. Review of the facility's laundry policy confirmed that daily lint removal and monthly washing of dryer vents are required, but there was no documentation to show these tasks had been completed.
Failure to Maintain Resident Dignity During Meal Assistance and Catheter Care
Penalty
Summary
Staff failed to ensure the right to a dignified existence for four residents. Certified Nurse's Aides (CNAs) were observed standing over three residents while assisting them with meals, rather than sitting or being at eye level. These residents were in bed with their heads elevated during meal assistance. Facility policies on meal supervision and promoting dignity did not specify that staff should be seated or at eye level when assisting residents with meals. The Interim Director of Nursing confirmed that staff typically stand while assisting, regardless of resident preference, and acknowledged the lack of policy guidance on this matter. Additionally, a resident with a urinary catheter was observed lying in bed with the catheter collection bag visible from the hallway and not covered with a privacy bag, despite a physician's order requiring a privacy cover. The Interim Director of Nursing confirmed that all urinary catheter collection bags are to be covered at all times, indicating a failure to follow established orders and maintain resident dignity.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. For one resident, there was no care plan in place to address the use of bed rails, despite the presence of a signed consent form for bed rail use and multiple observations of the resident with and without bed rails in place. The absence of a care plan for bed rail use was confirmed by the Interim Director of Nursing (IDON) during a phone interview. For another resident, the care plan did not address the resident's declining range of motion (ROM), even though assessments indicated impairments in both upper and lower extremities. The IDON confirmed that ROM exercises were not included in the care plan, and that ROM interventions were only added after the issue was identified. The lack of documentation and planning for ROM needs was acknowledged by facility staff during interviews and record reviews.
Failure to Maintain Clean and Homelike Environment Due to Dust Buildup
Penalty
Summary
Surveyors observed a buildup of dust on the back of ceiling-mounted televisions and their wires in multiple resident rooms. In one room, all four televisions had visible dust accumulation, and a resident reported not having seen staff clean the backs of the televisions. Additional observations in other rooms revealed similar dust buildup, including in rooms occupied by residents with tracheostomies. Photographic evidence was taken to document the condition. Interviews with facility leadership, including the Administrator, Interim Director of Nursing (IDON), and Environmental Services Supervisor (EVS), confirmed that housekeeping staff are expected to perform high dusting as part of their daily service, with high dusting specifically scheduled once a month. However, the EVS acknowledged that high dusting had not been performed recently due to the lack of appropriate equipment, specifically a long-handled duster needed to reach the backs of the televisions. Both the Administrator and IDON agreed that the dust buildup was present and should have been addressed.
Inaccurate Assessment of Range of Motion in Resident
Penalty
Summary
The facility failed to accurately assess a resident for limitations in range of motion. Review of the resident's electronic health record showed discrepancies in the Minimum Data Set (MDS) assessments over several periods. Initially, the MDS indicated no impairment in upper and lower extremities, but subsequent assessments coded impairments on both sides. Interviews with staff revealed that the resident was able to assist with turning on his right side, suggesting that the coding of impairments on both sides may not have been accurate. The MDS coordinator confirmed that, upon review, there was a coding error in the most recent assessment, where impairment should have been recorded on only one side rather than both. This deficiency was identified through record review and staff interviews, which highlighted inconsistencies between the resident's documented functional abilities and the MDS coding. The inaccurate assessment placed the resident at risk of not receiving proper treatment to maintain range of motion, as the documentation did not reflect the resident's actual physical capabilities at the time of the assessment.
Failure to Develop Baseline Care Plan for Insulin Use in Non-Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was receiving insulin for hyperglycemia following admission. Upon review, it was found that the resident did not have a documented diagnosis of diabetes mellitus or hyperglycemia in the electronic health record, despite having an active order for insulin glargine administered twice daily. The resident's Minimum Data Set indicated insulin administration, but did not reflect a diagnosis of diabetes or hyperglycemia. Family interview confirmed the resident was receiving insulin, which began during a prior hospital stay, and the resident's blood sugars were reportedly stable. Further investigation revealed that the attending physician's admission note documented hyperglycemia as the reason for insulin therapy, with no history of diabetes. However, this diagnosis was not added to the resident's official list of diagnoses, nor was a baseline care plan created to address hyperglycemia or the use of insulin. The Interim Director of Nursing confirmed the absence of both the diagnosis and the baseline care plan for managing the resident's blood sugar levels.
Failure to Follow Turning Schedule and Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow the care plan and facility policies for the prevention and treatment of skin breakdown for one resident with a pressure ulcer. Record review showed that the resident had a facility-acquired stage 3 pressure ulcer, which progressed to a stage 4 ulcer and remained at that stage over several months. The resident's care plan included following facility protocols for skin breakdown prevention and treatment. However, review of the turning logs revealed that on multiple occasions, the resident was documented as being positioned on the same side for consecutive turning intervals, rather than being repositioned as required. The Interim Director of Nursing confirmed that staff should have turned the resident and acknowledged the documentation discrepancies, noting that the resident's fiancé may have also moved the resident, which could have contributed to the inconsistent records.
Failure to Ensure Bed Rail Availability and Staff Awareness
Penalty
Summary
A deficiency was identified when a resident was observed resting in bed with the upper right bed rail missing. Staff, including the Environmental Services Supervisor, were unaware of the missing bed rail until it was brought to their attention. The Environmental Services Supervisor confirmed the bed rail was missing and speculated that the resident's wife may have removed it. The resident's medical record indicated significant health concerns, including a history of malignant brain tumor, dependence on supplemental oxygen, reduced mobility, muscle contractures, and tracheostomy status. The resident was documented as being totally dependent on staff for personal hygiene and movement, and had a signed bed rail consent form indicating the use of bed rails for fall prevention. The absence of the bed rail was not noticed or addressed by staff until questioned by the surveyor, and the bed rail was later found in the resident's bathroom and reattached. This incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents, particularly for residents who are dependent on staff and require bed rails for safety.
Failure to Act on Pharmacist Medication Regimen Review Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to act on a pharmacist's Medication Regimen Review (MRR) recommendation for one resident. The resident, who had diagnoses including paraplegia, depression, anxiety, hypertension, and pulmonary embolism, was receiving multiple medications such as Apixaban, Mirtazapine, Morphine Sulfate, Oxycodone, and Sertraline. The pharmacist's MRR recommended specific lab work (Primidone level, Phenobarbital level, Magnesium level), but there was no documentation that this recommendation was communicated to the physician. During staff interviews, the Interim Director of Nursing (IDON) acknowledged that the recommendation was not communicated due to a vacancy in the Director of Nursing position at the time. Review of facility policy confirmed that MRR recommendations are to be documented and acted upon, with follow-up to verify appropriate action. The failure to communicate and act on the pharmacist's recommendation resulted in the deficiency.
Medication Security, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors observed that medication cart keys, including those for controlled substances, were left unattended in a disposable cup on top of the medication cart near the nurse's station. When questioned, a registered nurse stated that staff had been instructed by management to leave the keys in this location, rather than keeping them on their person as required by facility policy. The nurse confirmed that the narcotic key was included in this set. Additionally, review of the narcotic endorsement log revealed missing signatures for the change of shift count on two occasions, indicating that the required reconciliation and documentation of narcotic counts were not consistently performed. Further inspection of the medication cart revealed a vial of Humulin R insulin that was past its discard date but had not been disposed of, and the medication administration record showed that a resident had received doses from this vial after the discard date. The cart also contained blood glucose testing supplies, including test strips and control solutions, that were not labeled with open or discard dates, contrary to manufacturer instructions and professional standards. Staff were unable to determine when these supplies had been opened or when they should be discarded.
Ice Machine Not Maintained in Sanitary Condition
Penalty
Summary
During an initial kitchen tour, a grayish-green buildup was observed under the area where ice is dispensed from the facility's ice machine. The Kitchen Manager confirmed the presence of this residue and was able to partially remove it with a dry paper towel. The Kitchen Manager stated that the ice machine had been serviced by an outside vendor recently, but the buildup under the dispenser had not been noticed prior to this observation. Documentation showed that monthly inspections of the ice machine were being logged, with the next service scheduled, but the unsanitary condition under the dispenser had not been addressed at the time of the survey.
Inaccurate Completion of POLST Due to Lack of Advance Directive and Surrogate Process
Penalty
Summary
The facility failed to accurately complete a Physician Orders for Life Sustaining Treatment (POLST) form for a resident with multiple complex medical conditions, including dysphagia, type 2 diabetes mellitus with skin complications, unspecified dementia, psychotic and mood disturbances, anxiety, and tracheostomy status. The resident's electronic health record did not contain an Advanced Health Care Directive (AHCD) appointing a Power of Attorney (POA) for healthcare decisions. Despite this, the POLST form prepared for the resident indicated that his wife was his agent designated in a Power of Attorney for Healthcare, which was not accurate, as confirmed by the social worker and facility records. Further review revealed that the correct designation on the POLST should have been 'Surrogate selected by consensus of interested persons,' as the resident's wife was not his healthcare POA. Additionally, the facility did not have documentation such as a surrogate form or a physician's letter identifying the resident as lacking capacity to make his own healthcare decisions. The social worker confirmed that the facility did not have a process in place for initiating a surrogate decision-maker for residents without capacity, contributing to the inaccurate completion of the POLST form.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to implement infection prevention and control measures in several instances involving residents with indwelling medical devices. One resident, who was totally dependent on staff and had an indwelling urinary catheter, was observed with the catheter tubing and urinary bag resting on the floor next to the bed, despite the bag being covered with a privacy bag. The Interim DON confirmed that no part of the Foley catheter system should be on the floor. Additionally, staff did not consistently perform hand hygiene between glove changes during resident care, as observed during medication administration and dressing changes. Facility policy requires hand hygiene before donning gloves and after removing them, but this was not followed by staff in multiple instances. Further observations revealed that staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents with gastrostomy tubes. In two separate cases, staff administered medications or flushed feeding tubes without wearing the required gown, and in one case, only gloves and a mask were used. The facility's policy mandates the use of gown and gloves during high-contact care activities for residents with indwelling medical devices, including gastrostomy tubes. The Infection Preventionist confirmed that staff are trained to follow these protocols, but the observed practices did not align with facility policy.
Inadequate Nursing Competency and Unauthorized Medication Application
Penalty
Summary
The facility nursing staff failed to demonstrate the necessary competencies and skills to provide adequate care for a resident, leading to significant harm. The resident, a male with a complex medical history including cerebral hemorrhage with quadriplegia, chronic respiratory failure, and other conditions, experienced a rapid heart rate, fever, and behavioral changes. Despite these symptoms, the nursing staff did not follow the proper protocol to obtain emergency physician services when they were unable to reach the on-call provider. This inaction persisted until the resident's mother intervened, expressing concern over the lack of transfer to an emergency department. Additionally, the nursing staff applied a scopolamine patch to the resident without a physician's order, which may have contributed to the resident's adverse symptoms, including hallucinations and an increased heart rate. The facility's medication administration records did not document the application of the patch, and there was no active order for its use. This oversight should have prompted an investigation by the responsible nurse, but it did not occur, leading to further complications for the resident. Interviews with facility staff, including the Director of Nursing and the resident's physician, confirmed the absence of an order for the scopolamine patch and the failure to follow the chain of command when the on-call provider was unreachable. The Director of Nursing acknowledged the lack of documentation and the inability to determine who applied the patch. The physician was unaware of the unauthorized use of the patch and had left instructions for the APRN to cover in his absence, but the staff failed to reach the APRN in a timely manner.
Inappropriate Discharge and Failure to Document
Penalty
Summary
The facility violated federal regulations by initiating a discharge for a resident without an adequate reason and failing to provide the necessary documentation and notification. The resident, a male with a history of hypertension, quadriplegia, and respiratory issues, was transferred to an acute care hospital due to a medical condition requiring a higher level of care. Despite the facility's capability to provide the necessary respiratory specialty services, they decided not to allow the resident to return post-hospitalization, citing issues with the behavior of the resident's parents. This decision was made without the resident's representative's request and was not aligned with the resident's care goals and preferences. The facility failed to document the required elements of the discharge in the resident's medical record. There was no documentation by a provider regarding the transfer on the specified date, nor was there a discharge summary after the decision not to allow the resident to return. The facility's policy on transfer and discharge was not followed, as it states that residents should be permitted to return to the facility unless their clinical or behavioral status cannot be met. The facility did not provide the resident's representative or the Ombudsman with the required written notice of the facility-initiated discharge, which should have included the date and specific reasons for the discharge. Interviews with facility staff revealed that the decision not to allow the resident to return was made by upper management, despite the facility having the capacity to care for the resident's respiratory issues. The Admissions Director confirmed that there were available beds at the time and that the decision was communicated to the hospital's Social Service staff. The facility's failure to follow its established transfer/discharge policy and comply with regulations resulted in the resident being denied the right to return to the facility and the representative being unable to appeal the discharge.
Failure to Notify Resident's Representative of Discharge Decision
Penalty
Summary
The facility failed to provide the required notification of transfer or discharge to a resident's representative and the ombudsman, resulting in a deficiency. The resident, a nonverbal male with a history of hypertension, quadriplegia, and other medical conditions, was transferred to a hospital for a higher level of care. The facility decided not to readmit the resident after his hospitalization but did not formally notify the resident's representative or the ombudsman of this decision, as required by regulations. The facility's social worker completed a notice of transfer/discharge, indicating that the resident's welfare could not be met at the facility. However, the notice was intended to address the initial transfer to the hospital, not the decision not to readmit the resident. The social worker assumed the resident would return and did not provide a formal notice of the facility-initiated discharge. The notice was sent via text to the resident's representative and left at the bedside, but it did not include the necessary information about the decision not to readmit. Interviews with facility staff revealed a misunderstanding of the transfer and discharge process. The social worker believed that a transfer equated to a discharge and did not send a separate notice for the decision not to readmit. The admissions director confirmed that the decision not to allow the resident to return was made by the facility team, but no formal notice was sent to the representative or ombudsman. This lack of communication prevented the resident's representative from exercising their right to appeal the discharge decision.
Failure to Follow Discharge Policy and Provide Notice
Penalty
Summary
The facility failed to adhere to its established transfer/discharge policy and did not comply with regulations regarding discharges. A resident, who had been at the facility since March 7, 2024, was transferred to the Emergency Department on May 31, 2024, for a higher level of care. Once stabilized, the hospital's Social Service department attempted to arrange for the resident's return to the facility. Despite having an open bed and the capability to care for the resident, the facility refused to readmit him, citing concerns about the mother's behavior. This decision was made after discussions among the Admissions Director, Administrator, and Director of Nursing, without involving the resident's representative or addressing the concerns with the family. The facility did not provide the required written notice of the facility-initiated discharge to the resident's representative or the Ombudsman. The Administrator confirmed that the refusal to readmit the resident was not based on the resident's behavior or medical condition. The facility's actions were based on previous interactions with the resident's mother, and no efforts were made to resolve these concerns through a conference or communication with the family. This lack of communication and failure to follow proper discharge procedures led to the deficiency.
Failure to Update Resident's Care Plan with Specific Preferences
Penalty
Summary
The facility failed to update a resident's care plan to include specific requests and preferences made by the resident's power of attorney (POA). The resident, a male with a history of cerebral hemorrhage, quadriplegia, chronic respiratory failure, and other medical conditions, was admitted for skilled nursing and respiratory care. Despite the POA's active involvement and the documentation of special instructions in the resident's medical records, the care plan did not reflect these agreed-upon interventions. The care plan included only the routine Facetime calls with family, omitting other critical instructions such as the use of pressure boots, call light placement, wearing gloves to prevent scratches, preference for gauze to wipe eyes, and temperature control measures. During an interview, the Director of Nursing acknowledged that the special instructions were documented in a specific chart location to ensure visibility to staff. However, she agreed that these instructions should have been incorporated into the care plan to ensure comprehensive and individualized care. The failure to update the care plan with these important details resulted in a deficiency, as the care plan was not comprehensive or individualized to meet the resident's needs and preferences.
Failure to Provide 24-Hour Physician Services
Penalty
Summary
The facility failed to provide 24-hour availability of physician services, which resulted in a delay in care for a resident. On 05/31/2024, the nursing staff was unable to reach a physician or provider to discuss the condition of a male resident with a history of cerebral hemorrhage, chronic respiratory failure with a tracheostomy, and other medical issues. The resident exhibited an increased heart rate, behavioral changes, and developed a temperature, necessitating the notification of a provider. Despite multiple attempts to contact the on-call APRN throughout the day, the nursing staff could not obtain a response before transferring the resident to the Emergency Department. The facility's policy on Notification of Changes requires prompt consultation with the resident's physician when there is a change in condition. However, the Director of Nursing confirmed that there was no documentation of the phone calls made to the covering APRN. The Respiratory Therapist on duty confirmed the resident's hallucinations and anxiety were suspected to be caused by a scopolamine patch, which was removed earlier that day. The lack of response from the on-call provider and the absence of documented attempts to reach them contributed to the deficiency in providing timely physician services.
Failure to Post Complete Daily Nursing Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to provide daily Nursing Staffing Information, which includes the hours worked by Registered Nurses (RNs) and Certified Nurse Aides (CNAs), as well as the resident census. On May 15, 2024, at 08:40 AM, an observation was made of the facility's Daily Assignment sheet posted near the nurse's station on the treatment cart. The sheet listed the names of RNs and CNAs, their assigned work areas, and shifts, but did not include the hours worked or the resident census for the day. On May 16, 2024, at 02:06 PM, the Director of Nursing (DON) was interviewed and confirmed that the posting was missing the required information regarding resident census and total hours worked by RNs and CNAs, as per the requirements of F732.
Inaccurate Facility Assessment Puts Residents at Risk
Penalty
Summary
The facility failed to conduct, document, and annually review a comprehensive facility-wide assessment, which is required to include both the resident population and the resources needed to care for them. The assessment was found to be outdated and inaccurate, particularly in the areas of special treatments and conditions. Specifically, the facility's assessment inaccurately reported zero residents requiring respiratory treatments, oxygen therapy, suctioning, tracheostomy care, or mechanical ventilation. However, a review of the facility matrix revealed that there were 24 residents with tracheostomies and 15 residents on mechanical ventilators who required special respiratory treatments. This discrepancy indicates that the facility used a template rather than an accurate and up-to-date assessment, placing all residents at an increased risk of harm.
Failure to Implement Comprehensive Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents who were prescribed psychotropic and sedative medications. These care plans did not include non-pharmacological interventions or monitored behaviors related to the medications administered. Specifically, Resident 4, who was diagnosed with major depressive disorder, generalized anxiety disorder, and insomnia, was prescribed trazodone and sertraline. However, their care plan lacked non-pharmacological interventions and behavior monitoring for these medications. Similarly, Resident 12, with diagnoses including dementia, major depressive disorder, and anxiety disorder, was prescribed lorazepam and escitalopram, but their care plan also omitted non-pharmacological interventions and behavior monitoring. Resident 29, diagnosed with adjustment disorder with anxiety and PTSD, was prescribed venlafaxine, aripiprazole, and lorazepam, yet their care plan did not include necessary non-pharmacological interventions or behavior monitoring. These omissions were identified during record reviews and interviews with a registered nurse.
Failure to Update Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R27, who has a tracheostomy and uses a Passy Muir valve (PMV) to improve communication. The resident's representative decided against a tracheostomy cap (T-cap) trial, a decision discussed during an interdisciplinary team (IDT) meeting but not documented in the care plan. This omission has the potential to disregard the rights of R27 and her representative. The report indicates that the IDT meeting minutes and care plan did not include any mention of capping the trachea or weaning off the tracheostomy. The care plan only included interventions such as monitoring respiratory rate and suctioning as necessary, without addressing the use of the PMV or the representative's wishes regarding T-cap trials. An interview with the respiratory therapy supervisor revealed that there was no prior discussion with the family about the T-cap trial, which is typically part of the IDT meeting discussions.
Failure to Withhold Stool Softener as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident, identified as R29, who was admitted with multiple diagnoses including chronic kidney disease, gastrotomy status, tracheostomy status, and long-term use of antibiotics. The deficiency arose from the facility's failure to adhere to the physician's orders regarding the administration of a stool softener, Senna-Docusate, which was to be held in the event of loose stools. Despite documentation of numerous instances of loose stools in March, April, and May, the medication was not consistently withheld as ordered, except on two occasions. This oversight was confirmed during a concurrent record review and interview with RN23, who acknowledged that the stool softener should have been held on days when the resident experienced loose stools. The failure to do so placed the resident at increased risk of avoidable skin breakdown, infection, and discomfort, as evidenced by documented skin issues such as a rash and redness in the groin and buttocks areas. The facility's policy on bowel elimination, which mandates regular monitoring and adjustment of bowel regimens to prevent complications, was not followed, contributing to the deficiency.
Failure to Document Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of medication regimen review (MMR) recommendations from the pharmacist for three residents. For Resident 4, the physician did not provide a rationale for continuing trazodone PRN medications past 14 days, despite recommendations from the pharmacist in August, October, and November 2023. The physician also failed to document the review of these recommendations. Similarly, for Resident 12, the physician did not document a review of the pharmacist's recommendation to limit acetaminophen intake to 3 grams per day, as the existing order allowed up to 4 grams. For Resident 29, the physician did not document a review of the pharmacist's recommendation to implement a behavioral monitor sheet and conduct specific tests such as a Lipid Panel, LFTs, and A1c. The Treatment Administered Record (TAR) and Medication Administered Record (MAR) for this resident lacked documentation of specific behaviors, and the recommended tests were not ordered. In all cases, the Registered Nurse (RN) was unable to find documentation that the physician had reviewed and responded to the pharmacist's recommendations.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to specify and monitor behaviors related to the use of psychotropic and sedative medications for three residents, leading to deficiencies in medication management. Resident 4 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia. The resident's physician orders included psychotropic medications such as trazodone and sertraline. However, the Treatment Administered Record (TAR) and Medication Administered Record (MAR) lacked documentation of monitored behaviors for these medications. Additionally, there was no documentation of the physician's rationale for extending the use of trazodone PRN medications beyond 14 days. Similarly, Resident 12, diagnosed with dementia, major depressive disorder, and anxiety disorder, had physician orders for lorazepam and escitalopram. The records for this resident also lacked documentation of monitored behaviors for these medications. Resident 29, with diagnoses of adjustment disorder with anxiety and PTSD, was prescribed venlafaxine, aripiprazole, and lorazepam. Again, the TAR and MAR did not specify monitored behaviors for these medications. In all cases, Registered Nurse 23 confirmed the absence of documentation in the Electronic Health Record (EHR), indicating a failure to adhere to the facility's policy on psychotropic medication use.
High Medication Error Rate Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a significant error rate of 38.36 percent. This was observed during medication administration to two residents and a review of a closed record for another resident. The errors included administering medications via the wrong route and not adhering to physician orders regarding when to hold medications based on vital signs. One resident, who had a history of cognitive communication deficit and hemiplegia, was administered medications via a gastrostomy tube that were ordered to be given by mouth. The nurse, RN80, crushed medications that were not supposed to be crushed and administered them through the G-tube without an order permitting this method. Additionally, medications that should have been held due to the resident's blood pressure were administered, contrary to the physician's orders. Another resident's closed record review revealed that a medication with specific hold parameters was administered despite the resident's blood pressure being below the threshold. Furthermore, during an observation, a nurse administered multiple medications together in one cup via a G-tube, contrary to the facility's policy of administering them one at a time. This practice was not corrected by the nurse manager, who was unaware of the nurse's method.
Inadequate Infection Control Program and Environmental Cleaning
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Environmental cleaning of resident rooms was not routinely conducted, with resident care equipment left uncleaned and disposable equipment being reused. For instance, a feeding pump with brown stains was found in a resident's room, and the floors in another room were soiled with various debris. Nursing staff were observed reusing purple tips for G-Tube feedings due to a shortage, contrary to the facility's policy that disposable equipment should never be reused. The Infection Preventionist was unaware of these practices, and the facility lacked a comprehensive infection control policy. The facility's infection control and prevention policy was incomplete and did not align with recognized guidelines. The policy did not cover essential areas such as environmental cleaning and disinfection, isolation precautions, and reporting protocols for reportable diseases. The Director of Nursing provided outdated and incomplete policy documents, and the infection preventionist was not actively involved in the infection control program. The facility's infection control committee lacked signatures from key members, indicating a lack of comprehensive oversight. Additional observations included peeling paint in the kitchen above the food prep area, which could lead to contamination, and a feather found near the trayline. A discarded glove was found on a resident's windowsill, and a fall mat in another resident's room was dirty. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for cleaning and maintaining hygiene standards, with staff citing short staffing as a reason for inadequate cleaning.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignity for three residents during care, as observed by surveyors. One resident, who was dependent and on a mechanical ventilator, was found exposed in his bed while receiving personal care, with the privacy curtain only partially closed and inadequate to cover the area around the ventilator and respiratory equipment. This left the resident visible to staff and visitors, compromising his dignity and privacy. Additionally, two other residents with urinary catheters had their catheter bags uncovered and visible to people in the hallway. One resident's catheter bag was observed uncovered on two separate occasions, while another resident's bag was later covered after initial observation. The facility's policy on dignity and privacy was not effectively implemented, as staff did not consistently cover urinary catheter bags, and the privacy curtain was insufficient to ensure bodily privacy during personal care.
Resident's Rights Violated in Tracheostomy Cap Placement
Penalty
Summary
The facility failed to ensure the rights of a resident's representative in a medical treatment decision involving the insertion of a tracheostomy cap (T-cap) for a resident. The resident, an elderly female with a diagnosis of respiratory failure and a tracheostomy, was under the care of a legal guardian who was responsible for making healthcare decisions. Despite the guardian's explicit disagreement with the treatment, a Speech Therapist (SLP) requested an order from the doctor, and a Respiratory Therapist (RT) placed the T-cap on the resident's trachea. This action was against the guardian's wishes and caused distress to the resident, who was visibly upset and began crying after the cap was placed. The incident was reported by the guardian to the Director of Rehabilitation (DOR), who acknowledged that the guardian should have given consent for the T-cap placement. The RT involved in the procedure noted that the resident was initially okay but became upset shortly after the cap was placed, indicating a misunderstanding as the resident thought it was a different device. The guardian was informed of the incident the following day and expressed significant distress over the unauthorized procedure, which was described as traumatic for the resident.
Failure to Provide and Acknowledge NOMNC Forms
Penalty
Summary
The facility failed to provide a written copy of the Notice of Medicare Non-Coverage (NOMNC) form to three residents or their representatives, as required by the NOMNC instructions. The residents involved were cognitively intact, except for one who had severe cognitive impairment. The facility documented that the NOMNC forms were left at the bedside for two residents and sent via secure email for the third resident. However, there was no evidence that the forms were acknowledged by the residents or their representatives, as required. Interviews with the facility's Administrator and Social Services Director (SSD) revealed that the facility did not have a policy regarding the NOMNC form and did not follow the NOMNC instructions. The SSD admitted to leaving the forms at the bedside without obtaining signatures, believing that verbal notification was sufficient. Additionally, the SSD confirmed that the NOMNC form was not emailed to the representative of the resident with severe cognitive impairment. The NOMNC instructions require that the beneficiary or representative sign and date the form to confirm receipt and understanding of the notice, and that providers develop procedures for delivering the notice to representatives when direct contact is not possible.
Failure to Timely Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Survey Agency (SA) within the required time frame. For the first resident, the Long-Term Care Ombudsman (LTCO) reported an incident where a family member accused a Certified Nurse's Aide (CNA) of mistreating the resident by using intimidation tactics and being rough during care. The LTCO informed the Director of Nursing (DON) and Administrator of the incident, but the facility did not report the allegation to the SA within the mandated two-hour window. The initial and completed investigation report was submitted two days later, which was confirmed by the DON as not being timely. In the second case, a resident had a large bruise on his right forearm, which was discovered to have occurred during a dialysis session. The facility did not have documentation of this injury, and there was no communication from the dialysis center regarding the incident. The Unit Manager (UM) and the resident's assigned nurse were unaware of how the bruise was acquired, and the DON was reminded to report this injury of unknown origin to the SA. The facility's failure to report these incidents in a timely manner constitutes a deficiency in adhering to regulatory requirements for reporting suspected abuse and injuries of unknown origin.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse or mistreatment during an investigation involving a resident and a CNA. The incident was reported by the Long-Term Care Ombudsman, who informed the Director of Nursing and Administrator of possible abuse between the resident and the CNA. Despite this, the facility did not remove the CNA from the premises, allowing her continued access to the resident and other vulnerable individuals. The resident reported feeling harassed by the CNA, who allegedly provided rough care and disregarded the resident's preferences during showering, which could exacerbate her ear infections. Interviews revealed that the CNA continued to work in the facility during the investigation, and the facility did not inform her of the ongoing investigation. The facility's policy required immediate suspension of any employee accused of abuse pending investigation, but this was not followed. The Director of Nursing acknowledged the oversight, confirming that the investigation was not completed until two days after the incident was reported. Ultimately, the facility found the allegations unsubstantiated, but the failure to remove the CNA during the investigation constituted a deficiency.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman (LTCO) as required. This deficiency was identified for one resident who was transferred to the hospital on three separate occasions due to medical conditions including tachycardia, recurrent aspiration pneumonia, acute aspiration pneumonia, and acute respiratory failure with hypoxia. A review of the resident's Electronic Health Record (EHR) revealed no documentation of the required written notifications for these hospitalizations. During an interview, the Social Services Director admitted that the facility did not issue the notifications due to the resident's Veteran Affairs (VA) insurance status. The facility's policy mandates that transfer/discharge notices be provided in a language and manner understandable to the resident and their representative, with copies sent to the Ombudsman for emergency transfers.
Failure to Conduct Quarterly Fall Assessment
Penalty
Summary
The facility failed to re-assess a resident, identified as R15, for falls on a quarterly basis as required. During a record review on May 14, 2024, it was found that R15's last fall assessment was conducted on December 12, 2023, and the subsequent quarterly assessment due on March 12, 2024, was not completed. Interviews with RN79, who was new to the facility, revealed a lack of awareness regarding the schedule for fall assessments, relying on the computer system to prompt when assessments are due. The Director of Nursing confirmed the oversight, acknowledging that the fall assessment for R15 was indeed missed, as per the facility's Fall Prevention Program policy, which mandates a fall risk assessment every 90 days and when the resident's condition changes.
Failure to Include Resident's Preferences in Baseline Care Plan
Penalty
Summary
The facility failed to include a resident's daily preferences in her baseline care plan within 48 hours of admission, as required. The resident, a [AGE] year old with adjustment disorder, unspecified, functional quadriplegia, a tracheostomy, and ventilator dependency, was admitted on [DATE]. Her baseline care plan, completed on 04/23/24, omitted the section for daily preferences, which should have included options such as choosing clothes, caring for personal belongings, and family involvement in care decisions. An interview with the resident and her daughter revealed that the resident's daughters are involved in her care decisions and are present at the facility daily. The Director of Nursing confirmed that nurses are required to fill out all areas of the baseline care plan, including daily preferences, within 48 hours of admission. However, this was not done for the resident in question, leading to the deficiency noted in the report.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oahu Care Facility | 0 mi | ★★★★★ | 15 | 0 |
| Hale Ola Kino By Arcadia | 0.2 mi | ★★★★★ | 0 | 0 |
| Arcadia Retirement Residence | 0.3 mi | ★★★★★ | 1 | 0 |
| Kalakaua Gardens | 0.8 mi | ★★★★★ | 33 | 0 |
| Hale Nani Rehabilitation And Nursing Center | 1 mi | — | 26 | 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.