Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azria Health Prairie Ridge during CMS and state inspections, most recent first.
Failure to Follow Wound Treatment Orders for Recurrent MASD: A resident with diabetes, incontinence, obesity, and recurrent MASD had an open left inner thigh wound documented by the ARNP, who ordered daily cleansing and Triad cream BID/PRN with frequent brief changes due to moisture. The MAR/TAR did not reflect the ordered wound care, staff documented the wound as resolved despite later reopening, and nursing notes later described active MASD wounds on the thigh and buttock. Staff interviews showed inconsistent understanding of whether the wound was healed and whether treatment orders were still active.
A facility failed to keep resident rooms, shower rooms, and hallways clean and homelike, with surveyors noting missing transition strips, stained and dirty flooring, black marks on doors and walls, scrape marks, missing tiles, holes, broken drywall, loose conduit boxes, peeling anti-slip strips, and strong urine odors in multiple bathrooms and hallways. Cognitively intact residents reported long-standing issues such as weekly room cleaning, damaged ceilings from a leak, and missing flooring and wall damage, while staff described limited housekeeping coverage, weekend cleaning of the whole facility, and a month-long shortage of enzyme spray for urine odors. The ADM, housekeeping, and maintenance staff also described staffing gaps, incomplete repairs, and limited maintenance rounding.
Incomplete Background Screening for RN: The facility failed to complete a thorough background check for an RN whose SING report included a child abuse section requiring an HHS record check evaluation, but the employee file lacked documentation that this step was completed. The HR manager stated the child abuse section was missed, and the Administrator said it was overlooked because of where it appeared on the form; the facility policy required background checks to be initiated with the offer of employment and completed prior to employment.
A resident with intact cognition reported that a dining room window trim piece and a baseboard heater guard had been missing for more than a year. Surveyors observed the missing trim, exposed heating elements on a dining room baseboard heater, and a bent guard on another heater in the front sitting area. Work orders did not show these items, and the MDS, Maintenance Director, Regional Maintenance Manager, and Administrator interviews reflected a lack of awareness and follow-through on the repairs.
The facility failed to manage resident alcohol use and sharing, secure a topical pain relief product, and complete a required smoking evaluation. Residents with intact cognition were documented drinking alcohol, hiding or sharing it with peers, and appearing intoxicated, while staff were unclear on the alcohol policy. A severely cognitively impaired resident accessed ActiveIce from a medication cart and may have ingested it, and a smoker’s admission evaluation was missing despite smoking being addressed in the care plan.
Room tray food was not kept at a palatable temperature during breakfast service. A resident with intact cognition said the food was horrible, cold, and did not taste good, and that they always requested a room tray. During observation, dietary staff filled carts with multiple trays and delivered them to resident rooms; a test tray later showed eggs and mechanical ground sausage were cold to the touch and below palatable temperature, while Cream of Wheat remained hot. The Dietary Manager agreed the egg and sausage were too cold.
Failure to Honor Resident Meal Preferences: During an observed breakfast meal, staff did not follow meal ticket instructions or resident preferences for three residents with intact cognition and diet-related diagnoses. One resident with diabetes, dementia, morbid obesity, and weight loss was served eggs and bacon despite documented dislikes and a request for different items; another resident with diabetes, dysphagia, and morbid obesity was served sausage despite a documented dislike and request for an egg and muffin; a third resident with heart failure, diabetes, and dysphagia did not receive the extra portions requested. The Dietary Manager stated the cook missed giving double or extra portions and needed to read meal tickets better.
A facility failed to honor resident rights when three residents with intact or near-intact cognition were not taken out for scheduled smoke breaks. Care plans identified smoking as an ongoing preference and required supervision, but nursing notes, resident interviews, and staff statements showed smokers were sometimes kept inside because staff were short staffed or unavailable, leaving residents upset when the designated smoking times were missed.
A cognitively intact resident reported that his purchased Lunchables were missing from a hall refrigerator after staff had placed them there, and he said an employee took them. He told a CNA and a manager about the missing food, but staff did not promptly follow up, and the Administrator later stated she was hearing about it for the first time. Facility policy required resident property to be respected and complaints of missing property to be promptly investigated.
The facility failed to consistently provide a resident with the correct size bariatric incontinence brief, and staff reported that smaller briefs were sometimes used when the preferred size was unavailable or cost was an issue. The resident said the smaller briefs rubbed her skin and wound area, and staff confirmed the smaller size caused discomfort and irritation. The facility also failed to ensure another wheelchair-using resident could independently access her bathroom faucet and closet, with staff and observation confirming the faucet was hard to operate and the clothing bar was out of reach.
A resident with intact cognition had a missed famotidine dose because the medication was not available on admission. The PCP and POA were notified later, but staff interviews showed the expected timeframe for family notification was within 45 minutes to 24 hours, and the DON stated notifying the family 5 days later was not appropriate. The facility policy required prompt notification of the resident, physician, and resident representative, generally within 24 hours.
Two residents with indwelling catheters were observed multiple times with catheter tubing and drainage bags dragging on or touching the floor while they self-propelled in wheelchairs, despite staff acknowledging the tubing and bags should not touch the ground. One resident also had a UTI with a urine culture showing ESBL E. coli, and the antibiotic order for fosfomycin was not documented until several days after the culture was verified.
An RN left an insulin and wound treatment cart unlocked and unattended near the nurse's station while staff were nearby but not monitoring it. The cart contained insulin pens, glucagon, topical meds, needles, syringes, and other treatment supplies. A resident with dementia and moderate cognitive impairment was seated nearby with a walker within reach. Facility policy required medication carts to remain locked when not in use.
Meal service failed to match ordered dietary needs for two residents during breakfast. One resident ordered double protein portions and reported sometimes not getting enough to eat, yet was served a tray that did not reflect the double portions or his no-bacon preference. Another resident had an order for an extra egg when eggs were on the menu, but was served only one egg. The Dietary Manager stated the cook had missed giving double or extra portions and staff needed to read meal tickets better.
An LPN provided wound care to a resident with diabetes, incontinence, MASD, and multiple skin wounds without following EBP. During the observation, the LPN used the same gloves and gauze across multiple wounds and applied zinc oxide from the container with the same gloved hand, while the LPN and CNAs did not wear gowns. Staff later stated that gown and glove use was required for residents with wounds during personal and wound care.
Incomplete transfer documentation and missing required notices The facility did not thoroughly document hospital transfers for two residents, including missing details about the change in condition, current vitals, events before transfer, and forms sent with the resident. It also failed to give written transfer notices to two residents that included appeal rights, Ombudsman contact information, and contact information for agencies protecting residents with intellectual, developmental, mental, and related disabilities. In addition, the facility did not notify the Ombudsman after a resident was sent to the ED following a fall.
A resident with multiple medical conditions and moderate cognitive impairment, seated near the nurses’ station while on the phone, swung his arm back and struck another resident with severe dementia twice in the upper back as she self-propelled her wheelchair past him, following her usual routine. Staff reported that this resident could become irritable when redirected, and he then stood up and hit and pinched a CNA who intervened. The aggressor’s care plan identified mood and behavior issues and directed staff to anticipate needs, provide positive interaction, and intervene to protect others’ safety, while the other resident’s care plan addressed impaired cognition and the need for supervision and consistent routine. The facility’s abuse policy states residents must be protected from abuse by anyone, including other residents.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for mobility allowed a CNA to use her EBT food stamp card to buy snacks for her and also to purchase items for the CNA, without specifying a spending limit. The CNA used the card at a grocery store to buy a large volume of items, and later could not clearly recall what she had purchased for herself. When the receipt was reviewed, the resident identified numerous items she had not requested that were believed to be for the CNA, totaling a substantial amount. Other staff reported they understood from dependent adult abuse training that using a resident’s resources or accepting gifts was wrong, and facility policy explicitly prohibited exploitation and misappropriation of resident property, yet the resident’s EBT benefits were used inappropriately by staff.
Two residents were issued emergency discharges following repeated altercations, with the facility failing to adequately address their needs or properly notify and involve their guardians and families in the process. Both residents were transferred to hospitals for psychiatric evaluation, found not to require admission, and were subsequently refused readmission by the facility, resulting in one resident remaining hospitalized and the other returning to independent living with limited support.
Surveyors identified multiple instances where staff failed to store raw meat on the bottom shelf, handled food with gloved hands without changing gloves between tasks, and left an ice scoop handle in contact with ice. Staff interviews confirmed awareness of proper procedures, but these were not consistently followed, resulting in unsanitary food storage and handling.
Three residents experienced a lack of dignity and respect due to staff actions, including inappropriate verbal and physical cues during feeding, use of personal phones during care, and inadequate supply of properly sized incontinence briefs. These actions were confirmed by resident and staff interviews, observations, and review of facility policies, highlighting failures to follow care plans and maintain resident dignity.
A resident with multiple chronic conditions experienced significant weight loss over several months. Although dietary staff documented the weight loss and implemented interventions, the facility failed to provide evidence that the physician was notified of these changes, as required by policy.
Care plans were not updated for two residents who experienced significant weight loss and for another resident who was no longer receiving dialysis, despite clear evidence of these changes. Staff interviews revealed lapses in responsibility for updating care plans, and the facility's policy requiring timely revisions after significant changes was not followed.
A resident with lower extremity impairment and intact cognition did not consistently receive restorative nursing interventions as recommended by therapy, due to inconsistent staff assignment and lack of dedicated restorative personnel. The care plan outlined specific exercises and activities, but staff interviews revealed that restorative programming was often missed or inadequately implemented when the responsible staff member was reassigned to other duties.
The facility did not ensure that its services met professional standards of quality, as observed through practices that did not align with established care guidelines.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Three medication errors were observed among twenty-seven opportunities, resulting in a medication error rate of 11.11%. Errors included a resident receiving insulin after eating instead of before meals, another resident receiving the wrong dosage form of Ferrous Sulfate, and a third resident being given a different formulation of Polyethylene Glycol than prescribed. These incidents occurred despite facility policies requiring medications to be administered as ordered and within specified time frames.
Multiple residents experienced significant medication errors involving anticoagulants, insulin, and narcotic pain medications due to failures in documentation, communication, and order transcription. In several cases, residents received double doses of medications or had medications administered at incorrect times, and one resident received an incorrect anticoagulant regimen due to a transcription error that was not clarified with the discharging hospital. These errors were identified through observation, interviews, and record review, and were not consistent with the facility's medication administration policy.
The facility failed to complete quarterly MDS assessments on time for several residents, with delays noted in the completion of assessments beyond the required 14-day period from the ARD. Interviews with staff, including the MDS Coordinator and DON, confirmed these delays, and the facility's policy did not address quarterly MDS requirements.
The facility did not complete annual MDS assessments on time for two residents. One resident's assessment was still in process beyond the required timeframe, while another's was completed late. Staff interviews confirmed the delay, which was against the facility's policy requiring completion within 14 days of the ARD.
A facility failed to update a PASRR for a resident with new mental health diagnoses and medications. The resident had a history of anxiety, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite significant changes in diagnoses and medication orders, the PASRR was not resubmitted. The MDS coordinator misunderstood the criteria for significant changes, which was later clarified by the administrator. The facility's policy required a PASRR Level II evaluation for new or changed behaviors indicating a serious mental disorder, but this was not followed.
A facility failed to administer a pneumococcal vaccine to a resident who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination and consent for the PCV 20 was obtained. However, due to a lack of communication and clarity among staff regarding responsibility for vaccinations, the vaccine was not administered. The DON relied on the Infection Preventionist, who was unaware of the need to offer the vaccine, resulting in a disconnect in the process.
The facility failed to maintain a clean and hazard-free environment, with observations of debris and trash under beds, cluttered hallways, and inconsistent cleaning practices. A resident reported that their room was not always cleaned thoroughly, contributing to the deficiency.
The facility failed to follow enhanced barrier precautions and hand hygiene practices. A resident on enhanced barrier precautions was assisted by CNAs without protective gowns. Another resident received care without staff sanitizing hands before providing a snack. Observations revealed empty sanitizer dispensers and staff not using them, violating the facility's hand hygiene policy.
Failure to Follow Wound Treatment Orders for Recurrent MASD
Penalty
Summary
The facility failed to accurately assess and implement a physician order for a resident with a history of moisture associated skin damage (MASD). Resident #18 had diagnoses including diabetes, incontinence without sensory awareness, and morbid obesity, and the record identified MASD and recurrent skin breakdown in the left inner thigh and buttock areas. The resident’s care plan addressed frequent redness in skin folds requiring antifungal treatment as needed, and the treatment record included weekly skin assessments. On 4/16/26, an ARNP documented an open left inner thigh wound with moist, fluid-filled intact blisters and noted the area was constantly moist due to incontinence. A physician order was then issued to clean the left inner thigh wound daily and if soiled, discontinue Marathon dressing, start Triad cream BID and PRN if soiled, and ensure the resident was checked and changed frequently due to MASD. The April and May 2026 MAR/TAR did not contain the ordered daily cleansing or Triad cream treatment for the left inner thigh wound, and the Marathon order had been discontinued on 4/1/26. Subsequent documentation showed the wound was not consistently tracked as active. Skin check notes on 4/15/26 stated no new skin issues and that the skin issue was resolved, yet on 5/13/26 nursing documented an open area associated with MASD to the right buttock and a reopened inner left thigh area. During interviews, staff described the thigh wound as coming and going, with one RN stating she did not consider a scab over a wound as healed, while another RN reported the wound had healed if the treatment was discontinued. The ARNP later assessed the resident and stated the left thigh wound looked worse than the prior assessment and that zinc oxide would not be effective. Facility policy required treatments to be administered only upon written order and for physician orders to be followed.
Dirty Rooms, Urine Odors, and Deferred Maintenance Throughout Facility
Penalty
Summary
The facility failed to maintain a clean, odor free, comfortable, and homelike environment in 31 of 32 resident rooms, 2 of 2 shower rooms, and 2 of 3 hallways. During a continuous walk-through of all resident rooms, surveyors observed missing transition strips, discolored and dirty flooring, black marks on doors and frames, scrape marks on walls, stained tiles, rings of discoloration around toilet bases, missing basecoat along flooring strips, dirt and trash on floors, spider webs, dirt buildup in corners, missing floor tiles, holes in doors, broken drywall on ceilings, leaking or running toilets and faucets, loose conduit boxes, and peeling or missing anti-slip strips in numerous rooms. The 100 and 200 hallways also had multiple scraps and black marks above and below the handrails, and both shower rooms had dirt, dust, stained tiles, and other visible buildup. Several residents and staff described ongoing cleanliness and maintenance concerns. One cognitively intact resident reported housekeeping had only been cleaning rooms once per week, while another cognitively intact resident stated the ceiling above the bed had needed repair for at least 8 months after a roof leak caused damage. A third cognitively intact resident reported missing flooring and wall scrapes had been present for as long as she had been in the room. During later observations, surveyors noted additional rooms with missing flooring basecoat, discolored floors, toilet base rings, cracked caulk, dirt buildup, missing call light cover, and strong urine odors in bathrooms and hallways. Staff interviews described limited housekeeping coverage and maintenance delays. The housekeeping manager reported that for the first two weeks she worked at the facility, she had to clean the resident rooms in the 100 and 200 hallways by herself. A housekeeping staff member stated that on weekends she had to clean the whole facility, felt this was impossible, and did not have time to mop every resident room floor. That staff member also reported the facility had been out of the enzyme spray used to remove urine odors for about a month. The administrator reported problems with housekeeping staff not showing up, and the regional maintenance manager reported he had not done rounding for 6 months. The maintenance director stated she knew about several concerns, including missing flooring basecoat, missing transition strips, black marks on walls, and unsecured conduit boxes, but was unaware of other issues such as stained toilet bases and some electrical boxes not mounted in walls. The facility policy on work orders stated maintenance requests were to be prioritized and followed up as indicated, including emergency requests.
Incomplete Background Screening for RN
Penalty
Summary
The facility failed to complete a thorough background check for 1 of 5 employees reviewed for background checks. Review of the employee record for Staff A, an RN with a start date of 7/16/25, showed a Single Contact License & Background check dated 7/14/25 that included a child abuse section instructing the user to initiate a record check evaluation process by completing a form and submitting it to HHS. The employee file did not contain any further documentation showing that the child abuse evaluation was completed. During interviews, the Business Office/Human Resource Manager stated she missed the child abuse section on Staff A’s SING report and had reviewed only the dependent abuse and sex offender sections. She stated the facility suspended Staff A and submitted the record evaluation for expedited review, and that she intended to review all staff SING reports to ensure nothing else was missed. The Administrator stated the child abuse section was overlooked because of where it appeared on the paper and that the facility would go back and review all staff files to make sure no one else was missed. The facility policy titled Background Screening Investigations Policy stated that background checks, reference checks, and criminal conviction checks are conducted on all potential direct access employees and contractors and are initiated with the offer of employment or contract agreement and completed prior to employment.
Missing Heater Guard and Window Trim in Dining Area
Penalty
Summary
The facility failed to maintain a safe and homelike environment by leaving a missing metal guard over the heating elements of a baseboard heater in the dining room and by not replacing missing molding trim at the base of a dining room window. Resident #7, whose MDS assessment dated 3/12/26 showed a BIMS score of 15 out of 15 indicating intact cognition, told the surveyor on 5/11/26 that the dining room window trim and the heater guard had been missing for more than a year and was upset about the conditions in the dining room. During observation, the dining room window was noted to be missing the bottom piece of trim molding, with the outline of the missing piece visible. The baseboard heater on the north dining room wall was missing its metal guard and had exposed heating elements, and the baseboard heater in the front sitting area had a bent metal guard that exposed the heating elements. Review of work orders showed no requests for these items, and the Maintenance Director stated she was unaware of the missing trim and missing heater guard. The Regional Maintenance Manager reported he had not reviewed the facility’s itemized repair list and had not done rounding for 6 months due to covering another building. The Administrator stated she did not have control over when maintenance items would be replaced or fixed.
Alcohol sharing, unsecured medication, and missing smoking evaluation
Penalty
Summary
The facility failed to ensure ongoing, personalized interventions for residents with alcohol use and alcohol sharing among residents. Resident #13 had intact cognition, diagnoses including depression and alcohol use, and care plan entries noting intoxication, alcohol consumption, and medication holds, but the care plan did not address interventions to prevent drinking at the facility or bringing alcohol in. Nursing notes documented the resident drinking over a weekend, being observed pouring vodka into a cup with red juice, and later appearing intoxicated with slurred speech, flushed face, stumbling, and alcohol on the breath. Staff interviews indicated residents could bring alcohol into the facility, that alcohol was sometimes hidden or left in the open, and that staff were unclear on the alcohol policy. Resident #3 also had intact cognition and diagnoses including alcoholic cirrhosis, alcohol use, anxiety, depression, and PTSD. The care plan only addressed encouraging alcohol cessation and holding medications when alcohol use was suspected. Nursing notes documented the resident admitting to drinking alcohol, stating the alcohol was not in the room and refusing to identify where it came from, then later being found slurring words, flushed, unable to stay awake, and reported by staff to have received alcohol from a peer. Resident #2 had moderately impaired cognition and diagnoses including stroke, hemiplegia/hemiparesis, and diabetes. A behavior note documented Resident #19 handing Resident #2 a cup of amber liquid, watching him drink, and the cup smelling of alcohol when staff took it away. Resident #19 had intact cognition, diagnoses including anxiety, depression, alcohol dependence, and alcoholic cirrhosis, and orders related to no alcohol consumption while taking pain medication, yet notes documented intoxication, alcohol-smelling breath, slurred speech, and another incident in which he handed alcohol to Resident #2. The facility also failed to keep a topical pain relief medication secured in a medication cart, allowing Resident #10, who had severely impaired cognition and dementia, to access ActiveIce from the cart and possibly place some in her mouth. Staff documented that the resident took the product from the cart, possibly ingested it, and smelled like the product when evaluated. In addition, the facility failed to complete a smoking evaluation for Resident #12 on admission. The resident was identified as a smoker, had intact cognition, and the care plan addressed smoking instruction, but the EMR lacked documentation of the required smoking evaluation. Observation showed the resident going outside to smoke with a walker and oxygen equipment, and staff later acknowledged the smoking evaluation had not been completed and should have been done on admission.
Room Tray Food Served at Improper Temperature
Penalty
Summary
Food and drink were not maintained at a palatable temperature during room tray service. Resident #20 had a BIMS score of 15 out of 15 on the MDS dated 3/19/26, indicating intact cognition, and stated during interview that the facility food was horrible, cold, and did not taste good. The resident said they ate in their room and always requested a room tray. During breakfast observation on 5/12/26, dietary staff served residents in the dining room first and then served residents who requested room trays. Staff R and Staff S placed six resident meal trays per open service cart, and when the cart was full, staff in the dining room took the cart to resident rooms. The Dietary Manager later tested a state agency test tray after it had been delivered to a room and found eggs at 107.8 F and mechanical ground sausage at 96.8 F; both were cold to the touch and not palatable, while Cream of Wheat was 137 F and hot to the touch. The Dietary Manager stated the egg and sausage temperatures were too cold and agreed the food would not taste good at those temperatures. The facility policy stated that proper hot and cold temperatures are maintained during food service.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to serve food based on resident preferences during an observed breakfast meal for 3 residents with intact cognition and documented food dislikes and diet preferences. Resident #1 had diagnoses including diabetes, dementia, morbid obesity, and abnormal weight loss, and the care plan directed staff to offer an alternate if the resident disliked food or fluids given or on the menu. During the meal observation, the resident was served an egg, cold cereal with milk, and bacon even though the ticket identified dislikes for eggs and bacon and the resident requested a double portion of entree, cold cereal, and a breakfast muffin. Resident #5 had diagnoses including diabetes, dysphagia, and morbid obesity and was on a mechanically altered diet with a care plan directing staff to modify diet according to food tolerances and preferences. During the same meal observation, the resident was served an egg, cream of wheat, and mechanically ground sausage even though the ticket showed the resident disliked sausage and sausage gravy and requested an egg and a muffin. Resident #7 had diagnoses including heart failure, diabetes, and dysphagia and was also on a mechanically altered diet; the resident reported concerns about not getting extra portions at meals when requested. During breakfast observation, the resident was served one egg, two bowls of cream of wheat, mechanically ground sausage with gravy, a muffin, and toast, while the ticket showed the resident requested 3 portions of eggs, 2 pieces of toast, 2 bowls of hot cereal, a muffin, and ground sausage. The Dietary Manager stated the cook had missed giving double or extra portions during breakfast service and needed to read meal tickets better.
Residents Were Denied Scheduled Smoking Opportunities
Penalty
Summary
The facility failed to respect resident rights by not allowing residents to go out and smoke during the designated smoking times for 3 of 4 residents reviewed. Resident #12 had a BIMS score of 15 out of 15, indicating intact cognition, and his care plan noted that he continued to enjoy smoking and required supervision while smoking. He stated that the facility allowed him to smoke three times a day, but sometimes staff did not show up to let residents smoke, and he reported that the residents were not allowed to go out and smoke at 7:30 PM on two recent occasions. Resident #13 also had a BIMS score of 15 out of 15 and a care plan identifying smoking as a continued interest with supervision required while smoking. A nursing note documented that the resident was upset when staff were unable to take smokers out, and staff told residents they could not leave unassisted and that staff was unable to take them out. Resident #3 had a BIMS score of 13 out of 15 and a care plan noting continued smoking with supervision required. Nursing notes and staff interviews showed that on one weekend smoking session residents did not get their smoke break because staff said they were short staffed and did not have time to take smokers out, and Resident #3 was upset about not being able to smoke. The facility policy stated residents with smoking privileges requiring monitoring must have direct supervision while smoking, and the facility’s designated smoking times were 9:30 AM, 1:30 PM, and 7:30 PM.
Failure to Follow Up on Missing Resident Food Items
Penalty
Summary
The facility failed to follow up after a resident reported that food he had purchased was missing. Resident #12 was cognitively intact with a BIMS score of 15 out of 15 and stated he bought Lunchables because he gets sick every time he eats and does not eat dinner. He reported that an employee took the Lunchables from the refrigerator in the hall, and he told a CNA to get him one, but none were found. He also stated he told a manager, who said the items would be replaced, and that three Lunchables were taken. The resident said he was upset about the missing Lunchables, not the money, and stated he did not know whether the food had been labeled. Staff interviews showed the report was not promptly addressed. A CNA stated resident food items are labeled and placed in the refrigerator, but she could not find the Lunchables when the resident asked for them. An LPN/unit manager stated the resident reported the missing Lunchables the day he left and that he would follow up with the Administrator, but he had not yet spoken with her. The Administrator stated it was the first time she heard about the missing Lunchables and said they should have been taken care of within that day it was reported. Facility policy required resident belongings to be treated with respect and complaints of misappropriation or mistreatment of resident property to be promptly investigated, and the food policy required resident food items to be labeled and stored separately.
Failure to Provide Appropriate Brief Size and Accessible Room Features
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not consistently providing the correct size bariatric incontinence brief for a resident with morbid obesity, incontinence without sensory awareness, and dependence for toileting hygiene and bed mobility. The resident’s MDS showed she was always incontinent of bowel and urine and required substantial to maximum assistance with toileting-related care. Staff and the resident reported repeated problems obtaining the resident’s usual size 5XL brief, and staff stated that when the facility ran out, smaller 4XL briefs were used instead. Staff also reported that the smaller briefs were too tight and caused rubbing sores on the resident’s inner thighs, and the resident stated the smaller briefs rubbed on her wound and made her angry because she had not been asked if she agreed to the change. The record and interviews showed the resident had skin issues on admission, including left inner thigh shearing from an incontinent brief, MASD in the right intragluteal cleft, and an abrasion on the right hip. Staff reported that the facility’s supply process sometimes left the resident without the correct size brief, and that the briefs were kept in the medication room or nurse’s office. Staff also stated there were times when management or the purchasing process pushed use of the smaller size because of cost or availability. The resident reported that at times she had to wear the smaller brief until the next supply delivery, and staff acknowledged that the resident became upset when this occurred. The facility also failed to ensure room features were accessible for another resident who used a wheelchair and required substantial to maximum assistance with multiple ADLs. That resident reported she could not turn on the bathroom faucet without staff help and could not reach her clothes in the closet from her wheelchair. Observation confirmed the faucet handle was difficult to pull and the resident could only reach the bottom of the hanging clothing. The resident reported frustration with waiting for staff and said she had broken multiple hangers trying to retrieve clothing herself. Staff interviews confirmed the faucet was hard to turn on and that the resident had difficulty accessing the closet, while the facility’s policy stated resident needs and preferences, including environmental modifications, are to be evaluated upon admission and reviewed ongoingly.
Failure to Timely Notify Family of Missed Medication
Penalty
Summary
The facility failed to notify a family member in a timely manner after a missed medication for Resident #12, who was admitted with a BIMS score of 15 out of 15 indicating intact cognition. Review of the electronic health record showed an order for famotidine 20 mg by mouth twice daily for gastro-esophageal reflux disease without esophagitis. A nursing note documented that the PCP and POA were notified of the missed dose of famotidine on 5/7/26, and that the dose had been missed on admission because the medication was not available. During staff interviews, an LPN stated the family should be notified when a medication is not available and said she would try to call within 45 minutes to an hour. Another LPN/unit manager stated family notification for situations such as a medication not being available should occur within 24 hours. The DON also identified medication not available as an example of when the family should be notified and stated that notifying the family 5 days later was not appropriate. The facility policy stated the resident, attending physician, and resident representative are to be promptly notified of changes in condition or status, and except in emergencies, notifications are to be made within 24 hours.
Catheter tubing and drainage bags left on the floor; UTI antibiotic delayed
Penalty
Summary
The facility failed to keep urinary catheter tubing and drainage bags off the floor for two residents with indwelling catheters. Resident #3 had diagnoses including neurogenic bladder, type II diabetes mellitus, and a recent UTI, and the care plan identified impaired urinary elimination with a catheter. During multiple observations, Resident #3’s catheter tubing and bag were seen dragging on or touching the floor while the resident self-propelled in a wheelchair, including in the hallway, dining room, and shower room area. Staff observed the condition and one CNA stated the catheter could not be kept better positioned, while an LPN later stated catheter tubing and bags could not drag on the floor and was not aware of the resident’s antibiotic order at the time of interview. Resident #14 also had neurogenic bladder and used an indwelling suprapubic catheter. The care plan noted impaired urinary elimination related to neuromuscular bladder dysfunction and bladder spasms with urine leaking around the catheter, and a separate care plan focus addressed a UTI. During observations, Resident #14’s catheter tubing was seen dragging on the floor while the resident self-propelled in the hallway, resting on the floor under the wheelchair, and dragging on the floor while going outside to the smoking area, where the resident’s foot rested on the tubing. Staff interviews confirmed that catheter tubing and bags should not touch the floor for infection control, and the DON stated the tubing and bag should not touch the ground. The facility also failed to start an antibiotic in a timely manner for Resident #3’s UTI. A urine culture showed greater than 100,000 cfu/ml of ESBL E. coli, and notes documented that the culture results were received and faxed to the PCP, with a later note stating the urine culture grew multidrug resistant E. coli and fosfomycin was ordered. The antibiotic order was not documented until several days after the culture verification, and the order was still waiting on pharmacy delivery when recorded. The facility policy titled Urinary Catheter Care directed that catheter tubing and drainage bags be kept off the floor.
Unattended medication cart left unlocked
Penalty
Summary
Nursing staff failed to keep an unattended medication and treatment cart locked. During a walkthrough of the facility, a four-drawer insulin and wound treatment cart was observed positioned across from the nurse's station by the medication room and left unlocked without staff supervision. At the time of the observation, an RN was at the nurse's station and not watching the cart, a CMA was stationed at another medication cart with her back to the unlocked cart, and the Unit Manager/Infection Preventionist was in the hall talking with another staff person. The Maintenance Director called the Unit Manager over and asked him to lock the cart. Resident #22, who had dementia, a BIMS score of 11 out of 15 indicating moderate cognitive impairment, and a care plan focus for elopement risk/wandering, was sitting in a chair near the cart with a walker within reach. Review of the unlocked cart showed multiple medications and supplies, including insulin pens, glucagon products, topical medications, stock medications, needles, syringes, and other treatment items. The RN stated she had unlocked the cart to put gloves in it, went into the nurse's station to get a computer, and forgot to lock the cart. The facility policy stated that drugs and biologicals are stored in locked compartments and that unlocked medication carts are not left unattended.
Meal trays did not match ordered dietary supplements
Penalty
Summary
The facility failed to serve meals that met physician-ordered dietary needs for 2 residents during breakfast service. Resident #9 had diagnoses including hip fracture, left tibia fracture, other fractures, and anemia, and his care plan and physician orders directed a consistent carbohydrate diet with double protein portions at meals. During interview, he stated he was not getting enough to eat and reported that his meal tickets said he was supposed to get double portions, but sometimes he received them and sometimes he did not. On the observed breakfast tray, he was served one egg, cold cereal with milk, hot cereal, and 2 pieces of bacon, despite the ticket indicating double protein portions and a line through bacon because he did not like it. Resident #16 had diagnoses including low back pain, weakness, and spinal stenosis, and her care plan and physician order directed an extra egg when eggs were on the menu. During the breakfast observation, she was served one egg, 2 ounces of mechanically ground sausage, cold cereal with milk, and a muffin. Her meal ticket identified that she had requested extra eggs, but the tray did not reflect the ordered extra egg. The Dietary Manager later stated the cook had missed giving double or extra portions during breakfast service for some residents that morning and that staff needed to read the meal tickets better.
Failure to Follow Enhanced Barrier Precautions During Wound and Personal Care
Penalty
Summary
The facility failed to ensure nursing staff followed enhanced barrier precautions during personal care and wound care for a resident with diabetes, incontinence without sensory awareness, morbid obesity, and moisture associated skin damage. The resident’s record showed an admission date of 10/8/25, intact cognition with a BIMS score of 15, wheelchair use, substantial to maximum assistance needed for toileting hygiene and bed mobility, dependence for lower body dressing, transfers, and moving between positions, and that the resident was always incontinent of bowel and urine. Nursing notes documented skin issues on admission, including shearing on the left inner thigh, MASD in the right intragluteal cleft, and an abrasion on the right hip, with Triad cream ordered for the affected areas. During an observation on 5/13/26, an LPN assessed and treated the resident’s wounds while two CNAs were present to assist. The LPN wore gloves and used a disposable measuring tape to measure open wounds on the upper right coccyx and left inner thigh, then sprayed the wounds with cleanser and used woven gauze to clean the coccyx wounds and the left lower thigh wounds without changing gloves. The LPN then used the same gloved hand to obtain zinc oxide from the container and apply it to both the coccyx and left thigh wounds. The LPN, CNA, and another CNA did not wear gowns during the observation. The LPN later stated EBP should be used for personal care on residents with wounds or catheters and that staff needed to wear a gown and gloves for personal or wound care. The Unit Manager, who had recently started as Infection Preventionist, stated EBP should be used for residents with catheters, wounds, ostomies, or gastric tubes and that PPE included at least a gown and gloves, with signs posted to identify residents on EBP. Facility policy defined EBP as targeted gown and glove use during high-contact resident care activities, including hygiene, changing briefs, toileting assistance, and wound care.
Incomplete transfer documentation and missing required notices
Penalty
Summary
The facility failed to thoroughly document resident transfers to the hospital for Resident #2 and Resident #13. For Resident #2, who had a BIMS score of 9/15 and diagnoses including stroke, hemiplegia/hemiparesis, and diabetes mellitus, the record showed chest pain treated with nitroglycerin, followed by an eInteract Transfer Form completed for transfer to the hospital that did not document the change in condition or the forms sent with the resident. Staff interview confirmed the transfer process should include documentation of the change of condition and what was sent with the resident, and Staff B acknowledged the documentation may have been missed. For Resident #13, who had intact cognition, diagnoses of depression and alcohol abuse, and a care plan addressing mood and behavior concerns and suspected alcohol use, the record showed the resident was stumbling, had slurred speech, smelled of alcohol, and was sent to the ER for a blood alcohol level. The eInteract Transfer Form for this transfer lacked documentation of current vital signs, events that occurred before transfer, and forms sent with the resident. The nurses note documenting the transfer was entered the next day and reflected that the resident was noncompliant with a full assessment and upset about being sent out. The DON confirmed that a progress note with the change of condition and the forms sent with the resident should have been completed. The facility also failed to provide written transfer notices for Resident #1 and Resident #11 that included resident appeal rights, Ombudsman contact information, and contact information for agencies responsible for the protection of residents with intellectual, developmental, mental, and related disabilities. Resident #1 had intact cognition and was transferred to the ED for severe abdominal pain on two occasions, and the bed hold authorizations documented phone calls with the POA or resident representative, but the transfer notices lacked the required appeal information. Resident #11, who had intact cognition and unspecified dementia, was transported to the ER after abnormal vital signs were noted during a cardiology appointment and later admitted to the hospital; the bed hold authorization again reflected a phone call with the resident representative, but the transfer notice lacked the required information. The facility further failed to notify the Ombudsman after Resident #10 was sent to the hospital. Resident #10 had severely impaired cognition and unspecified dementia with anxiety. After the resident was found on the floor, staff phoned the on-call provider, received an order to send the resident to the ED, called 911, and gave report to the ED before EMS transported the resident. The Notice of Transfer Form to the Long Term Care Ombudsman for April 2026 did not include Resident #10's name for a transfer. The Administrator stated she only reported if residents were discharged or hospitalized and did not know she needed to notify the Ombudsman if they went to the hospital and came back.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident-to-resident altercation. On the date of the incident, one resident was seated near the nurses’ station while using the phone, and another resident, who routinely self-propelled her wheelchair around the nurses’ station in the evenings, attempted to pass by. As the second resident tried to pass, the seated resident swung his arm back and struck her twice in the upper back. This event was witnessed by a restorative aide and a registered nurse, and was later documented in nursing progress notes and a facility-reported incident. The resident who initiated the altercation had multiple medical diagnoses, including cerebrovascular accident, hemiplegia, aphasia, adjustment disorder with depressed mood, a history of falls, and diabetes. His most recent MDS prior to the incident showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that he was usually able to make himself understood and to understand others. His care plan identified mood and behavior issues, including verbal aggression and a tendency to not want to wear clothes, and directed staff to anticipate and meet his needs, assist with coping and interacting, provide positive interaction, discuss inappropriate behavior when reasonable, and intervene as necessary to protect the rights and safety of others by approaching calmly, redirecting, and removing him from situations as needed. The resident who was struck had diagnoses including non-Alzheimer’s dementia, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood, with a BIMS score of 6/15 indicating severe cognitive impairment. She was sometimes able to make herself understood and to understand others, and used a wheelchair as her primary mode of transport. Her care plan addressed impaired cognitive function and directed staff to ask yes/no questions, cue, reorient, supervise as needed, keep her routine consistent, and provide consistent caregivers. On the day of the incident, she was following her usual routine of self-propelling around the nurses’ station when she was hit. Staff interviews described that the striking resident could become irritable when redirected and that he hit the other resident before staff could intervene, then stood up and subsequently hit and pinched the CNA who attempted to stop him. The facility’s abuse prevention policy states that residents have the right to be free from abuse by anyone, including other residents, and that the facility will protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone.
Failure to Protect Resident From Financial Exploitation of EBT Food Benefits
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation by a staff member. The resident had multiple diagnoses including adult failure to thrive, type 2 diabetes with complications, alcoholic cirrhosis of the liver, anxiety, and depression, and had a BIMS score indicating moderate cognitive impairment, though she was always able to make herself understood and to understand others. She was totally dependent on staff for substantial assistance with repositioning, transfers, and was unable to stand or ambulate. Her care plan identified that she had difficulty coping with lifestyle changes, limitations in functional abilities, and the loss of her husband as caregiver, and that she needed assistance with problem solving and psychosocial support. The events leading to the deficiency began when the resident, who received monthly EBT food stamp benefits, asked a CNA to use her EBT card to purchase snacks for her and told the CNA she could also buy items for herself with the card. The resident did not specify an amount the CNA could spend, did not know exactly what the CNA purchased for herself, and recalled the total purchase being a little over $100. Some purchased items required refrigeration and were placed in a refrigerator outside the resident’s direct control, and the resident later reported she had lost track of those items. The resident stated she did not think she had done anything wrong and was unaware at the time that designated facility staff were available to shop for residents. Interviews and document review showed that the CNA acknowledged using the resident’s EBT card at a grocery store, spending a little over $100, and purchasing food for both the resident and herself, but could not clearly recall all items she bought for herself. A grocery store receipt showed 68 items purchased for a total of $268.93 with the resident’s EBT card. When the receipt was later reviewed with the resident, she identified several items totaling $115.96 that she stated she had not requested and believed were purchased for the CNA. Other staff, including another CNA/Restorative Aide, stated they knew it was wrong to use a resident’s resources or accept gifts from a resident based on dependent adult abuse education. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy required protection of residents from exploitation and misappropriation of property, development of protocols to prevent and identify such incidents, and investigation of possible misappropriation, underscoring that the resident’s funds were wrongfully used by staff despite these policies.
Failure to Meet Resident Needs Prior to Emergency Discharge
Penalty
Summary
The facility failed to make adequate attempts to meet the needs of two residents prior to issuing emergency discharges following a series of resident-to-resident altercations. Both residents had intact cognitive status, as indicated by their BIMS scores, and required varying levels of assistance with activities of daily living. The clinical records showed a pattern of verbal disputes and threats of violence between the residents and their peers, with interventions primarily consisting of moving residents to different rooms and de-escalating situations. On the date of the final altercation, the facility obtained orders for emergency psychiatric evaluations and arranged for both residents to be transferred to local hospitals. The process of discharge was initiated while the residents were at the hospitals, with the facility citing the safety of individuals in the facility as the reason for the emergency discharges. The discharge forms included information about placement and appeal rights, but there were lapses in communication with the residents' guardians and family members. One resident's guardian was not informed about the appeals process and did not receive any forms to sign, while the other resident's family could not be reached prior to the discharge. Both residents were ultimately not admitted to the hospitals for psychiatric reasons, and the facility refused to readmit them upon the hospitals' requests. Interviews with facility staff revealed that the decision to discharge was made due to a perceived lack of available rooms to accommodate residents with behavioral issues. The staff also demonstrated a lack of awareness regarding the proper notification and involvement of guardians in the discharge process. As a result, one resident remained hospitalized while the other was taken to his apartment by family members, with concerns noted about his ability to manage medications and daily living needs.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and handling practices within the facility's kitchen. Raw hamburger was found thawing in a metal basin on an upper shelf above meal trays, and frozen chicken breasts were placed on a refrigerator shelf above containers of fruit, contrary to facility policy requiring raw meat to be stored on the bottom shelf to prevent cross-contamination. Staff interviews confirmed that staff were aware of the correct procedures but did not consistently follow them, with several staff acknowledging the improper placement of raw meat and the risk of contamination. During meal service, staff were seen using tongs to remove buns from packaging and then using their gloved hands to handle the buns and other items without changing gloves between tasks. Additionally, an ice scoop was repeatedly left in the ice container with the handle in contact with the ice, and staff continued to use the scoop without changing gloves after touching other surfaces. Staff interviews revealed knowledge of proper glove use and ice scoop handling, but these practices were not consistently implemented. The facility's policy requires measures to prevent cross-contamination, including proper storage of raw meat, adherence to hygiene and sanitary practices, and changing gloves between tasks, all of which were not followed during the observations.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Staff failed to treat three residents with dignity, as evidenced by multiple interviews, observations, and record reviews. One resident with severe cognitive impairment and a history of stroke and aphasia was repeatedly told by staff to chew and swallow his food, despite care plan instructions to avoid such directives. Staff were observed and reported to have taken away the resident's plate, rubbed his cheek in an aggressive manner, and used a mean tone when instructing him to eat. The speech therapist and physical therapist both confirmed witnessing inappropriate staff interactions, including frustration and aggressive verbal and physical cues, which made the resident feel 'disgusting.' The Director of Nursing acknowledged that telling the resident to swallow was a trigger and that staff should not touch the resident's cheek or plate. Another resident with intact cognition reported that staff on the third shift used their personal phones during work hours, making the resident feel undervalued and uncomfortable asking for help. Multiple staff interviews confirmed that personal phone use occurred during shifts, including during resident care and in hallways. The facility's cell phone policy prohibits personal phone use during working hours and in patient care areas, except for authorized business purposes, but staff and social services confirmed that the policy was not consistently followed, leading to resident dissatisfaction and irritation. A third resident, also with intact cognition and total incontinence, reported that the facility frequently ran out of appropriately sized incontinence briefs, resulting in the resident having to wear briefs that were too large or of a different type. Staff confirmed that supply shortages led to residents wearing incorrect sizes, which caused discomfort and skin issues. The staffing coordinator and Director of Nursing acknowledged the supply issues, with staff sometimes borrowing briefs from other rooms and residents being left without the correct size until new supplies arrived. The facility's policy requires staff to be trained on resident dignity and respect, but these incidents demonstrate a failure to uphold those standards.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident on two separate occasions, as required by facility policy. The resident, who had intact cognition and multiple comorbidities including CHF, diabetes, COPD, morbid obesity, gout, hypothyroidism, and hyperlipidemia, experienced a weight loss of over 10% in six months and over 5% in one month. Documentation showed that the dietitian identified and documented the significant weight loss and made recommendations, including meal enrichment and weekly weights, and noted that faxes were sent to the clinician. However, the facility was unable to provide documentation that the physician was actually notified or made aware of the weight losses, despite multiple staff interviews and record reviews. The resident's care plan and dietary notes reflected ongoing monitoring and interventions for nutritional risk, including the use of supplements and meal enrichment strategies. The resident herself was aware of her weight loss and attributed it to poor appetite following her husband's death and a recent illness. Despite these interventions and awareness by dietary staff, there was no evidence in the medical record or from staff that the physician was notified of the significant changes in the resident's condition, as required by the facility's policy on change in condition.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents following significant changes in their conditions. One resident experienced a significant weight loss of over 10% in six months, as documented in the weight summary, but the care plan was not updated to reflect this change. Another resident, who was at nutritional risk due to multiple medical conditions and had severely impaired cognition, also experienced a weight loss of nearly 15% over five months, yet the care plan did not reflect this significant change. Staff interviews confirmed that the care plans for both residents should have been updated to address the significant weight loss, but this was not done, partly due to a recent change in dietician staffing and unclear responsibilities for updating care plans. Additionally, a third resident's care plan continued to indicate the need for dialysis, despite the resident no longer receiving dialysis services. The resident and staff interviews confirmed that the resident had not been on dialysis for some time, and the care plan had not been revised to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not followed in these cases.
Failure to Implement Restorative Nursing Program for Resident with Mobility Impairment
Penalty
Summary
A deficiency occurred when the facility failed to implement a restorative nursing program as recommended by therapy for a resident with impaired lower extremity mobility. The resident, who was cognitively intact and had no upper extremity impairment but did have lower extremity impairment, reported only participating in restorative exercises once. The care plan indicated a need for restorative programming to maintain functional mobility and prevent decline, with specific interventions outlined, including the use of a seated bike, sit-to-stand activities, and lower extremity strengthening and stretching exercises. Despite these documented interventions, staff interviews revealed inconsistent implementation of the restorative program. The staff member primarily responsible for restorative care was frequently reassigned to other duties, such as providing showers, and could not explain how restorative programming was completed when working on the floor. No other staff were officially assigned to restorative programming, and coverage was sporadic. The Restorative Nurse's involvement was limited to documentation assistance, and the Director of Nursing stated that nurses were expected to fill in if the primary staff was unavailable. The facility's policy allowed for restorative nursing care upon discharge from therapy, but the recommended program was not consistently followed.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the services rendered, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Medication Error Rate Exceeds Regulatory Standard
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 11.11%. This was identified through observation, interview, and record review, where three medication errors were found among twenty-seven opportunities for three residents. One resident, with intact cognition and a history of insulin use, received insulin after already consuming food, contrary to the prescribed administration of insulin before meals. Another resident, also with intact cognition and a diagnosis of anemia, was administered a 324 mg enteric-coated tablet of Ferrous Sulfate instead of the prescribed 325 mg oral tablet. A third resident, with intact cognition and a prescription for Polyethylene Glycol 1450, was given Clearlax 3350 instead of the ordered medication. The facility's policies require medications to be administered as prescribed, within specified time frames, and in accordance with prescriber orders. However, staff failed to follow these protocols, as evidenced by the administration of medications at incorrect times, incorrect dosages, and substitution of medications. These actions directly contributed to the facility's elevated medication error rate, exceeding regulatory standards.
Significant Medication Errors Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of anticoagulants, insulin, and narcotic pain medications. In one case, a resident with intact cognition and a physician order for Warfarin received a double dose due to a lack of communication and documentation between nursing staff and a medication aide during a shift change. The nurse administered the medication but did not document it, leading the medication aide to administer a second dose. This resulted in the resident receiving 8 mg instead of the prescribed 4 mg of Warfarin. Another incident involved a resident with diabetes who was prescribed sliding scale insulin. The LPN checked the resident's blood sugar and administered insulin after the resident had already eaten, contrary to the physician's order to administer insulin before meals. The blood sugar was recorded at 200 mg/dL, and 2 units of insulin were given, but the timing did not align with the prescribed protocol. A third resident, also with intact cognition, was prescribed oxycodone for chronic pain. Due to a similar breakdown in communication and documentation, both an LPN and a medication aide administered a 5 mg dose of oxycodone, resulting in the resident receiving a double dose. Additionally, a resident with severe pulmonary hypertension was prescribed Apixaban following hospital discharge, but a transcription error led to the incorrect entry of the medication order. The facility failed to clarify the discharge instructions with the hospital, resulting in the resident receiving an incorrect dosing regimen. These incidents were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policy.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for five residents out of nineteen reviewed. Specifically, the assessments for Residents #9, #18, #26, #29, and #34 were not completed within the required timeframe. For instance, Resident #18's assessment had an Assessment Reference Date (ARD) of 4/25/24, but the completion date was 5/20/24. Similarly, Resident #26's assessment with an ARD of 8/9/24 was still in process at the time of the review. Other residents also experienced delays in the completion of their assessments, with completion dates extending beyond the 14-day requirement from the ARD. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and the Administrator, confirmed the delays in completing the MDS assessments. The MDS Coordinator acknowledged the lateness of the assessments for Residents #18 and #26. Both the DON and the Administrator expressed their expectations for timely completion of the MDS assessments. Additionally, the facility's Comprehensive Assessment Policy, dated December 2023, did not address the requirements for quarterly MDS assessments.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure timely completion of annual Minimum Data Set (MDS) assessments for two residents, as required by their policy. Resident #18's MDS assessment, with an assessment reference date (ARD) of July 25, 2024, was still in process at the time of the survey. Resident #26's MDS assessment, with an ARD of May 9, 2024, was completed on June 3, 2024, indicating a delay. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the assessments were late and should have been completed within 14 days of the ARD. The facility's Comprehensive Assessments Policy mandates that annual assessments be completed at least every 366 days unless a significant change or correction assessment has been conducted since the last comprehensive assessment.
Failure to Update PASRR for Resident with New Diagnoses and Medications
Penalty
Summary
The facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) for a resident with new mental health diagnoses and psychotropic medications added to their plan of care. The resident, who was reviewed for PASRR, had a history of anxiety disorder, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite these changes, the PASRR Level 1 Screen Outcome indicated no Level II was required unless a significant change occurred. However, the resident's care plan and medical records showed significant changes, including new diagnoses of major depressive disorder with psychotic symptoms and delusional disorders, as well as new medication orders for Depakote, Duloxetine, and Seroquel. The MDS coordinator, during an interview, acknowledged a misunderstanding regarding what constituted a significant change, believing it only applied to hospital admissions for mental issues. The administrator later clarified that changes in medications and medical diagnoses also required a new PASRR. The facility's policy stated that new onset or changes in behavior indicating a serious mental disorder should be referred for a PASRR Level II evaluation. Despite this policy, the necessary PASRR update for the resident was not completed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident #8, who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination in 2019 and was noted to be eligible for the PCV 20 as of February 13, 2024. The resident's immunization record was reviewed by the ARNP, and verbal consent for the vaccine was obtained from the resident's daughter, with education provided on the risks and benefits. However, the vaccine was not administered. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for administering the vaccine. The DON stated that he relied on the Infection Preventionist to manage vaccinations, but the ADON/IP was unaware of the need to offer the vaccine to Resident #8. The DON acknowledged the oversight and expressed an expectation for follow-through, but there was a disconnect in the process, resulting in the resident not receiving the vaccine. The facility's policy indicated that pneumococcal vaccines should be administered per CDC recommendations, but this was not followed in this instance.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and cluttered hallways. On several occasions, debris such as rubber gloves and trash were found under the bed in a resident's room and remained there for multiple days despite housekeeping services being performed. Additionally, a gown and deodorant container were observed on the floor in another room, with the deodorant container remaining even after partial cleaning. Hallways were also noted to be cluttered with mechanical lifts, standing devices, and wheelchairs, posing potential hazards. Interviews with staff and residents further highlighted the deficiency in maintaining cleanliness. The Housekeeping and Laundry Supervisor stated that resident rooms are supposed to be cleaned daily, including sweeping, mopping, and sanitizing, with deep cleaning scheduled for one room per hall each day. However, a resident reported that their room was not consistently cleaned, with housekeeping often neglecting areas under or behind furniture. This inconsistency in cleaning practices contributed to the observed deficiencies in maintaining a safe and clean environment.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions and consistent hand hygiene practices, as observed during a survey. Resident #6, who has intact cognition and requires moderate assistance with daily activities, was on enhanced barrier precautions due to a catheter. However, during personal care, two CNAs, Staff E and Staff F, did not wear protective gowns as required. Both staff members acknowledged the oversight during interviews, with one stating she forgot to wear a gown. Additionally, Resident #5, who is severely cognitively impaired and dependent on staff for assistance, was observed receiving care without proper hand hygiene practices being followed. Staff G and Staff H assisted with transfers and incontinence care but did not sanitize hands before providing a snack to the resident. Furthermore, sanitizer dispensers were found empty, and staff were not observed using them. Other staff members, including a registered nurse and a CNA, were also seen assisting multiple residents without sanitizing their hands between contacts, contrary to the facility's hand hygiene policy.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 25 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mediapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wapello Specialty Care | 4.9 mi | ★★★★★ | 2 | 0 |
| New London Specialty Care | 13.6 mi | ★★★★★ | 6 | 0 |
| Southeast Iowa Regional Medical - Klein Center | 13.6 mi | ★★★★★ | 2 | 1 |
| Oakview Nursing And Rehabilitation | 14.3 mi | ★★★★★ | 0 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 16.9 mi | ★★★★★ | 0 | 0 |
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