Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Avoca Specialty Care during CMS and state inspections, most recent first.
Failure to Include Psychotropic Care Plan Interventions: The facility did not identify individualized behaviors or non-pharmacological interventions for 5 sampled residents receiving psychotropic medications. Residents receiving antipsychotic, antianxiety, antidepressant, and hypnotic medications had care plans that lacked targeted behaviors and non-pharmacological interventions, including residents with intact cognition and residents with dementia, depression, and behavioral disturbance. The MDS coordinator and DON acknowledged the missing care plan content.
A facility failed to include key problems, goals, and interventions in care plans for four residents. Records showed one resident on an antianxiety med, one on antianxiety and diuretic meds, and two residents on opioid therapy; one of those residents also received an antipsychotic for dementia with behaviors. Staff and the DON acknowledged the care plans did not address the identified meds, pain, or related needs.
Delayed response to call lights and toileting needs occurred when staffing was limited, with residents reporting waits of more than 15 minutes and sometimes up to 30 minutes or longer. A resident with no cognitive impairment said a call light took over 30 minutes to answer, another resident with moderate cognitive impairment reported repeated delays and periods with only one CNA or no staff, and a third resident said he waited hours for help back to bed. A family member and grievance records also described prolonged waits for toileting assistance, while staff and the DON acknowledged shifts with only one CNA and staffing below the facility’s preferred PPD.
A resident’s advance directive documentation did not match the EHR and physician orders. The resident’s CPR/DNR form documented DNR, while the EHR listed CPR and the physician order also showed CPR. An RN said she would check the EHR in an emergency and was not aware of an Advance Directives book, and the DON confirmed the records did not match.
A resident with no cognitive impairment reported that after a fall and skin tear, his sheets remained unchanged despite visible dried blood on them. Staff said bedding was usually changed on bath days, but also stated soiled sheets with blood, urine, or debris should be changed immediately; the DON said sheets were to be changed on bath days or at least weekly.
A facility failed to ensure accurate MDS assessments for 3 residents. Two residents were incorrectly coded as receiving antipsychotic medications even though EHR orders, MAR-TAR, and staff statements showed no such meds, and one resident was incorrectly coded as having an indwelling catheter despite the resident, family, DON, and EHR documentation showing no catheter or related order.
A resident with schizophrenia, anxiety disorder, and depression had a PASRR Level II outcome requiring psychiatric medication management by a psychiatrist and supportive counseling, but the care plan did not document these specialized services. The DON stated specialized services were expected to be included in the care plan, and the facility policy said the care plan should describe PASRR-related specialized services.
A resident’s care plan was not revised to reflect current medication use. The MDS showed antipsychotic use, but the EHR orders listed Buspirone HCL, an antianxiety medication, and no antipsychotic medication. The care plan still identified antipsychotic use and did not list antianxiety medication. The MDS coordinator and DON both confirmed the care plan was inaccurate and should have been updated.
A resident with DM received an insulin injection from a multi-dose vial that had been opened beyond the manufacturer’s 28-day storage limit. The MDS Coordinator administered the insulin and stated she thought the vial was good for 30 or even 90 days, while the DON confirmed the vial should be discarded 28 days after opening. The facility policy required staff to check expiration dates and record the expiration date and time on opened insulin vials.
A facility failed to ensure 2 residents received scheduled bathing. One resident with mild cognitive impairment said she did not get baths twice weekly, and records showed only a few showers documented despite a twice-weekly schedule. Another resident, who was dependent on 2 staff for bathing, reported receiving only bed baths; staff said baths were sometimes missed and not made up, and the resident had not been given showers because the facility lacked enough correctly sized slings.
Failure to order and clean CPAP equipment: A resident with obstructive sleep apnea used a CPAP mask at night, but the EHR had no physician order for CPAP use and no order for cleaning the CPAP machine or mask. The resident stated staff had not cleaned the CPAP equipment since admission, and staff interviews confirmed the missing orders and uncertainty about who was responsible for cleaning. The DON acknowledged the lack of CPAP and cleaning orders, while the facility policy required physician orders and routine cleaning of the device and mask.
A resident with a suprapubic catheter received catheter care and a full body mechanical lift transfer, but staff did not complete hand hygiene after removing gown and gloves before moving the resident out of the room and down the hall. One CNA/CMA later acknowledged the missed hand hygiene opportunity, and the DON stated hand hygiene was expected whenever gloves were removed.
A resident with diabetes, hypertension, and hypothyroidism did not receive physician-ordered laboratory tests, including A1c and other labs, as required. Despite clear orders documented in the EMR and care plan, staff failed to ensure the labs were completed, and there was no documentation of the required testing after a certain point. The DON and Administrator confirmed the orders were not followed, and the facility's policy did not specifically address adherence to physician orders.
Two residents who required assistance with bathing did not consistently receive scheduled baths or showers, and there was a lack of documentation showing that staff offered or encouraged bathing as required. One resident did not receive any baths during their stay, while another experienced gaps in bathing and inconsistent documentation, with staff and DON interviews confirming these deficiencies.
Multiple residents did not receive scheduled baths or timely toileting assistance due to staffing shortages and inconsistent follow-up, with documentation showing missed or unoffered baths, long wait times for call lights, and poor hygiene observed among residents. Staff interviews and resident council notes confirmed that care was often delayed or omitted, and facility procedures for documenting refusals and notifying supervisors were not consistently followed.
The facility did not maintain sufficient nursing staff to meet residents' needs, resulting in missed or delayed baths, long call light response times, and inadequate assistance with toileting and personal hygiene. Two residents reported infrequent bathing and extended waits for help, leading to accidents and discomfort. Staff interviews and documentation confirmed that care tasks were often postponed or missed due to staffing shortages, and support staff observed residents left in soiled conditions after night shifts.
The facility did not maintain complete and accurate records for several residents, including missing documentation of bathing refusals, behavioral incidents, and attempts to arrange telehealth appointments. Staff interviews confirmed that required documentation was often omitted, and care plans were not updated in a timely manner to reflect changes in resident needs.
A resident who required assistance for toileting and had no cognitive impairment was left waiting for help and subjected to dismissive treatment by two CNAs, with concerns not reported within the required timeframe. The LPN who witnessed the incident delayed reporting, and the facility's investigation was incomplete, lacking follow-up interviews with the resident, her roommate, and all relevant staff, as well as proper documentation of the resident's psychosocial status.
A resident who required substantial assistance for toileting was subjected to neglectful and condescending treatment by two CNAs, who delayed responding to call lights and refused to assist the resident to the bathroom without a mechanical lift. An LPN witnessed these actions but did not report the concerns to management or authorities within the required two-hour timeframe, resulting in a delayed report to the State Agency. Facility policy required immediate reporting of suspected abuse or neglect, but the process was not followed.
A facility failed to thoroughly investigate allegations of staff misconduct and possible mistreatment of a resident who required substantial assistance for toileting. The investigation lacked follow-up interviews with the resident after her report of being left without help, did not include input from her roommate or all relevant staff, and omitted documentation of psychosocial checks, contrary to facility policy.
A resident who became dependent on a mechanical lift for transfers did not have this change reflected in her care plan, despite staff using the lift and communicating the change verbally. The care plan and Kardex continued to indicate assistance of two staff without specifying the use of the EZ stand, and staff reported that care plans were not updated promptly, relying instead on verbal communication and the EHR.
A resident with moderate cognitive impairment and dementia, who required substantial assistance for toileting, repeatedly refused staff help and became verbally aggressive when told a mechanical lift was needed. Staff, including CNAs and an LPN, did not attempt further individualized interventions beyond documenting the refusals, despite facility policy requiring non-pharmacological approaches for problematic behaviors. The care plan directed calm communication, but no additional strategies were used when the resident continued to refuse care.
Surveyors found expired medications and supplies, including multiple bottles of Aspirin and a syringe, in the medication room and on medication carts. An LPN and a CMA were present during these findings, and staff interviews revealed inconsistent practices for checking expiration dates. The DON stated that both pharmacy and staff are responsible for reviewing items as they are stored, in accordance with facility policy.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for several residents. A resident with quadriplegia and another with Multiple Sclerosis reported significant delays, with staff confirming that insufficient staffing contributed to these issues. Another resident experienced long wait times affecting family visits, and a resident dependent on staff for transfers waited over an hour for assistance. The DON acknowledged the expectation for call lights to be answered within 15 minutes but noted the absence of a formal policy.
A facility failed to accurately assess a resident's use of an anticoagulant during the MDS observation period. The resident was documented as using an anticoagulant, but was only taking baby Aspirin, an anti-platelet. The MDS coordinator misidentified Aspirin as an anticoagulant due to the resident's history of blood clots, leading to incorrect coding on the MDS. The facility's policy requires accurate resident assessments, which was not followed.
A resident with quadriplegia and an enteral tube did not receive proper infection prevention measures during medication administration. A nurse failed to wear a gown, as required by the facility's enhanced barrier precautions policy for residents with indwelling medical devices. The Director of Nursing confirmed the expectation for appropriate PPE use, indicating a lapse in infection control protocols.
The facility failed to provide adequate bathing and personal hygiene care for several residents due to staffing shortages. Residents reported missed baths and inadequate grooming, with staff confirming that baths were not consistently completed. The Director of Nursing acknowledged the issue, stating that residents should receive baths twice a week unless they refuse, and that nail trimming should occur during bath times.
The facility experienced significant staffing shortages, resulting in delayed responses to resident call lights, with some waiting up to 40 minutes. Residents and staff reported consistent issues with insufficient staffing, particularly during evening and weekend shifts, affecting the quality of care. The DON acknowledged staffing was based on census rather than resident acuity, contributing to the problem.
The facility failed to maintain adequate kitchen staffing, leading to untrained staff from other departments, such as CNAs and LPNs, stepping in to perform dietary tasks. Residents expressed dissatisfaction with meal services, and staff reported being asked to assist in the kitchen without proper training or certification. The dietary manager's absence and the facility's inability to retain kitchen staff contributed to this issue.
The facility was found to have deficiencies in food storage and handling practices. Hamburger meat was improperly stored, and moldy green peppers were found in the cooler. A dietary aide used the same gloves for handling both dirty and clean dishes, violating infection control practices. Additionally, a staff member handled ready-to-eat food with bare hands, contrary to facility policy.
The facility failed to maintain resident dignity and respect, as evidenced by an LPN's inappropriate behavior towards multiple residents. A resident reported the LPN's dismissive and unhelpful attitude, while another overheard her using profane language and speaking negatively about residents. Staff interviews confirmed the LPN's frequent use of profanity and complaints about residents, impacting the residents' sense of dignity. The facility's policies emphasize treating residents with kindness and respect, which was not upheld in these instances.
A resident with mild cognitive impairment and identified as an elopement risk left the facility unsupervised. Staff failed to follow proper procedures when responding to a door alarm, assuming another staff member had triggered it. The resident was later found and returned without injury, but the incident highlighted inconsistencies in staff understanding and execution of elopement protocols.
The facility failed to dispose of room trays with leftover food in a timely manner, as trays were found in residents' rooms long after meals. A dietary aide noted finding dishes after weekends, and a resident reported uncollected dishes from breakfast and lunch. The DON acknowledged shared responsibility for tray collection but noted policy ambiguity regarding timing.
The facility failed to ensure proper storage and use of vape pens for two residents. One resident had vape pens in his room without documentation of his ability to smoke safely, while another used a THC and CBD vape pen indoors, contrary to the facility's smoking policy. The policy requires smoking evaluations and prohibits smoking inside, but the resident was found with a vape pen and THC gummies in her room, which were later removed.
Failure to Include Individualized Behaviors and Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify individualized behaviors and non-pharmacological interventions for residents receiving psychotropic medications. Review of clinical records, staff interviews, and the facility policy showed that 5 of 5 sampled residents reviewed did not have care plans that addressed targeted behaviors or non-pharmacological interventions related to their medications, including antipsychotic, antianxiety, antidepressant, and hypnotic drugs. Resident #4 had a BIMS score of 15 and was receiving buspirone and venlafaxine, but the care plan lacked non-pharmacological interventions for antianxiety and antidepressant use. Resident #8 had a BIMS score of 9 and was receiving risperidone, clonazepam, and escitalopram, but the care plan lacked non-pharmacological interventions for antipsychotic, antianxiety, and antidepressant use. Resident #25 had a BIMS score of 15 and was receiving lorazepam, paroxetine, and zolpidem, but the care plan lacked non-pharmacological interventions for antianxiety, antidepressant, and hypnotic use. Resident #23 had a BIMS score of 13 and diagnoses including unspecified dementia with behavioral disturbance and depression; records showed orders for Rexulti for dementia with behaviors, venlafaxine ER, and sertraline, but the care plan did not include individualized behaviors or non-pharmacological interventions for antidepressants or antipsychotics. Resident #33 had a BIMS score of 12 and diagnoses including major depressive disorder, malaise, weakness, and failure to thrive; records showed orders for lamotrigine, sertraline, and clonazepam, but the care plan did not include individualized behaviors or non-pharmacological interventions for antidepressants. Staff A, the MDS coordinator, and the DON acknowledged that these residents should have had individualized behaviors and non-pharmacological interventions included in their care plans when such medications were used, and that they did not.
Incomplete Care Plans for Medication and Pain Management
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans with measurable objectives and timetables for 4 of 6 residents reviewed. The deficiency involved Resident #4, Resident #25, Resident #23, and Resident #33, whose records showed medications and conditions that were not reflected in their care plans. The facility census was 33. Resident #4 was admitted from a short-term general hospital stay and had diagnoses of anxiety disorder and depression. The EHR showed an order for Buspirone HCL, an antianxiety medication, but the care plan revision dated 1/20/26 contained no documentation of antianxiety medication. Resident #25 was admitted from a skilled nursing facility and had used antianxiety and diuretic medications during the look-back period. The EHR showed orders for Lorazepam and Lasix, but the care plan revision dated 3/2/26 contained no documentation of antianxiety or diuretic medications. Resident #23 had a BIMS score of 13 and orders for Rexulti for dementia with behaviors and oxycodone-acetaminophen for pain, yet the care plan contained no focus, goal, or interventions related to opioid use, pain, or antipsychotic medication. Resident #33 had a BIMS score of 12 and diagnoses including malignant neoplasm of breast, malaise, weakness, and failure to thrive; she stated on 3/2/26 that she had back pain and the medication was not helping. Her EHR showed an order for oxycodone for pain, but the care plan had no focus, goal, or interventions related to opioid use or pain. Staff A, the MDS coordinator, and the DON acknowledged that these care plan elements were missing for the residents identified.
Delayed Response to Call Lights and Toileting Needs Due to Staffing Shortages
Penalty
Summary
The facility failed to provide nursing staff sufficient to meet resident needs and to have a licensed nurse in charge on each shift, as evidenced by delayed responses to call lights and toileting requests for multiple residents. Resident #10, who had a BIMS of 15 with no cognitive impairment, stated during a resident council meeting that call lights were taking longer than 15 minutes to be answered and that the prior night there had been only 1 CNA on the pm shift; he reported waiting more than 30 minutes for his call light to be answered. Resident #33, who had a BIMS of 12 and diagnoses including malignant neoplasm of breast, malaise, weakness, and failure to thrive, stated that call lights could take longer than 15 minutes to answer, sometimes up to 30 minutes, and that in the prior 2 weeks there had been only one CNA on the floor and at one point no staff, requiring nurses to get her ready. Resident #34, who had a BIMS of 15 and a diagnosis of obesity, stated he had remained in his chair for longer than 2 or 3 hours waiting for staff to assist him to bed after using the call light, and that repeated call light use sometimes did not help. Additional interviews and records supported the staffing concerns. Resident #15’s husband reported that a resident in the day room had requested toileting and waited an hour for staff to take the resident to the restroom, and a grievance investigation documented Resident #15 sitting in bed for 25 minutes with the call light on to use the commode, with repeated delays reported between 1:00 PM and 10:00 PM. Resident #14 reported waiting 30 minutes after timing call lights. Staff interviews confirmed staffing shortages, including shifts with only one CNA on the floor and call lights lasting longer than 15 minutes. The DON stated that when census was under 30 she tried to have 3 CNAs on day shift, 2 CNAs on pm shift, and 2 CNAs overnight, but acknowledged that the facility was under the PPD minimum at times and that on the pm shift 1 nurse and 2 CNAs would work even though it was not ideal.
Advance Directive Code Status Mismatch
Penalty
Summary
The facility failed to verify that Resident #7’s advance directive choice was accurately documented. Resident #7’s CPR and DNR Order Declaration Form, signed by the resident and physician, documented DNR, but the Clinical Resident Profile in the EHR listed the resident’s code status as CPR. The Clinical Physician Orders form also documented a physician’s order for CPR with a revision date. During interview, a registered nurse stated she would check the resident’s advance directive choice in the EHR during an emergency and was not aware whether the facility had an Advance Directives book to check residents’ code status. The DON confirmed the records did not match and stated the expectation was for the CPR and DNR Order Declaration Form and the EHR to be accurate and match. The facility policy stated residents are to be provided information about the right to refuse or accept treatment and to formulate an advance directive, and that whether an advance directive has been executed shall be displayed prominently in the medical record.
Soiled bedding not changed for resident with dried blood on sheets
Penalty
Summary
The facility failed to provide a resident with a comfortable, clean, homelike environment by not changing soiled sheets for one resident reviewed. Resident #3 had a BIMS score of 15, indicating no cognitive impairment, and reported that he had bled on his sheets after a fall on 2/28/26. He stated on 3/3/26 that the sheets on his bed had not been changed since the bleeding occurred, and an observation at that time noted three 50-cent-sized circular areas of dry red-colored fluid on the sheets. Staff interviews showed that bedding was typically changed on the resident’s bath day, and Staff F stated Resident #3 had not yet had a bath and the bedding had not been changed that day. Staff F also stated that if there was blood, urine, or debris on the sheets, they would be changed immediately. Staff I later stated she stripped Resident #3’s bed because it was dirty and needed to be changed, and described the sheets as looking like they had dried blood on them. Staff C, the RN/NP, stated Resident #3 had a skin tear to the left posterior forearm from the fall and acknowledged that bedding was changed on bath days. The DON stated sheets were supposed to be changed on bath days or at least once a week, and that soiled sheets were expected to be changed and fresh ones applied.
Inaccurate MDS Coding for Medications and Catheter Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to represent an accurate picture of residents' status during the MDS observation period for 3 of 5 residents reviewed. Resident #25's MDS documented use of an antipsychotic medication during the look-back period, but the EHR clinical physician's orders showed no orders for any antipsychotic medication. Resident #33's MDS also documented use of an antipsychotic medication, yet the EHR orders and MAR-TAR contained no physician's order for an antipsychotic, and Staff A stated Resident #33 was not on any antipsychotic medication, explaining the MDS may have been coded incorrectly when reviewing lamotrigine. Resident #5's MDS documented a BIMS score of 9 and placement of an indwelling catheter, but the resident stated he had never had a catheter, and the resident's son also stated he did not remember his father ever having one. The EHR care plan had no focus, goal, or interventions related to a catheter, the DON's progress note documented no catheter at admission, and the EHR orders and MAR-TAR showed no physician's order for catheter placement. Staff A acknowledged the MDS incorrectly documented an indwelling catheter, and the DON stated Resident #5 had never had a catheter since admission.
PASRR Specialized Services Not Included in Care Plan
Penalty
Summary
The facility failed to incorporate PASRR Level II recommendations into the care plan for Resident #13. The resident’s MDS assessment dated 2/6/26 listed diagnoses of schizophrenia, anxiety disorder, and depression. The Notice of PASRR Level II Outcome dated 1/21/26 stated that the resident required specialized services for ongoing psychiatric medication management by a psychiatrist and rehabilitative services of supportive counseling. However, the resident’s care plan with a target date of 5/7/26 did not include documentation of these PASRR specialized services. During interview on 3/4/26 at 4:00 PM, the DON stated that specialized services were expected to be included in the resident’s care plan. The facility’s Comprehensive Person-Centered Care Plans policy stated that the care plan will describe any specialized services to be provided as a result of PASRR recommendations.
Care Plan Not Updated to Match Current Medication Use
Penalty
Summary
The facility failed to revise and implement the care plan for one resident reviewed, Resident #4, whose MDS dated [DATE] showed use of antipsychotic medications during the seven-day look-back period. However, the resident’s EHR Clinical Physician Orders showed an order for Buspirone HCL oral tablet 10 mg, given one tablet by mouth in the morning, which is an antianxiety medication, and no antipsychotic medication was listed in the orders. The resident’s care plan, revised on 1/20/26, still identified the resident as utilizing antipsychotic medications and did not list antianxiety medications. During interviews, the MDS coordinator confirmed the resident was not taking an antipsychotic medication and was actually taking an antianxiety medication, and stated the care plan should have been updated. The DON also confirmed the resident was on anti-anxiety medication, that the antipsychotic medication should not have been on the care plan, and that care plans should be updated and revised in an appropriate time frame. The facility policy stated that assessments are ongoing and care plans are revised as resident information and conditions change.
Expired Insulin Vial Used for Resident Injection
Penalty
Summary
The facility failed to meet professional standards of care when administering insulin to one resident with a diagnosis of Diabetes Mellitus who received insulin. During observation, the MDS Coordinator drew up 4 units of Novolog Aspart insulin from a multi-use vial and administered it by injection to the resident. The vial was labeled with an open date of 1/19/26, and the package insert for Insulin Aspart Injection stated that a multi-dose vial should be stored for 28 days after opening. The facility’s insulin administration policy also required staff to check the expiration date and record the expiration date and time on a newly opened vial, following manufacturer recommendations. When interviewed, the MDS Coordinator stated she thought the insulin was good for 30 days, maybe 90 days, and the DON later stated the vial was only good for 28 days after opening and should be disposed of 28 days after the open date.
Missed Scheduled Showers and Baths
Penalty
Summary
The facility failed to ensure residents received showers to maintain personal hygiene for 2 of 3 residents reviewed. Resident #7 had a BIMS score of 12, indicating mild cognitive impairment, and stated she did not get baths twice a week even though she wanted them. Her shower task form for a 30-day period showed showers documented on only 5 days, while the schedule called for showers on Wednesdays and Saturdays. Resident #34 had a BIMS score of 15 and was documented as very important to choose between bathing options, with the ability to shower or bathe self not attempted due to medical condition or safety concerns. He stated he had only received bed baths since admission and did not always get 2 baths a week. His care plan identified him as dependent on 2 staff for bathing, but the EHR and follow-up report showed only a few bathing entries during the review period. Staff stated residents were supposed to get baths at least twice a week, baths were sometimes missed and not made up, and Resident #34 had not been given showers because the facility did not have enough correctly sized slings.
Failure to Order and Clean CPAP Equipment
Penalty
Summary
Respiratory services were not provided in accordance with professional standards of practice for a resident with obstructive sleep apnea who used a CPAP machine. The resident’s MDS documented a BIMS of 15 and a diagnosis of obstructive sleep apnea. During interview, the resident stated he had not had his CPAP machine or mask cleaned by staff since admission to the facility. Review of the EHR showed no physician’s order for CPAP use and no orders to clean the CPAP machine or mask. Staff interviews confirmed the absence of documented orders and uncertainty about the resident’s CPAP care. A CNA stated she had seen a CPAP machine in the resident’s room but had not assisted with the mask application. A CMA/CNA stated she had seen the CPAP machine but had never seen the resident use it. The MDS Coordinator stated the resident does wear a CPAP mask at night, but acknowledged there was no order for CPAP use or cleaning on the TAR and was not sure who was supposed to clean it. The DON stated the resident should have had a physician’s order for CPAP use and an order for cleaning the CPAP machine and mask, and acknowledged there was no such order on the TAR. The facility policy stated CPAP care should follow physician orders and include cleaning instructions for the machine and daily cleaning of masks.
Missed Hand Hygiene During Catheter Care and Resident Transfer
Penalty
Summary
Appropriate infection prevention practices were not provided during catheter care for a resident with an indwelling suprapubic catheter. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment, and also documented use of an indwelling catheter. The TAR included a physician order to cleanse the suprapubic catheter site with soap, rinse and dry thoroughly, and apply a 4x4 or drain sponge every shift. During observation of catheter care and transfer, two CNAs/CMA completed hand hygiene at the start, and one staff member cleansed the abdomen and catheter tubing, applied a split sponge, and both staff removed gloves and performed hand hygiene before applying gloves again for the transfer. After the resident was moved with a full body mechanical lift, one staff member removed gown and gloves and opened the room door without completing hand hygiene. That staff member then backed the resident out of the room and down the hall before using hand sanitizer at a wall dispenser. The staff member later stated there was a missed opportunity for hand hygiene when removing gown and gloves in the bathroom, and the DON acknowledged concern that hand hygiene was not completed appropriately after doffing gloves and gown and stated hand hygiene was expected whenever gloves were removed.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to follow physician orders for laboratory testing for one resident with diagnoses including diabetes mellitus, hypertension, and hypothyroidism. The resident's care plan and electronic medical record (EMR) included multiple physician orders for A1c and other labs to be completed at specified intervals. Despite these orders, there was no documentation that the required labs were completed after a certain date. The Director of Nursing (DON) confirmed that orders for A1c checks and other labs were not carried out as directed, and this was further corroborated by a review of the EMR and staff interviews. The deficiency was identified through interviews, record reviews, and policy review, which revealed that staff did not consistently enter or complete lab orders in the EMR as required. The DON and Administrator both stated their expectations that staff should enter and complete orders as directed, but the lack of documentation and follow-through resulted in missed laboratory testing for the resident. The facility's policy on medication and treatment orders did not specifically address the requirement to follow physician orders, contributing to the failure to ensure labs were completed as ordered.
Failure to Provide Scheduled Bathing Assistance and Inadequate Documentation
Penalty
Summary
The facility failed to provide scheduled bathing assistance to two residents who required help with activities of daily living. One resident, with diagnoses including cancer, anemia, atrial fibrillation, hypertension, heart failure, and end stage renal disease, was admitted and discharged within a week and required assistance from one staff member for bathing. Despite being scheduled for sponge baths or showers twice weekly, there was no documentation that this resident received any baths during their stay, nor were there records of attempts to offer or encourage bathing. Another resident, with moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, diabetes mellitus, and a history of stroke, required substantial assistance for bathing. This resident was scheduled for baths or showers twice weekly, but records showed inconsistent documentation between electronic and paper forms. There was a period of several days without a documented bath, and no evidence of additional attempts to offer or encourage bathing after a refusal. Staff interviews confirmed that documentation practices were inconsistent and that required follow-up after refusals was not always performed or recorded.
Failure to Provide Scheduled Bathing and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure that residents received baths at the frequency required by their care plans, specifically twice a week or as requested, for six residents reviewed. Documentation revealed multiple instances where baths were not offered or documented as being offered, particularly after a resident refused or when 'not applicable' was recorded. In several cases, there were extended periods where no bath was documented, and residents reported receiving baths far less frequently than scheduled. Some residents also reported not being offered alternative hygiene measures, such as washcloths for freshening up, when baths were missed. Additionally, the facility failed to provide timely toileting assistance for two residents. Residents described long wait times for call lights to be answered, sometimes up to an hour, resulting in incontinence episodes and discomfort. Staff interviews confirmed that staffing shortages contributed to delays in providing care, including both bathing and toileting assistance. Staff also reported that when there were not enough CNAs on shift, baths would be postponed or missed entirely, and documentation practices included marking 'not applicable' when baths were not completed due to staffing issues. Resident council notes and grievances further corroborated concerns about inadequate bathing and nail care. Staff interviews revealed inconsistent practices regarding documentation and follow-up when residents refused baths, as well as reliance on the next shift to complete missed baths. Observations of residents confirmed poor hygiene, such as long and dirty fingernails and strong odors, further evidencing the lack of consistent care. Facility policy required documentation of refusals and notification of supervisors, but these procedures were not consistently followed.
Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the daily needs of all residents, as evidenced by multiple observations, interviews, and documentation reviews. Residents reported not receiving scheduled baths, experiencing long wait times for call light responses, and not receiving timely assistance with toileting needs. For example, one resident with a left below-knee amputation and significant assistance needs stated he was only receiving one bath per week instead of the scheduled two, and sometimes went two weeks without a shower. He also described waiting up to 45 minutes for help during the day and having accidents due to delayed assistance, particularly at night when staff would turn off his call light while he was asleep without providing care. Another resident, who was dependent on staff for bathing and dressing, reported receiving a bath only once a month, despite preferring weekly baths. He also described long waits for call light responses, sometimes up to an hour, resulting in accidents while waiting for help with toileting. Observations confirmed that his fingernails were long and dirty, and a strong odor was present during care, indicating lapses in personal hygiene assistance. Staff interviews corroborated these issues, with CNAs and LPNs acknowledging that baths and other care tasks were often missed or delayed due to insufficient staffing, especially when only one or two CNAs were present on a shift. Resident council notes and grievance forms further documented ongoing concerns about inadequate staffing, missed baths, and long call light response times. Staff described a routine of passing missed baths to the next shift and documenting 'NA' when baths were not completed due to staffing shortages. The Director of Nursing confirmed that staffing levels were often insufficient, leading to delays or missed care, and that baths would be postponed when there were not enough staff members available. Housekeeping and laundry staff also reported finding residents soaked in bed in the mornings, particularly after night shifts with minimal staffing.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for all seven residents reviewed, as evidenced by missing or incomplete documentation regarding bathing, behavioral incidents, and telehealth appointment attempts. For multiple residents, scheduled bath or shower documentation frequently indicated refusals or was marked as 'not applicable,' yet corresponding progress notes lacked explanations for these refusals or the reasons for the 'not applicable' entries. Facility policy required that refusals and interventions be documented, but this was not consistently done. Additionally, staff interviews confirmed that documentation of refusals and interventions was often omitted, and supervisors were not always notified as required. In the case of a resident with no cognitive impairment but significant physical care needs, there was a lack of documentation regarding behavioral incidents and refusals of care. Staff described episodes where the resident refused to use a mechanical lift for transfers, became combative, and refused assistance with toileting and hygiene. Despite these events, there were no corresponding progress notes or behavior documentation in the resident's record for the relevant period. The care plan also did not reflect the use of the mechanical lift until months after the resident began requiring it, and staff acknowledged that these behaviors and refusals should have been documented according to facility policy. Another resident's record lacked documentation of failed attempts to arrange telehealth appointments with a specialist. The resident reported being informed by the facility that the specialist discontinued services due to missed appointments and that the clinic was uncooperative in setting up telehealth visits. Management confirmed that communication with the clinic occurred but admitted that documentation of these efforts was not completed. These omissions in recordkeeping are contrary to accepted professional standards and the facility's own policies.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policies when concerns about the treatment of a resident were not reported within the required two-hour timeframe, and a thorough investigation was not completed. A staff LPN observed two CNAs neglecting call lights, delaying rounds, and interacting with a resident in a condescending and dismissive manner during the night shift. The resident, who had a BIMS score indicating no cognitive impairment and required assistance for toileting, was denied timely help and subjected to inappropriate communication by staff. The LPN reported these concerns to a day shift RN but was unsure if further reporting occurred, and only provided a written statement to the DON after a delay of more than two days. The facility's investigative file revealed significant gaps in the investigation process. Although the facility's policy required immediate reporting of abuse allegations to the administrator and a thorough investigation, the initial report to the state agency was not made until several days after the incident. The investigation did not include follow-up interviews with the resident after her initial statement, nor did it include interviews with her roommate regarding the incident or with all staff who had contact with the resident during the relevant period. The social worker who interviewed the resident did not pursue further questions or follow-up, and the DON was unaware of key statements made by the resident. Documentation of the investigation was incomplete, lacking evidence of follow-up on the resident's psychosocial status and missing interviews with relevant staff and witnesses. The facility's own policies outlined the need for comprehensive documentation and interviews, but these steps were not fully carried out. The resident involved reported being left on the side of her bed for two hours in pain and feeling abused, but there was no documented follow-up to assess her well-being after the incident.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report concerns regarding the treatment of a resident within the required two-hour timeframe after the alleged incident was observed. According to the records, a resident with a BIMS score indicating no cognitive impairment, who required substantial assistance for toileting and was frequently incontinent, was involved in an incident where two CNAs were observed neglecting call lights, delaying rounds, and interacting with residents in a condescending and dismissive manner. The CNAs were also reported to have refused to assist the resident to the bathroom without the use of a mechanical lift, despite the resident's insistence that she did not need it, and ultimately denied her request to use the bathroom. The LPN who witnessed these events reported that the CNAs left call lights unanswered for extended periods, failed to perform regular rounds, and did not provide basic care such as turning hospice residents or passing out ice water. The LPN observed the CNAs speaking to residents in a manner she found inappropriate and witnessed them laughing at and dismissing the resident's needs. The LPN did not immediately report these concerns to facility management or the appropriate authorities, instead waiting until after her next shift to provide a written statement to the DON. The facility's policy required that any suspicion of abuse, neglect, or exploitation be reported immediately, defined as within two hours, to the administrator and other officials as required by law. However, the initial report to the State Agency was not made until several days after the incident, and the LPN acknowledged uncertainty about the reporting process and who to contact at the time. The delay in reporting was confirmed by both the LPN and the DON, who stated that the LPN was educated on the need for immediate reporting after the fact.
Failure to Conduct Thorough Investigation of Alleged Resident Mistreatment
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of staff misconduct and potential resident mistreatment. Documentation revealed that a resident, who had no cognitive impairment and required substantial assistance for toileting, reported being left on the side of her bed for two hours after being told by an aide that she would not be helped. The resident described experiencing pain as a result. Staff statements indicated that call lights were ignored for extended periods, rounds were delayed, and staff interactions with residents were at times rude and dismissive. An LPN observed aides refusing to assist residents promptly and speaking to them in a condescending manner, including an incident where a resident was denied bathroom assistance unless she agreed to use a mechanical lift, which she refused. The facility's investigative file included statements from some staff and a resident questionnaire, but lacked critical follow-up. There was no documented follow-up interview with the resident who made the abuse allegation to assess her psychosocial status after the incident. The investigative file also did not include an interview with the resident's roommate regarding the specific morning in question, nor were staff from all shifts who had contact with the resident after the alleged incident interviewed. Additionally, a key RN who was reportedly informed of the concerns was not interviewed, and attempts to contact her were unsuccessful. The facility's policy required thorough investigation of all allegations, including interviews with witnesses, the resident, staff from all shifts, and the resident's roommate, as well as complete documentation. The investigation did not meet these requirements, as several necessary interviews and follow-ups were omitted, and there was a lack of documentation regarding checks on the resident's well-being after the incident.
Failure to Update Care Plan After Change in Transfer Assistance
Penalty
Summary
The facility failed to update the care plan for one resident after her transfer assistance needs changed to require the use of a mechanical lift (EZ stand). The resident, who had no cognitive impairment and was dependent on staff for toileting and transfers, experienced a decline in mobility and began requiring mechanical lift assistance. Despite this change, her care plan and bedside Kardex continued to document the need for substantial assistance of two staff for transfers, without specifying the use of the EZ stand. Staff interviews revealed that the change in transfer method was communicated verbally between shifts rather than through formal care plan updates. Multiple staff members, including CNAs and the LPN, confirmed that the resident's transfer method had changed and that the care plan was not updated to reflect this. The DON acknowledged that care plans should be updated as needed and that staff rely on the Kardex and EHR for resident care information. The facility's policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in this instance, resulting in the care plan lacking documentation of the mechanical lift requirement.
Failure to Implement Individualized Interventions for Resident with Dementia-Related Behaviors
Penalty
Summary
The facility failed to implement additional individualized interventions for a resident with moderate cognitive impairment and dementia who exhibited behavioral issues during toileting assistance. The resident, who required substantial assistance for transfers and toileting and was frequently incontinent, refused staff help to use the bathroom and to be checked or changed when incontinent. Staff interactions revealed that the resident became upset and combative when told she needed to use a mechanical lift, refusing both the equipment and staff assistance, and using verbal aggression toward staff members. Staff interviews indicated that after the resident refused care, the CNAs and the LPN did not attempt further individualized approaches or interventions beyond documenting the refusal. The LPN declined to assist further, stating that nothing more could be done if the resident refused, and the CNAs continued to check on the resident but were unable to provide care due to her continued refusals. The staff did not attempt to involve other potential interventions, such as involving the nurse in a different approach or contacting the resident's family, despite the facility's policy on problematic behavior management and the DON's later statements about possible alternative strategies. The care plan for the resident included directions for staff to use calm communication and not to argue, but there was no evidence that additional or individualized non-pharmacological interventions were attempted when the resident refused care. The facility's policy required staff to identify and manage problematic behaviors with appropriate interventions, but in this instance, staff actions were limited to initial attempts and documentation, without further escalation or adaptation to the resident's behavioral needs.
Expired Medications and Supplies Found in Medication Storage Areas
Penalty
Summary
Surveyors observed that medications and supplies in the medication room and on medication carts were not consistently stored within their expiration dates. During a medication room inspection with an LPN present, 12 unopened bottles of Aspirin 81 mg were found to be expired. The LPN stated she believed the DON had overlooked these items. Additionally, a check of two medication carts with a CMA present revealed an expired, empty syringe and an opened bottle of expired Aspirin 81 mg filled to the rim. The CMA was informed of the expired items at the time of the observation. Staff interviews indicated a lack of consistent oversight regarding expired items. One LPN denied having issues with expired items, stating that if expired items are found, they are usually treatment supplies that are rarely used and are discarded when noticed. The DON reported that she attempts to review the medication room and that the pharmacy conducts monthly checks, with staff also reviewing medications and supplies as they are put away. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Resident #15, who has quadriplegia and is dependent on staff for various activities, reported that call lights often took longer than 20 minutes to be answered, with delays extending up to an hour during overnight shifts. Observations confirmed that call lights in Resident #15's room were not answered promptly. Similarly, Resident #20, diagnosed with Multiple Sclerosis, experienced delays of up to 30 minutes or more for call light responses, as corroborated by staff interviews indicating that insufficient staffing contributed to these delays. Resident #37, who requires assistance with transfers, reported long wait times for call light responses, affecting her ability to accommodate family visits. Resident #21, who is totally dependent on staff for transfers, recounted an incident where he waited over an hour on a bedpan for assistance. The Director of Nursing acknowledged the facility's expectation for call lights to be answered within 15 minutes but admitted there was no formal policy in place. These findings highlight the facility's failure to meet the needs of residents due to inadequate staffing levels, as evidenced by the delayed response to call lights.
Inaccurate Assessment of Anticoagulant Use
Penalty
Summary
The facility failed to accurately assess the use of an anticoagulant for a resident during the observation period of the Minimum Data Set (MDS). The MDS for the resident documented the use of an anticoagulant, but upon review, it was found that the resident was only taking baby Aspirin, which is an anti-platelet, not an anticoagulant. The resident confirmed that the only blood thinner they took was baby Aspirin. The Medication Administration Record (MAR) showed a physician's order for Aspirin 81 mg daily for pain. The MDS coordinator identified Aspirin as an anticoagulant due to the resident's history of blood clots. However, the Regional Clinical Reimbursement Specialist clarified that Aspirin should be coded as an anti-platelet according to RAI guidelines, indicating the MDS was incorrectly coded. The facility's policy requires the MDS Coordinator to ensure accurate resident assessments, which was not adhered to in this case.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices during medication administration for a resident with an enteral tube. The resident, who had a BIMS score indicating no cognitive impairment and a diagnosis of quadriplegia, was observed receiving medication through an enteral tube by a registered nurse. Although the nurse completed hand hygiene and wore gloves, they did not don a gown as required by the facility's policy for enhanced barrier precautions for residents with indwelling medical devices such as feeding tubes. The facility's policy, aligned with CDC guidelines, mandates the use of personal protective equipment, including gowns, during high-contact care activities for residents with indwelling medical devices, regardless of their MDRO colonization status. The Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including gowns, during such procedures. The failure to follow these precautions was acknowledged by the Director of Nursing, highlighting a lapse in adherence to infection control protocols.
Inadequate Bathing and Hygiene Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate bathing and personal hygiene care for several residents, as observed through clinical record reviews, interviews, and facility policy reviews. Resident #5, who required assistance from two staff members for bathing, did not receive a bath on one scheduled day, and reported receiving only one bath per week due to staff shortages. Resident #8, who required total assistance for bathing, was found to have long fingernails and reported not having a bath for a month, with no staff offering or explaining the lack of bathing services. Resident #9, who required assistance from two staff members for bathing, went ten days without a bath, despite being scheduled for three baths a week. His son confirmed the inconsistency in bathing schedules and noted that staff often cited understaffing as the reason for missed baths. Resident #11, who required partial assistance with personal hygiene, was observed with long leg hair and stated that staff did not assist with shaving, although she desired it. Staff interviews revealed that baths were not consistently completed due to insufficient staffing, with some staff stating that baths were not done on evening shifts unless there was enough staff. The Director of Nursing confirmed that residents should receive baths twice a week unless they refuse, and that nail trimming should occur during bath times. The facility's policies emphasized the importance of maintaining residents' personal hygiene and dignity, which were not upheld in these instances.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly in answering call lights in a timely manner. Observations on a specific date revealed numerous call lights going unanswered for extended periods, ranging from 16 to 40 minutes. This issue was corroborated by resident council meeting notes and grievance forms, where residents consistently reported delays in call light responses. For instance, Resident #9 expressed frustration over the time it took to get assistance, and Resident #6 reported waiting 45 minutes in soiled conditions before receiving help. Interviews with staff and residents further highlighted the staffing inadequacies. Staff members, including CNAs, reported that call lights could take over 30 minutes to be answered due to insufficient staffing levels. They described scenarios where only two CNAs were available to assist a significant number of residents, many of whom required two-person assistance for transfers. This staffing shortage was particularly acute during evening and weekend shifts, leading to delays in attending to residents' needs and completing routine tasks. The facility's Director of Nursing (DON) acknowledged that staffing was based on census rather than resident acuity, which contributed to the problem. Despite the expectation that call lights be answered within 15 minutes, this standard was not consistently met. The DON admitted that while efforts were made to increase staffing, call-ins and other issues often left the facility understaffed, impacting the quality of care provided to residents.
Inadequate Kitchen Staffing Leads to Unqualified Staff Performing Dietary Tasks
Penalty
Summary
The facility failed to ensure that qualified staff were consistently available to assist in the kitchen, leading to untrained staff from other departments stepping in to perform dietary tasks. This issue was highlighted by grievances from residents who expressed dissatisfaction with meal services, such as not receiving ordered meals and being asked to prepare their own food. The facility's census was reported to be 30 residents, and the dietary manager's unexpected absence exacerbated the staffing shortage, prompting the administrator to pull staff from other departments to fill in. Multiple staff members, including CNAs, nurses, and maintenance personnel, reported being asked to assist in the kitchen without proper training or certification. Some staff members, like Staff E CNA, were involved in cooking meals despite lacking dietary certifications, relying instead on previous experience and kitchen charts to guide them. Others, like Staff P LPN, assisted with meal service under the supervision of the dietary manager, who was unable to perform her duties due to medical reasons. The facility's job descriptions for CNAs and cooks did not include kitchen duties for CNAs, indicating a misalignment between staff roles and responsibilities. Despite the lack of formal training, staff were frequently asked to perform dietary tasks, such as serving meals and preparing room trays, due to the facility's inability to maintain adequate kitchen staffing. This situation persisted over several months, with staff expressing concerns about their lack of training and the facility's reliance on unqualified personnel to meet dietary needs.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and serve food in a sanitary manner, as observed during a survey. On two separate occasions, hamburger meat was found in a gray hard plastic bin with red, bloody fluid at the bottom, indicating improper storage. Additionally, moldy green peppers were found in the walk-in cooler, suggesting a lack of proper food inspection and disposal. These observations were made despite the facility's policy requiring food to be stored in a manner that complies with safe food handling practices. In the dish area, a dietary aide was observed using the same pair of gloves to handle both dirty and clean dishes, violating infection control practices. The aide moved a trash can, handled clean dishes, and cleaned the dirty side of the dish area without changing gloves or washing hands between tasks. This practice was contrary to the facility's policy, which requires handwashing between tasks to prevent cross-contamination. Furthermore, a staff member was seen handling ready-to-eat food with bare hands, contrary to the facility's policy that prohibits direct contact with food without gloves. The staff member plated sandwiches and handled various items without wearing gloves, even after touching her hairline and clothing. This behavior was inconsistent with the facility's guidelines, which mandate the use of gloves or utensils when serving ready-to-eat foods.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the behavior of Staff P, an LPN, towards multiple residents. Resident #5, with no cognitive impairment, reported that Staff P was dismissive and unhelpful, refusing to assist her roommate and declining to turn off the overhead light when requested. Resident #6, also cognitively intact, overheard Staff P using profane language and speaking negatively about residents while at the nurse's station. Resident #8, who communicates using a board, indicated that Staff P was not nice when speaking with him. These interactions suggest a pattern of disrespectful communication by Staff P, impacting the residents' sense of dignity. Interviews with other staff members corroborated the residents' accounts, with several CNAs and LPNs acknowledging Staff P's use of inappropriate language and negative comments about residents. Staff I and Staff E reported that Staff P frequently used profanity and complained about residents, while Staff H noted that Resident #5 refused treatment from Staff P due to her demeanor. The Director of Nursing was informed of these issues and acknowledged the need to address the negative environment created by Staff P's behavior. The facility's policies on resident rights and dignity emphasize the importance of treating residents with kindness and respect, which was not upheld in these instances.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to an elopement incident. The resident, who had a BIMS score indicating mild cognitive impairment and was identified as an elopement risk, left the building without staff knowledge. On the day of the incident, staff responded to an alarmed door but did not physically check outside to confirm if a resident had exited. The staff member assumed they saw another staff member and did not initiate a head count to ensure all residents were accounted for. The resident was later found by an Assisted Living (AL) attendant and returned to the facility without injuries. The facility's investigation revealed that the staff member who responded to the alarm did not follow proper procedures, such as going outside to check for residents or conducting a head count. The facility's policy and procedures for responding to door alarms were not effectively followed, contributing to the resident's unsupervised exit. Interviews with staff indicated a lack of consistent understanding and execution of the facility's elopement protocols. Some staff members were unaware of the need to conduct a head count or physically check outside when an alarm sounded. The facility's documentation and training on elopement prevention and response were insufficient, as evidenced by the staff's varied responses and the absence of a clear protocol for handling such incidents.
Improper Disposal of Room Trays
Penalty
Summary
The facility failed to properly dispose of room trays with leftover food in a timely manner, as observed during a survey. On multiple occasions, trays with leftover food and drinks were found in residents' rooms long after meals were served. For instance, a dietary aide reported finding dishes in residents' rooms after returning from a weekend off, indicating that trays were not collected promptly. Additionally, a resident reported that her dishes from breakfast and lunch were not picked up until after she had gone to the dining room for dinner. Another resident's room was observed with a plate, silverware, and a coffee mug left on the bedside table for an extended period. The Director of Nursing acknowledged that the responsibility for collecting room trays is shared between dietary and nursing staff, but noted that there is some ambiguity in the facility's policy regarding the timing of tray collection. The policy states that trays should be collected within an hour of meal completion, but the Director mentioned that it is often left to the discretion of the resident. The facility's meal times are set, but the lack of adherence to the policy resulted in trays being left in rooms for prolonged periods, contributing to the deficiency.
Improper Storage and Use of Vape Pens
Penalty
Summary
The facility failed to ensure proper storage and use of vape pens for two residents. Resident #6 had three vape pens observed in his room without any documentation in his clinical record regarding his ability to smoke with or without supervision. Additionally, Resident #6 was seen outside with staff assistance using his vape pen. Resident #7 also had no documentation in her clinical record about her ability to smoke with or without supervision. Staff were aware that Resident #7 used her vape pen in her room, which contained THC and CBD, and she claimed it was prescribed for pain management. Despite the facility's policy requiring smoking evaluations and designated smoking areas, Resident #7 used her vape pen indoors. The facility's smoking policy, revised in 2017, mandates that residents be informed of designated smoking areas and evaluated for their ability to smoke safely. The policy prohibits smoking inside the facility and requires that residents with smoking privileges not keep smoking articles in their possession. However, Resident #7 was found with a vape pen and THC gummies in her room, which were later removed by management after a police officer's visit. The Director of Nursing confirmed that Resident #7 had not been going outside to smoke as required by the policy, and the resident was educated about the prohibition of such items in the facility.
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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.
Illustrative
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Nursing homes near Avoca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elm Crest Retirement Community | 10.3 mi | ★★★★★ | 8 | 0 |
| Oakland Manor | 13.1 mi | ★★★★★ | 31 | 0 |
| Salem Lutheran Home | 18 mi | ★★★★★ | 10 | 0 |
| Heritage House | 21.3 mi | ★★★★★ | 8 | 0 |
| Atlantic Specialty Care | 21.7 mi | ★★★★★ | 9 | 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.