Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Garden View Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a comprehensive, effective QAPI program, as evidenced by repeated deficiencies over multiple surveys in areas including failure to report, protection of resident-identifiable information, infection prevention and control, environmental cleanliness and comfort, and ADL care for dependent residents. Although a written QAPI policy described broad data monitoring and committee review processes, survey history showed that these processes were not effectively implemented to prevent recurrence of the same problems, and leadership acknowledged only recent efforts to change QAPI activities.
The facility failed to maintain a safe, clean, and homelike environment when a resident’s room had a cracked, drafty window and nonfunctional closet doors that had remained unrepaired for many months, and the outside door contained a hole. Surveyors also observed multiple stained, split, or holed ceiling tiles in several halls and near the nurse’s station, bent ceiling hardware, and walls with paint chipping and dark marks above grab bars. The Maintenance Director reported he was unaware of the resident’s closet issues and acknowledged ongoing problems with stained ceiling tiles related to a leaking roof and limited replacement supplies.
Surveyors found unsecured resident medical records in an unlocked conference room and resident-identifiable documents stored in an easily accessible garage trash can, while the Administrator acknowledged records were also kept off campus with known payment issues for the storage unit. In addition, a resident with multiple comorbidities and a left BKA had a physician-ordered follow-up appointment that was missed after the facility’s transportation staff was terminated and an Assistant Administrator, who was uncomfortable driving the large van out of town, assumed transport duties. No progress note or documentation of the missed appointment was found in the resident’s chart, contrary to facility policy requiring all services and changes to be recorded in the medical record.
The facility failed to implement its infection prevention and control program by not correcting ongoing water intrusion and black, mold-like substances in the laundry room and basement. Surveyors observed cracked paint and a black fuzzy substance on a wall near the laundry floorboard, along with stagnant water behind a water heater and near washers, which the Maintenance Director attributed to periodically clogged drainage hoses. In the basement, there was a strong mildew/musty odor, stagnant water along walls and at a sealed window, mud under the water, and wooden work benches standing in the water, as well as an exposed lower wall area with a large black substance. The ground outside sloped toward the building, contributing to repeated water seepage during heavy rain, and leadership staff were initially unaware of the basement water problem despite a written IPC policy requiring a safe, sanitary environment and surveillance for infection risks.
A resident with no cognitive impairment, bowel incontinence, and dependence on staff for toileting requested a bedpan for a bowel movement, consistent with his usual practice due to a leg amputation. A CNA, who reported being unable to find an appropriate bedpan and did not obtain one from storage, told the resident to defecate in his incontinence brief instead, reportedly using crude language. Other staff later confirmed that a bedpan was available in the resident’s bathroom and that fracture pans were available in storage. This conduct conflicted with the resident’s care plan, which called for assistance with toileting and consideration of his preferences, and with the facility’s policy on promoting and maintaining resident dignity and respecting resident rights.
A resident with mild cognitive impairment, multiple chronic conditions, and a left BKA had physician orders for daily dressing changes, non-weight bearing status, and a scheduled out-of-town follow-up appointment. Due to the termination of the prior transportation staff and reassignment of transport duties to an Assistant Administrator who was uncomfortable driving the large van out of town, the resident was not transported and missed the scheduled clinic visit. The clinical record contained no progress notes documenting the follow-up appointment, and staff interviews confirmed the appointment was missed because no appropriate transportation was provided.
A resident with intact cognition, multiple medical conditions, and dependence on staff for toileting requested assistance to have a bowel movement, and a CNA told the resident to defecate in an adult brief instead of assisting with a bedpan, despite a bedpan being available. A CMA overheard the exchange, later found the resident’s brief soiled, and provided care but did not report the concern until the next day. The DON and ADON interviewed the CNA, who admitted telling the resident to use the brief, and the resident confirmed being told to go in the diaper against his preference. Although facility policy required immediate reporting of abuse allegations to the Administrator and notification of the state within 2 hours of an allegation, the incident was not reported to the state agency until the following day, outside the required timeframe.
A resident with intact cognition, bilateral extremity impairment, and dependence on staff for toileting requested a bedpan for a bowel movement but was reportedly told by a staff member to defecate in his brief when the bedpan could not be found. The resident, who typically used a bedpan and was only sporadically incontinent, subsequently soiled his brief and required cleanup by a CMA who responded to his call light. Staff interviews confirmed the resident’s usual toileting pattern and the reported statement by the staff member, while facility policy required appropriate ADL support, including toileting assistance, in accordance with the care plan.
A resident dependent on staff for tracheostomy care experienced repeated delays and refusals of suctioning by an LPN, despite physician orders for as-needed suctioning. The resident reported severe anxiety and fear due to these delays, and multiple CNAs confirmed the LPN's pattern of not responding promptly to requests. The DON was informed of concerns but did not initially identify any issues with the LPN's performance, and documentation of suctioning was lacking.
A resident dependent on staff for tracheostomy care reported that an LPN frequently refused or delayed suctioning, causing distress and anxiety. Multiple CNAs confirmed the LPN's refusal to provide care and reported these concerns to the DON, but no thorough investigation or separation of the LPN from the resident occurred. The resident's medical records showed no documentation of the suctioning order being followed, and the facility did not adhere to its abuse prevention and investigation policy.
A resident with severe cognitive impairment, an indwelling catheter, tube feedings, and a recent UTI was placed on antibiotics, but staff did not consistently obtain or document vital signs and did not notify the MD about repeated fevers. The chart showed multiple elevated temperatures over several weeks, with gaps in monitoring and no documented physician contact until the resident had a 102 temperature, edema, and was sent to the hospital with infection and fever. Hospital records showed UTI, pneumonia, and sepsis due to UTI.
A resident with COPD, respiratory failure, asthma, and continuous oxygen orders was observed removing her nasal cannula and independently setting up and starting a nebulizer treatment. EMR review found no self-administration assessment and no order allowing her to self-administer meds or manage oxygen, yet a CMA and an LPN stated they left the Albuterol or nebulizer setup for the resident to complete herself. The DON and physician both stated the resident should not have been self-administering the treatment.
A facility failed to maintain required 24-hour licensed nurse coverage when an LPN left the premises during an overnight shift, leaving no licensed nurse on site for several hours. Staff reported frequent absences by the LPN during overnight shifts, and documentation of concerns was lacking despite facility policy requiring continuous licensed nurse presence.
Nursing staff were assigned to work independently without documented orientation or competency-based training, as required by facility policy. Two LPNs reported not receiving an orientation checklist or formal training before caring for residents alone, and their files lacked evidence of completed orientation. A former RN and the administrator confirmed the absence of a formal orientation program, despite policy requiring a 10-hour orientation with a checklist.
Failure to complete annual staff evaluations was identified for 3 of 3 CNA personnel files reviewed. The files for three CNAs lacked any annual performance evaluations, and the Administrator stated evaluations had not been done because no staff had received a raise for 5 years. Facility policy required each employee’s job performance to be reviewed and evaluated at least annually.
The facility failed to properly oversee the hiring and monitoring of an LPN whose nursing privilege had been revoked in another state and whose personnel file lacked documented reference checks and further review of his adverse license history. Staff and the resident reported repeated refusals to suction a tracheostomy, with the resident stating he had to ask multiple times and felt neglected. The report also noted the facility’s QAPI efforts were incomplete after SFF designation, with action plans lacking documented progress or evaluation.
The facility failed to show good faith efforts in its QAPI/QAA process after repeated deficiencies were cited in multiple areas, including care planning, pressure ulcer care, staffing, pharmacy services, food service, and resident records. Several QAA action plans for skin assessment, PCC documentation, bowel/constipation management, MARS/TARS, and baths were developed with target dates, but most had no documented progress or evaluation and several key sections were left blank. The Administrator stated the plans were discussed in QAPI, but medication and treatment errors still occurred, and there were no updates to measure success or track performance.
A facility failed to follow the menu and prepare modified-texture meals to meet the needs of residents with dysphagia and cognitive impairment. During lunch observation, staff served mechanical soft pepper steak using an inconsistent scoop method, and leftover food remained after 7 servings were reportedly prepared for 7 residents. The Kitchen Manager, consulting RD, and Administrator acknowledged the portioning did not match the menu or expected serving size.
Incorrect Food Consistency for Modified Diets: The facility failed to prepare foods in the proper form for 7 residents with ordered modified diets, including residents with dysphagia and cognitive impairment. During meal observation, kitchen staff processed mechanical soft meat but left a large unprocessed onion piece in the food, and the sample plate showed pepper steak with crisp onion. The kitchen manager stated whole pieces should not remain in mechanical soft meat, and the RD noted crisp onion should have been processed with the meat.
Food storage and meal service practices were not sanitary. Open food items in the walk-in refrigerator and freezer were left undated, and some stored condiments were past the expected use period. During meal prep and lunch service, a staff member handled food equipment and resident plates without proper hand hygiene, touched her face during service, used a thermometer from the shelf without sanitizing it first, and handled bread and other items in a way that raised cross-contamination concerns.
QAPI action plans were developed for skin assessment, PCC documentation, bowel elimination/constipation management, MARS/TARS, and baths, but the facility did not document ongoing progress or evaluation for most of the interventions. Several plan sections were left blank, and one or more action items lacked a team member or target date. The ADM stated the facility discussed PIPs in QAPI, but medication errors and treatment errors continued, and acknowledged there was no measure in place to track whether the action plans were successful.
Three cognitively intact residents who regularly received room trays reported that their meals were often cold upon delivery, with one noting the absence of heated carts and delays in tray delivery. Observation confirmed that at least one food item on a sample tray was below the required 135°F, and both dietary staff and facility policy affirmed that food should be served at or above this temperature.
Missing GDR Documentation for Psychotropic Medications The facility failed to document a clear rationale for continued psychotropic use and failed to show completed GDR review for multiple residents. Records showed ongoing use of antipsychotic, antidepressant, hypnotic, and anticonvulsant medications in residents with dementia, schizophrenia, depression, and other chronic conditions, but supporting physician progress notes and GDR documentation were missing. Pharmacy recommendations for dose reduction were noted for several medications, yet the chart did not contain the required justification for maintaining the current doses.
Inaccurate MDS Restorative Nursing Documentation: A resident with traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia had an MDS that showed restorative PROM services, but the resident stated ROM had stopped when OT ended and that restorative nursing had not been provided for quite some time. Staff reported the RNA used paper documentation, the MDS Coordinator relied on POC data, and the DON, MDS Coordinator, and Administrator gave conflicting accounts about oversight and documentation of the restorative program.
A resident with COPD and continuous O2 use had a care plan that addressed smoking and respiratory risk, but it did not include resident-centered interventions for managing O2 before, during, or after smoking. The plan did not identify who was responsible for the resident's O2 or where it should be placed while smoking, even though the resident required supervision and a smoking apron and staff reported the resident removed O2 when going outside to smoke.
A resident with traumatic spinal cord dysfunction, neurogenic bladder, quadriplegia, and impaired BUE/BLE ROM had a care plan focused on contracture management and PROM, but the plan was not revised when restorative nursing services were no longer being provided. The resident stated PROM had stopped when OT ended and that he had not been receiving restorative nursing for quite some time; staff confirmed he was not on restorative services and that no Restorative Nurse Plans had been written, while the DON said the care plan was expected to match the restorative plans being completed.
A resident with severe cognitive impairment, stroke, HF, HTN, PVD, depression, multiple ulcers, and several high-risk medications had repeated gaps in documented wound care, weight checks, leg elevation, protein encouragement, Darco boot use, and monitoring for medication side effects and bleeding. Staff stated refusals should have been documented in the TAR, and the DON stated orders were expected to be completed as written; if not documented, the treatment or medication was assumed not to have been completed.
Failure to provide and document ordered wound care for two residents with complex pressure ulcers and other wounds. One resident had severe skin breakdown, was totally dependent, and had a sacral wound that progressed to Stage IV while multiple treatments were missed and refusals were not fully documented or reported to the MD. Another resident, also totally dependent with multiple diagnoses and devices, had missed wound treatments for the scrotum, groin, foot, ankle, and heel, with no charted reason for refusals or evidence the MD was notified.
Failure to provide ROM and restorative nursing services to a resident with quadriplegia and limited BUE/BLE ROM. The resident’s care plan included PROM and contracture management, but the EMR showed inconsistent restorative task documentation and the resident stated he had not been receiving PROM or restorative nursing for quite some time. Staff gave conflicting accounts about who wrote, documented, and oversaw the restorative program, and the PTA/DOR and OTR/L were unaware of the resident’s restorative nursing plan.
Failure to complete ordered catheter care for a resident with a suprapubic catheter, neurogenic bladder, and quadriplegia. The resident had a care plan for catheter management and intake/output monitoring, but the MAR/TAR lacked documentation for ordered acetic acid irrigation and catheter care on two occasions, and POC output records were frequently incomplete. The DON stated a blank MAR/TAR entry meant the treatment was not given, and the facility catheter care policy did not address how often to empty the catheter bag.
A resident with intact cognition and scheduled pain meds had three blister packs of PRN tramadol stored in the med cart, including large quantities from an old order. CDA records and the MAR did not match for multiple months, and staff acknowledged the extra narcotics should not have remained in the drawer.
A resident with a BIMS score of 15 had no inventory list completed upon admission, despite facility records showing the resident was admitted from the hospital. Staff acknowledged the inventory list should have been completed at admission, and the Administrator stated that was the facility expectation.
Three residents who required staff assistance for bathing did not consistently receive scheduled baths or showers as outlined in their care plans, with EHR reviews showing significant gaps in care and a lack of documented refusals. Staff and DON interviews confirmed that missed baths were not always made up or properly documented, and that the facility's policy for regular bathing was not consistently followed.
The facility failed to follow physician orders, resulting in medication administration errors for multiple residents. A resident did not receive diabetes medication as ordered, and another resident's insulin was not administered per the sliding scale. Additionally, a resident's Oxycodone was destroyed without a discontinuation order. The facility's medication administration policy was not followed, leading to discrepancies in documentation and adherence to medication parameters.
A facility failed to properly assess and respond to an unwitnessed fall involving a resident with severe cognitive impairment, as neurological checks were not initiated immediately and the first set of vitals was delayed. Additionally, the facility did not conduct consistent respiratory assessments for residents who tested positive for COVID-19 and Influenza A, as required by protocol. These deficiencies highlight significant lapses in care and documentation.
The facility failed to maintain the required RN coverage for 8 consecutive hours, 7 days a week, as revealed by nursing schedules and staff interviews. The DON's frequent absences and reliance on a part-time RN contributed to inconsistent coverage. Staff reported communication issues and unresponsive management, leading to difficulties in scheduling RNs. Despite the facility's assessment claiming adequate coverage, the reality was insufficient, as indicated by staff comments and laughter about the ongoing issue.
The facility did not consistently update nurse staffing information daily for residents and visitors. Observations showed outdated postings on multiple occasions, with the DON indicating that night nurses were responsible for this task. The facility had a census of 37 residents.
A facility experienced a significant staffing deficiency when no licensed nurse was present for three hours, leaving the Administrator, who is not currently licensed, to oversee care. During this time, a resident fell, and proper protocols were not followed. The report also highlights a toxic work environment, with staff expressing frustration over the lack of support from the DON and ADON.
The facility's QAPI program was ineffective, as evidenced by repeated deficiencies in areas such as nursing staff sufficiency, quality of care, resident records, and infection control. Despite a revised QAPI plan, the facility continued to exhibit non-compliance, with the administrator acknowledging inconsistent corrective actions.
During an outbreak, a facility failed to enforce mask-wearing and proper infection control measures. Staff, including the Administrator and DON, were observed without masks, and masks were not available at the entrance. Additionally, a staff member did not use alcohol wipes before blood sugar checks or insulin administration, contrary to facility procedures. Residents and staff reported these issues, highlighting deficiencies in infection control and resident care.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan did not reflect the presence of an indwelling catheter and ostomy, while another resident's care plan lacked instructions for using a fall mat, despite a history of falls. Staff observations and interviews confirmed these oversights, which were not aligned with the facility's policy requiring timely care plan revisions.
A facility failed to complete ordered treatments for a resident with pressure ulcers, as shown by incomplete treatment administration records and inconsistent skin assessments. The resident, who had no cognitive impairment, reported that treatments were sometimes skipped depending on the staff. The DON noted that measurements were not taken during weekly assessments, contrary to facility protocol, and mentioned that the resident often refused treatments, although this was not documented.
A resident with severe cognitive impairment and physical limitations fell out of bed and was assisted back into a wheelchair by staff without the use of a gait belt, contrary to facility policy. The incident occurred when no nurse was present, and the Administrator conducted an assessment without performing neurological checks. Staff interviews indicated confusion about the facility's lifting policy, and the DON confirmed that a gait belt should have been used.
A LTC facility experienced a lapse in nursing coverage when an LPN, who had been working extended hours, was advised by the Administrator to leave for rest and medication retrieval. This left the facility without a licensed nurse from 1:30 PM to 4:30 PM, despite the presence of high-risk residents. The Administrator, not currently licensed, attempted to fill the gap, but critical medical protocols were not followed, highlighting inadequate staffing contingency measures.
A resident with severe cognitive impairment fell out of bed when no licensed nurse was present. The Administrator, a former nurse without an active license, assessed the resident and assisted in transferring her without a gait belt. The facility lacked proper nursing coverage for three hours, and necessary neurological assessments were not conducted.
A resident with severe cognitive impairment and multiple health conditions was frequently administered a PRN narcotic pain medication without clear evidence of pain. Staff interviews revealed that the medication was often given to ensure a quieter night shift, despite the resident being on a sleeping pill. The facility's policy required re-evaluation of frequent PRN use, but no such re-evaluation was documented.
The facility failed to store medications properly after delivery, as observed when a bag containing various medications was left unattended on the nurse's station counter. Staff interviews confirmed that medications should be put away immediately, but the incident revealed a lapse in following the facility's storage policy.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. A resident with severe cognitive impairment experienced an unwitnessed fall that was not properly documented or assessed. Additionally, two residents' positive test results for Influenza A and COVID-19 were not recorded in their medical records, contrary to facility policy.
A CNA at a long-term care facility was found to have physically and verbally abused two residents with severe cognitive impairments. The abuse included rough handling and derogatory language, leading to bruises on one resident. Despite staff awareness, the incidents were not reported to the state agency, and the CNA was not immediately removed from resident care, resulting in Immediate Jeopardy.
A facility failed to report abuse allegations to the state agency within the required timeframe. A CNA witnessed another CNA abusing two residents, but the incident was not reported to the administration or state agency. One resident had severe cognitive impairment and was found with bruises consistent with fingerprint marks. Staff interviews revealed a history of abuse by the same CNA, but fear of retaliation and a belief that nothing would be done prevented reporting. The facility's policy for immediate reporting was not followed.
Repeated Deficiencies Reveal Ineffective QAPI Program
Penalty
Summary
The deficiency involves the facility’s failure to provide a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program despite having a written QAPI policy. Review of the state agency’s website showed repeated deficient practices cited over multiple complaint investigations and recertification surveys from early 2024 through late 2025, including failures related to reporting requirements, protection of resident-identifiable information in records, infection prevention and control, maintaining a safe, clean, comfortable, homelike environment, and provision of ADL care for dependent residents. QAPI-specific deficiencies were cited on several surveys, indicating that the facility’s QAPI program and plan were not effectively implemented to prevent recurrence of these issues. During an interview, the Administrator, who began as Interim Administrator in February 2026, stated he could only speak to what had been started since his arrival and that he planned to revamp QAPI. He described a general process of reviewing CMS Form 2567, discussing it with the QAPI team and departments, developing plans of correction, and initiating audits to prevent repeat deficiencies, but the survey findings showed that repeated deficiencies continued to occur over time. The facility’s written QAPI policy, updated in early 2025, described broad goals such as developing a culture of proactive leadership, using multiple data sources (including surveys, grievances, adverse events, and performance audits), and having the QAPI committee review findings against benchmarks. However, the persistence of repeated citations in areas such as reporting, resident records confidentiality, infection control, environment, ADL care, and QAPI itself demonstrated that the described processes were not effectively carried out to ensure a comprehensive, functioning QAPI program.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for residents. One resident’s room had a cracked window and broken closet doors that had been in disrepair since her admission, which she reported was for nearly a year. The resident stated the window rattled when doors opened and closed and that her room became chilly in the winter when the wind blew, while she sat in a recliner positioned next to the window. Both closet doors in her room did not open or close properly and were not secured on the track, and the outside door had a hole approximately the size of a half dollar. Additional environmental concerns were observed throughout the facility’s hallways and common areas. Multiple ceiling tiles in various hall locations had brown to light brown circular or linear stains of various sizes, and one ceiling tile was beige with a large split, with an adjacent tile having a hole. A ceiling tile bracket in one hall appeared bent downward. Walls in several halls and near the nurse’s station had paint chipping, and one hall had a long light black line on the wall above the grab bars with paint chipping. The nurse’s station ceiling also had a tile with a hole in it. The Maintenance Director reported he was not aware of the resident’s closet door issues and acknowledged awareness of the stained ceiling tiles, which he attributed to a leaking roof and limited availability of replacement tiles within his budget.
Failure to Secure Medical Records and Incomplete Documentation of Missed Medical Appointment
Penalty
Summary
The deficiency involves the facility’s failure to secure and properly maintain resident medical records and other resident-identifiable documents. Surveyors observed an unlocked conference room near the main entrance containing a file cabinet with resident medical records and no locking mechanisms. Outside, in a garage with doors that could be opened without unlocking, they found a 60-gallon trash can filled with resident documents with visible identifiers. The Administrator stated that medical records were stored off campus at a storage unit company and acknowledged there was an issue with non-payment, and also acknowledged that the documents in the garage were records that needed to be shredded but were not secured. The deficiency also includes the facility’s failure to ensure a resident’s medical record was complete and accurate. A resident with heart failure, renal insufficiency, non-Alzheimer’s dementia, anxiety, depression, and a left below-knee amputation had a physician order dated 3/27/2026 for daily dry dressing changes, non-weight bearing to the left leg, and a follow-up appointment on 4/3/2026 at 9:30 AM. Review of the progress notes on 4/7/2026 showed no documentation related to the scheduled follow-up appointment. The former DON stated the resident missed the appointment and that she only became aware of it shortly before the scheduled time, after the facility’s transportation staff member had been let go and the Assistant Administrator had been asked to take residents to appointments. The Assistant Administrator reported she was now providing transportation, did not feel comfortable driving the large van out of town, and confirmed that a resident missed an out-of-town appointment for that reason, with no corresponding documentation of the missed appointment in the medical record despite facility policy requiring all services and changes in condition to be documented.
Failure to Address Water Intrusion and Mold-Like Conditions in Laundry and Basement Areas
Penalty
Summary
The facility failed to provide appropriate infection prevention and control by not resolving ongoing water intrusion and the presence of a black substance in the basement and laundry room. Observations in the laundry room showed cracked paint on the wall between the washers and dryers, with a black fuzzy substance visible behind an area near the floorboard. Stagnant water was present behind the water heater and to the left of the first washer on the dirty side of the laundry room. The Maintenance Director reported that drainage hoses sometimes became clogged, causing water to overflow from the water compartment, and the water was observed pooling on a flat surface above the slope to the drain. In the basement, surveyors noted a heavy mildew/musty odor and stagnant water where the walls met the floor, with water draining from a sealed basement window and mud present under the water. Some rooms contained wooden work benches or storage shelves standing in the stagnant water. One room had a wall that appeared to have been removed about half a foot from the basement floor, exposing a large area of black substance. Outside the building, the ground near the problem window and wall sloped toward the building rather than away, and the Maintenance Director stated that during heavy rainfall the water had no place to go and that downspout extensions had not been sufficient. The Administrator and Clinical Services Director were initially unaware of the water in the basement; when later observing the area, the mildew/musty smell persisted and rainwater, though receded, remained with mud present. These conditions occurred despite the facility’s written Infection Prevention and Control Program policy stating it would maintain a safe, sanitary, and comfortable environment and use a system of surveillance to prevent, identify, report, investigate, and control infections and communicable diseases.
Failure to Provide Dignified Toileting Assistance and Respect Resident Preferences
Penalty
Summary
The deficiency involves a failure to treat a resident with dignity during assistance with Activities of Daily Living (ADLs), specifically toileting. The resident had a BIMS score of 13, indicating no cognitive impairment, and was dependent on staff for toileting hygiene and transfers, with documented bowel incontinence and multiple medical diagnoses including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain. His care plan documented a self-care deficit, the need for assistance of one staff for toileting, and his preference for having a urinal at the bedside, as well as staff responsibilities to check him every two hours, assist with toileting as needed, and provide peri-care after incontinent episodes. The resident reported that on one occasion, when he requested a bedpan because he needed to have a bowel movement, a staff member told him to defecate in his adult brief instead, which made him feel bad. He usually used a bedpan due to an amputation of one leg, having previously been able to use the toilet. Interviews with facility staff confirmed that a CNA told the resident to soil his brief rather than use a bedpan. The ADON reported being present when the former DON interviewed the CNA, who acknowledged telling the resident to soil his brief and later justified it by saying that was what briefs were for. The CNA stated she could not find an appropriate bedpan and did not go to the main storage to obtain another one. Another staff member (a CMA) informed the DON that the CNA had told the resident he could "sh*t himself" when he requested a bedpan. The DON stated that the CNA reported looking for a fracture bedpan in a storage closet and then telling the resident to use his brief because that is what briefs are for, while other staff later found a bedpan in the resident’s bathroom and the DON knew fracture pans were available in storage. The facility’s written policy on promoting and maintaining resident dignity states that residents are to be treated in a manner that maintains or enhances quality of life, recognizes individuality, and respects resident rights and personal choices.
Failure to Provide Transportation for Out-of-Town Medical Appointment
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need for transportation to an out-of-town medical follow-up appointment, resulting in the resident missing the scheduled visit. The resident had a Significant Change MDS with a BIMS score of 9, indicating mild cognitive impairment, and diagnoses including heart failure, renal insufficiency, non-Alzheimer’s dementia, anxiety, depression, and a left leg below-knee amputation. Physician orders and progress notes dated 3/27/2026 directed daily dry dressing changes to the left lower extremity, non-weight bearing status for the left leg, and a follow-up appointment on 4/3/2026 at 9:30 AM. Review of the clinical record showed no progress notes related to this follow-up appointment, and the resident did not attend the scheduled visit. Staff interviews revealed that the previous transportation staff member had been let go, and the Assistant Administrator had been assigned to transport residents to appointments. The Assistant Administrator reported she did not feel comfortable driving the large van for out-of-town appointments and informed the Administrator of her discomfort. On the day of the scheduled follow-up, the DON learned shortly before the appointment time that the resident would miss the visit because the Assistant Administrator was unwilling to drive out of town. The Assistant Administrator acknowledged that a resident missed their appointment that morning for this reason and that, at that time, she was the only person covered under the facility’s insurance to drive the transportation van.
Failure to Timely Report Allegation of Verbal Abuse and Dignity Violation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse within 2 hours of the alleged incident, as required by policy. Resident #1, who had a BIMS score of 13 indicating no cognitive impairment, was dependent on staff for toileting hygiene and transfers, was always incontinent of stool, and had multiple diagnoses including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain. His care plans documented a self-care deficit, the need for assistance of one staff for toileting, use of a bedside urinal, and that staff were to check him every two hours, assist with toileting as needed, and provide peri-care after incontinent episodes. On the evening of 2/19/2026, between approximately 6:00 PM and 10:00 PM, Staff C, a CMA, heard Resident #1 ask Staff B, a CNA, to be taken to the bathroom to have a bowel movement. Staff C reported that Staff B told the resident to “just sh*t himself.” Staff C later entered the room, noted the resident’s call light was on, found his brief full, and provided hygiene care. Staff C did not report this concern until the following day, 2/20/2026, when she informed the DON (Staff A), describing the incident as a dignity issue. The facility’s investigative file shows that Staff A and the ADON interviewed Staff B on 2/20/2026; Staff B acknowledged telling the resident to go in his brief, stating that is what briefs are for, and reported difficulty finding an appropriate bedpan. Other staff later confirmed that a bedpan was present in the resident’s bathroom and that fracture pans were available in storage. At approximately 3:30 PM on 2/20/2026, Resident #1 was interviewed by the DON and Scheduler. He confirmed that when he requested to go to the bathroom the previous night, the staff member told him to go in his diaper, stating there were no bedpans, and he denied that this was his preference. He pointed out a bedpan visible in his room. Subsequent interviews with the ADON and Staff A confirmed that Staff B admitted telling the resident to soil his brief and that Staff C and another CNA should have reported the incident immediately. The Administrator stated that staff should have immediately reported this incident. Despite the facility’s written policy requiring all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation to be reported immediately to the Administrator and to the state entity not later than two hours after the allegation is made, the allegation from 2/19/2026 was not reported to the state agency until 4:08 PM on 2/20/2026, exceeding the required 2-hour reporting timeframe.
Failure to Provide Required Toileting Assistance and Respect Resident’s ADL Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assistance with activities of daily living (ADLs), specifically toileting and elimination support, for one resident who required staff help. The resident had a BIMS score of 13, indicating no cognitive impairment, and his MDS documented dependence on staff for toileting hygiene and toilet transfers, with a pattern of always being incontinent of stool. His care plan identified a self-care deficit, impaired balance, incontinence, and the need for assistance of one staff for toileting, including the use of a bedpan or urinal at the bedside. The resident had multiple medical diagnoses, including atrial fibrillation, heart failure, renal failure, urinary retention, insomnia, and acute pain, and used a wheelchair due to bilateral extremity impairment and a leg amputation. According to the resident, on one occasion when he requested a bedpan because he needed to have a bowel movement, a staff member told him to “poop in his pants” after being unable to locate the bedpan, and he subsequently defecated in his adult brief. He reported that this made him feel very bad. A CMA stated she believed she heard the same staff member tell the resident to “sh*t himself” when he asked to go to the bathroom; shortly afterward, the CMA responded to the resident’s call light, found that he had soiled his brief, and assisted with cleaning and changing him. Staff interviews indicated that the resident usually requested a bedpan, was only sporadically incontinent, and knew when he needed to use the bathroom. Facility policy on Supporting ADLs required that residents who are unable to carry out ADLs independently receive appropriate care and services, including support and assistance with elimination and toileting, in accordance with their care plan.
Failure to Provide Timely Tracheostomy Suctioning Results in Resident Neglect
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN), identified as Staff A, repeatedly refused or delayed providing suctioning care for a resident who was dependent on staff for tracheostomy management. The resident had physician orders for deep suctioning as needed, with specific instructions for frequency and technique. Despite these orders, documentation revealed that Staff A did not record performing suctioning during his shifts, and multiple staff and the resident reported that Staff A would not respond promptly to requests for suctioning, often requiring the resident to activate the call light multiple times and for certified nursing assistants (CNAs) to repeatedly notify Staff A before the care was provided. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, reported experiencing severe anxiety and fear for his life when suctioning was not performed as needed. The resident stated that this neglect occurred nearly every night Staff A worked, and that all overnight CNAs were aware of Staff A's refusal to provide timely suctioning. Staff interviews corroborated the resident's account, with CNAs stating that Staff A would often refuse to suction the resident, sometimes claiming he had already done so or was busy, and that the resident appeared scared and anxious as a result. The director of nursing (DON) was made aware of concerns regarding the frequency and timeliness of suctioning, including receiving calls and text messages from staff about the issue. However, the DON did not identify or document any concerns with Staff A's performance at the time, and there was no evidence that the DON was aware of the ongoing pattern of neglect until later. Staff A denied refusing care and claimed to have provided suctioning as needed, but this was contradicted by multiple staff and the resident's statements, as well as the lack of documentation in the medical record.
Failure to Investigate and Respond to Alleged Neglect of Tracheostomy Care
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was dependent on staff for tracheostomy care. The resident reported that an LPN frequently refused or delayed providing suctioning, despite having physician orders for deep suctioning as needed every 20 minutes. The resident described having to activate the call light multiple times and rely on CNAs to communicate his needs to the LPN, resulting in significant anxiety and feelings of neglect. Multiple CNAs corroborated the resident's account, stating that the LPN routinely refused to suction the resident's tracheostomy when requested, and that these concerns were reported to the DON both verbally and via text message. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the allegations. Documentation and interviews revealed that the DON was made aware of the situation through staff communications, including text messages and phone calls, but did not initiate a formal investigation or separate the LPN from the resident during the period in question. The DON acknowledged receiving concerns about the frequency of suctioning and the LPN's response but did not document any follow-up actions or witness statements related to the alleged neglect. The clinical record lacked documentation of the suctioning order being utilized by the LPN, and there was no evidence of a comprehensive review of the resident's care or staff performance regarding the allegations. The resident involved had a history of acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, making timely and appropriate suctioning critical to his well-being. The failure to respond appropriately to the resident's needs and to staff reports of neglect constituted a deficiency in the facility's abuse prevention, identification, and investigation procedures. The facility's policy required immediate notification, investigation, and documentation of alleged abuse or neglect, but these steps were not followed in this case.
Failure to Monitor and Report Ongoing Fever
Penalty
Summary
The facility failed to provide accurate and timely assessment and intervention for a resident with severe cognitive impairment, an indwelling catheter, tube feedings, diabetes, aphasia, CVA, and hemiplegia who developed a UTI and was started on Cefpodoxime Proxetil on 11/6/25. The care plan directed staff to monitor for dehydration, pain, temperature, pulse, and signs of sepsis during antibiotic treatment, and to report fever, shivering, rapid breathing, heart rate changes, shortness of breath, and extreme pain to the physician. The resident’s chart showed intermittent fevers throughout November, including temperatures of 99.7, 100.2, 100.1, 100.7, and 102, along with multiple dates where no vital signs were documented in either the vitals tab or nursing progress notes. The record also showed that follow-up assessments were not consistently documented after elevated temperatures, and from 11/6/25 through 11/30/25 there was no documentation that the doctor had been contacted about the ongoing fever. Staff notes included Tylenol administration for some elevated temperatures, but the chart lacked consistent monitoring and escalation despite repeated febrile readings. On 12/1/25, the resident had a temperature of 102, edema was noted, and the doctor was finally called; the resident was then admitted to the hospital with infection and fever. Hospital records showed the resident was admitted with UTI and pneumonia, with sepsis due to UTI documented during the hospital course. A CNA reported that she had told an LPN the resident had been running a temperature for several nights and that Tylenol was refused because the temperature was considered normal for babies. The PCP stated he had not been aware of the continued high temperatures and would have wanted to know so repeat labs or urine cultures could have been considered. The DON stated that when a resident had an infection, staff should have taken at least a temperature per shift and notified the doctor of elevated temperatures.
Respiratory Treatments Left for Resident Self-Administration Without Authorization
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident who required continuous oxygen and scheduled nebulizer treatments. The resident had diagnoses including COPD, respiratory failure, asthma, obstructive sleep apnea, diabetes mellitus, anxiety disorder, and depression, and the care plan identified continuous oxygen use, altered respiratory status, and risk for respiratory distress. Physician orders included oxygen at 3 L continuous and Ipratropium-Albuterol inhalation solution three times daily. During observation, the resident was seen walking in the hallway with an E-tank and nasal cannula, then removing the cannula after entering the room and independently preparing a nebulizer treatment. The resident obtained the nebulizer mask, placed it on her face, turned the machine on, then stopped and corrected herself by removing the mask, opening the Albuterol vial, placing it in the medication cup, and putting the mask back on. The EMR did not contain an assessment for self-administration of medications, and there was no order allowing the resident to self-administer medications or manage her own oxygen. Staff interviews showed that a CMA and an LPN both allowed the resident to handle the nebulizer treatment herself by leaving the Albuterol for her to set up or by placing the medication in the cup and letting her turn the machine on when ready. The DON stated the resident should not have been left to administer the Albuterol or set up the nebulizer herself and acknowledged the resident did not have a self-administration assessment. The physician stated he could not envision the resident self-administering nebulizer treatments and noted documentation should have been better.
Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide a licensed nurse on the premises on a 24-hour basis, specifically during the overnight shift from 11/11/25 to 11/12/25, when the only scheduled LPN left the facility. Review of staffing records and timecards confirmed that the LPN clocked out at 1:15 AM, leaving the facility without a licensed nurse on site for several hours while 37 residents were present. Staff interviews revealed that the LPN had a pattern of leaving the building or being unaccounted for during overnight shifts, often leaving his phone at the nurses' station and instructing CNAs to call him if needed, though he was sometimes unreachable. On the night in question, the LPN left the facility to get gas and was subsequently detained by law enforcement after a traffic stop. CNAs reported being unaware that the LPN had left the premises and were unable to locate him when needed for resident care, including when a resident developed a fever. The DON was notified by staff and law enforcement after the LPN was taken into custody, and EMS was dispatched to the facility to provide medical coverage until the DON arrived. Staff interviews indicated that concerns about the LPN's absences had been previously reported to the DON, but there was no documentation of disciplinary action or ongoing concerns in the staff records. Facility policy and the facility assessment both required a licensed nurse to be present 24 hours a day to provide direct resident care. Despite this, the LPN was the only nurse scheduled for the overnight shift and left the premises, resulting in a period where no licensed nurse was available to meet residents' needs. Staff and resident interviews corroborated that the LPN was frequently absent from the building during his shifts, and the facility lacked documentation or monitoring to address these concerns.
Failure to Provide Adequate Orientation and Competency Training for Nursing Staff
Penalty
Summary
Nursing staff at the facility were scheduled to work independently with residents without adequate orientation or competency-based training. Two LPNs reported that they did not receive an orientation checklist or formal training before being assigned to care for residents on their own. One LPN stated he did not follow another nurse or complete any orientation checklist, and his personnel file lacked documentation of orientation or training. Another LPN reported receiving some instruction on medication times and paperwork but did not receive competency-based training on specific clinical skills such as catheter care, enteral tubes, or tracheostomy care, despite being expected to perform these tasks. His personnel file also lacked an orientation or training checklist. A former RN at the facility confirmed that there was no checklist for orienting new staff and expressed concerns about the competency and readiness of new hires, specifically noting that one LPN was allowed to work independently despite her concerns about his abilities. The facility administrator acknowledged the absence of a formal orientation or training program, and the DON stated that while a process was being developed, there was no formal orientation list in place. Facility policy required a 10-hour orientation program with a checklist for all new hires, but this was not followed or documented for the staff reviewed.
Failure to Complete Annual Staff Evaluations
Penalty
Summary
The facility failed to conduct annual staff evaluations for 3 of 3 personnel files reviewed. Personnel records for Staff L, Staff M, and Staff N, all CNAs, showed no annual performance evaluations in their files. Staff N was hired on 11/22/21, Staff M was hired on 8/20/21, and Staff L was hired on 8/23/21. During an interview on 12/03/25 at 1:20 PM, the Administrator stated that evaluations had not been completed because no staff had received a raise for 5 years and said the facility had a plan to begin implementing annual evaluations. Facility policy titled Performance Evaluations, dated September 2020, stated that the job performance of each employee would be reviewed and evaluated at least annually.
Failure to Verify LPN History, Check References, and Investigate Care Concerns
Penalty
Summary
The facility failed to provide effective administrative oversight related to hiring and monitoring Staff A, an LPN. A Nebraska nursing license verification showed Staff A had a revoked compact privilege effective 8/2/25, and a Nebraska DHHS record described prior disciplinary action and a revocation recommendation. Staff A was interviewed for the LPN position on 9/8/25 and began working on 9/17/25, but the personnel file did not contain documentation that the facility contacted the references he provided. The file also lacked documentation showing the facility conducted further research into his nursing history or developed measures to monitor his performance after hire. The facility’s policy required attempts to obtain information from prior employers and to check licensing boards for disciplinary actions. Staff interviews and resident statements described concerns about Staff A’s performance while caring for a resident with a tracheostomy. Staff C, CNA, texted the DON that another nurse checked on the resident because Staff A would not. Staff F, CNA, stated Staff A refused to suction the resident’s tracheostomy when requested and that this occurred during shifts she worked with him. The resident stated Staff A frequently refused to suction his tracheostomy, that he often had to ask multiple times before Staff A completed the suctioning, and that this caused severe anxiety. The resident also stated he felt neglected when Staff A did not suction him when requested and that overnight CNA staff knew Staff A would refuse. The clinical record lacked a thorough investigation of the allegations of neglect involving Staff A and the resident. Additional staff statements described concerns that Staff A left the building for long periods, appeared confused, did not retain information, and was not trusted by another RN to handle narcotic keys. The Administrator acknowledged the facility had not been doing reference checks before hire and that concerns had been raised about Staff A leaving the building and taking long breaks. The report also documented that the facility was selected as a Special Focus Facility on 7/30/25, yet the Quality Assessment and Assurance Action Plans reviewed for multiple areas had blank sections, no documented progress or evaluation, and the Administrator stated the plans did not seem to be making progress.
QAPI/QAA Action Plans Not Tracked or Completed
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct quality deficiencies through its QAPI/QAA process. Review of prior CMS Form 2567s showed repeated deficiencies in multiple areas, including care plan revision, quality care, pressure ulcer treatment, sufficient and competent nursing staff, administration, resident records, care plan development, ROM/mobility, pharmacy services/records, food temperature/palatability, and good faith attempt QAPI program requirements. The survey also identified 12 repeat deficiency areas over the last year, with 8 repeated deficiencies on one survey and 5 repeated deficiencies on another survey. Facility records showed several Quality Assessment and Assurance Action Plans with implementation date 10/16/25 for skin assessment, documentation in PCC, bowel elimination and constipation management, MARS/TARS, and baths. Each plan listed multiple action/intervention items with target dates of 11/15/25, but the documents showed little to no progress or evaluation after development. One plan had 2 of 8 areas with progress/evaluation documented, while the others had 0 of the listed areas documented with progress/evaluation. Several plans also had blank sections for the project, best results, worst result, biggest difference the plan would make, what the facility wanted to accomplish, and how completion would be measured. On 12/8/25, the Administrator stated the facility discussed the Quality Assessment and Assurance Action Plans during QAPI, but medication errors and treatment errors still occurred and the plans did not seem to be making progress. The Administrator acknowledged that alternative education was provided but not documented on the action plans, and that there were no updates or documentation after the plans were developed to measure success or track performance. The Administrator stated the action plans were developed from self-identified concerns, mock surveys, and state surveys, and noted that consistent management, a new DON, and an ADON would help moving forward.
Menu and Portion Control Failure for Residents on Modified Diets
Penalty
Summary
The facility failed to follow the menu and prepare food to meet residents’ nutritional needs for 7 of 37 residents reviewed. Several residents had documented dysphagia and altered diet orders, including mechanical soft, ground, or nectar consistency diets. The Minimum Data Set and electronic health record entries showed that these residents had moderate to severe cognitive impairment and diet orders that required specialized food textures or consistencies, but the facility’s meal service did not align with the documented menu and portioning requirements. During a lunch meal observation, staff served mechanical soft pepper steak by scooping portions from a steam table pan, but the serving method did not match the expected portioning for the number of residents on mechanical soft diets. Staff Q stated she used a 3 oz scoop for each mechanical soft resident and processed 7 servings for 7 residents, yet 1.25 cups of mechanical soft pepper steak remained after service. The Kitchen Manager, Consulting Dietitian, and Administrator all acknowledged that if 7 servings were prepared for 7 residents, there should not have been leftovers, and the dietitian stated the serving size should have been identified on the spreadsheet, recipe, or by volume method. The portion control policy stated food should be served according to standard portion sizes and that residents on diet variations should have the required information on the tray card or diet spreadsheet.
Incorrect Food Consistency for Modified Diets
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for 7 of 7 residents reviewed who had ordered modified diets. The residents had documented diagnoses of dysphagia and varying levels of cognitive impairment, with diet orders including mechanical soft, ground, and texture-modified diets, as well as modified fluid consistencies. The clinical record review showed these residents were supposed to receive foods prepared in specific forms based on their individual orders and assessments. During observation of the lunch meal service, staff processed pepper steak for a mechanical soft diet, but an onion larger than an inch remained unprocessed in the food processor output and was later observed in the steam table pan and in the leftover measured portion. The meat was initially found at too low a temperature and was placed in the oven before being returned to the steam table. A sample plate showed pepper steak that was still tender with onion very crisp, while the kitchen manager stated there should not have been any whole piece of food remaining when the mechanical soft meat was served. The consulting dietitian stated that if the onion was crisp, it should have been processed with the meat.
Food Storage and Hand Hygiene Deficiencies During Meal Service
Penalty
Summary
Food was not prepared and stored in accordance with professional standards. During a kitchen observation, multiple food items in the walk-in refrigerator were found open and undated, including containers of sour cream, cottage cheese, barbecue sauce, salad dressing, coffee creamer, and chocolate syrup. The walk-in refrigerator also contained two clear storage containers of salad dressing dated 11/17 and a clear storage container labeled ketchup dated 11/12, and the walk-in freezer contained an open, undated bag of dinner rolls and an open, undated bag of cookies. The Kitchen Manager stated the clear containers with salad dressing and ketchup should have been disposed of and washed after 7 days and acknowledged that the items observed in the refrigerator and freezer were not dated appropriately. Meal service observations also showed food handling practices that did not follow sanitary procedures. During mechanical soft diet preparation, Staff Q used tongs to place pepper steaks in a food processor, then removed the lid and blade with a bare hand, and an unsanitized thermometer was removed from the shelf and used to check food temperature before the meat was placed back in the oven and then served after reaching 166 degrees. During lunch service, Staff Q was observed touching and wiping her face and repeatedly handling residents' plates and serving items without completing hand hygiene. Later, Staff Q handled bread and related items with gloved hands after touching other objects, and the Consulting Dietitian and Administrator both acknowledged concerns with hand hygiene, cross contamination, and dating of open food items.
QAPI Action Plans Lacked Ongoing Evaluation and Performance Tracking
Penalty
Summary
The facility failed to properly monitor and measure the success of its Quality Assurance and Performance Improvement (QAPI) plan and failed to track whether improvement actions were being sustained. Based on document review, staff interview, and policy review, the facility had multiple Quality Assessment and Assurance Action Plans in place with implementation date of 10/16/25, but the plans did not show ongoing evaluation of the interventions after they were developed. For the area of concern related to skin assessment, 8 action/interventions were documented with target dates of 11/15/25, but only 2 of the 8 areas had any progress or evaluation documented, and the remaining areas had no documented follow-up. For documentation in PCC, bowel elimination and constipation management, MARS/TARS, and baths, the facility documented 6, 8, and 7 action/interventions respectively, but none of those plans had any documented progress or evaluation. One MARS/TARS action item and one baths action item also lacked a team member or target date. Each of these plans listed a goal completion date of 12/31/25. The last page of each action plan contained prompts asking for the project, best results, worst result, biggest difference the plan would make, what the facility wanted to accomplish, and how completion would be known, but all of those sections were blank. On 12/8/25 at 5:22 PM, the Administrator stated the facility talked about the PIPs during QAPI, but medication errors and treatment errors continued and it did not seem they were making progress. The Administrator acknowledged there was not a measure of action plans after development to measure success and track performance, and stated that consistent management and adding an ADON would help moving forward.
Failure to Serve Room Trays at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to three residents who consistently received room trays. All three residents were cognitively intact and reported that their meals were often cold upon delivery to their rooms. One resident specifically noted that the facility did not use heated carts for room tray delivery and expressed concern that food sat too long before being brought to her room. Another resident stated that every meal delivered to her room was cold, while a third resident mentioned that food was sometimes served cold and she would request reheating if needed. Observation of the meal delivery process revealed that room trays were loaded onto a cart and delivered to resident rooms, with a sample tray temperature check showing that one of the food items, pepper steak, was below the facility's required minimum temperature of 135 degrees Fahrenheit. Both the kitchen manager and consulting dietitian confirmed that food should be delivered at or above 135 degrees. Facility policy also indicated that potentially hazardous foods must be maintained above 135 degrees to prevent the growth of harmful pathogens, and the administrator confirmed the expectation for food temperature compliance.
Missing GDR Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications had documented rationale for continued use and that gradual dose reduction (GDR) was attempted or clearly justified for 3 of 5 residents reviewed. The deficiency involved residents with diagnoses including dementia, schizophrenia, depression, unspecified mood disorder, stroke, heart failure, hypertension, peripheral vascular disease, and seizure disorder, and the records showed ongoing use of antipsychotic, antidepressant, hypnotic, and anticonvulsant medications without complete supporting documentation for continued therapy. For one resident with moderate cognitive deficits and schizophrenia, the chart showed ongoing antipsychotic use and a pharmacy request in July for review of Zoloft 50 mg for GDR. The physician responded that the resident had a good response and to maintain the current dose, but the chart lacked a corresponding physician progress note with clinical rationale. For another resident with moderate cognitive deficits, non-Alzheimer dementia, depression, and an unspecified mood disorder, the chart showed Depakote 250 mg was reviewed for possible dose reduction in July, and the physician again responded to maintain the current dose with reference to a progress note, but no matching physician progress note with rationale was present in the record. For a third resident with severe cognitive impairment and multiple chronic conditions, the record showed regular use of quetiapine, zolpidem, duloxetine, escitalopram, Eliquis, and hydrocodone-acetaminophen, with care plan focus areas related to psychotropic and sedative medications and GDR review by pharmacy/physician. Pharmacy notes recommended GDR consideration for quetiapine, zolpidem, and duloxetine, and a physician form indicated quetiapine should be maintained, but the facility records and EMR did not contain further justification for declining the GDR for quetiapine and did not contain documentation for the zolpidem and duloxetine dose-reduction recommendations. Facility leadership acknowledged the missing signed GDR documentation and stated that declinations should include an explanation for refusal.
Inaccurate MDS Restorative Nursing Documentation
Penalty
Summary
The facility failed to accurately complete a comprehensive MDS for one resident. Resident #10’s MDS showed a BIMS score of 15/15, diagnoses of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia, and impairment of both upper and lower extremity ROM. The assessment also indicated the resident received restorative program services for passive ROM in the last 7 days. Record review and interviews showed the resident had restorative nursing and therapy-related documentation in the care plan and EMR POC, including PROM for the lower extremities and passive stretching for the upper extremities. The resident stated on interview that he had not been receiving ROM for the upper and lower extremities, that ROM had stopped when OT stopped working with him, and that he had not been receiving restorative nursing services for quite some time. He also stated he was concerned about contracture management. Staff interviews showed the DON stated therapy wrote the restorative programs and that the RNA worked 5 days a week, while the RNA stated she completed paper documentation because she could not document in the EMR and that Resident #10 was not receiving restorative services as he had been receiving therapy services. The MDS Coordinator stated she used data entered into POC to complete the MDS and did not oversee the restorative nursing program, and the Administrator stated she was unaware the RNA was completing paper documentation instead of POC. The CMS RAI Manual and facility policy required restorative nursing interventions to be documented in the care plan and medical record, with periodic RN evaluation and RN supervision.
Care Plan Missing Oxygen-Safety Interventions for Smoking Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident who used continuous oxygen. The resident had a BIMS score of 14/15 and diagnoses including dependence on supplemental oxygen, diabetes mellitus, anxiety disorder, depression, COPD, and respiratory failure. The record showed the resident received oxygen therapy and was prescribed antidepressant, diuretic, antiplatelet, and hypoglycemic medications. The care plan included a smoking-related problem area stating the resident preferred to smoke and did not want a smoking cessation program, with interventions for continuous observation while smoking, quarterly and PRN smoking assessment, and ensuring the smoking policy was followed. Another problem area addressed continuous oxygen use and respiratory risk, with interventions for medications, oxygen settings via nasal cannula, monitoring for respiratory distress, and a history of noncompliance with oxygen while ambulating. The care plan did not identify resident-centered interventions for the resident's continuous oxygen use in relation to smoking. It did not specify who was responsible for managing the resident's oxygen before and after smoking or where the oxygen should be placed while smoking. The Interdisciplinary Team nicotine/smoking safety assessment required a smoking apron and supervision, but it did not reference the resident's continuous oxygen use. Clinical physician orders printed later showed the resident required continuous oxygen at 3 L for COPD. Staff stated residents who smoke take their oxygen off and leave it in the building, and that housekeeping/laundry staff were responsible for taking residents out to smoke. The DON stated she expected all interventions, including what a resident should do with oxygen when smoking and who was responsible for oxygen management, to be included on the care plan.
Failure to Revise Care Plan for Restorative Nursing Services
Penalty
Summary
The facility failed to revise the Comprehensive Care Plan for Resident #10, who had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia, along with impaired ROM in both upper and lower extremities. The resident’s MDS assessment showed a BIMS score of 15/15 and documented that he received restorative program services for passive range of motion (PROM) on 2 days during the assessment period. The care plan included goals and interventions related to contracture management and PROM, including supportive devices and therapy recommendations, with revisions noted on 8/6/25 and a target date of 12/22/25. During interview, the resident stated he had not been receiving PROM for his upper and lower extremities and that ROM had stopped when OT stopped working with him. He said he had not been receiving Restorative Nursing services and was concerned about contracture management. Staff interviews confirmed that the resident was not receiving restorative services, had not been on Restorative Nursing services since the RNA returned in 6/25, and that the PTA/DOR and OTR/L had not written Restorative Nurse Plans for him. The Administrator stated she expected the EMR documentation regarding Restorative Nursing Plans to be the plans being completed, and the DON stated she expected the care plan to match the Restorative Nursing Plans being completed.
Failure to Follow Physician Orders and Document Ordered Treatments
Penalty
Summary
The facility failed to follow physician orders for Resident #32, a resident with severe cognitive impairment (BIMS 6/15) and diagnoses including stroke, heart failure, HTN, PVD, and depression. The resident’s MDS also documented use of antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, antiplatelet, and anticonvulsant medications, along with multiple venous and arterial ulcers and wound treatments to the lower extremities and feet. Review of the TAR showed multiple missed or undocumented treatments and monitoring entries. These included wound care to the left lower extremity and right foot/toes, MediHoney application, weekly weight monitoring related to skin breakdown, encouragement to elevate the legs, encouragement to use a Darco boot, encouragement of protein intake for wound healing, and monitoring for side effects of hypnotic, anticonvulsant, and antipsychotic medications. The record also lacked documentation for monitoring signs of bleeding while the resident was receiving anticoagulant therapy. Staff interviews confirmed that refusals should have been documented in the TAR and that there should not have been blanks. The LPN stated the resident would refuse treatments at times, but those refusals should be charted as refusals. The DON stated orders should be completed as written and that if there was no documentation, she would assume the medication or treatment had not been completed. The facility’s Medication Therapy Policy required medication orders to be supported by appropriate care processes and practices, and the Notification of Changes Policy required prompt consultation with the physician when a change required notification.
Failure to Document and Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatments as ordered for 2 residents with pressure ulcers and other complex wounds. Resident #2 had a history of peripheral vascular disease, diabetes mellitus, paraplegia, an indwelling catheter, and was totally dependent on staff for dressing, toileting, hygiene, transfers, and turning. His care plan identified a history of pressure areas to the coccyx, bilateral buttocks, and bilateral heels, and directed staff to administer treatments as ordered and monitor for effectiveness. A weekly pressure wound assessment showed a large sacral wound with drainage and odor, and later assessments documented progression to a Stage IV sacral wound. For Resident #2, the MAR/TAR showed multiple missed sacral wound treatments in September, October, and November 2025. The chart documented refusals on only 2 dates, but did not document why the resident refused the treatments or that the physician had been notified of the refusals. Staff interview confirmed that nurses were responsible for weekly wound assessments, documenting refused treatments, and contacting the doctor about refusals. The record also showed that the sacral wound increased in size and depth over time. Resident #34 had a BIMS score of 14 and was totally dependent on staff for all care areas. His diagnoses included anemia, renal insufficiency, neurogenic bladder, pneumonia, septicemia, urinary tract infections, quadriplegia, Multiple Sclerosis, and Bechet's disease, and he had an indwelling urinary catheter, ostomy, and feeding tube. Orders required wound care to the scrotum, bilateral groin, left lateral foot, right lateral ankle, left medial ankle, and right posterior heel. The MAR/TAR showed missed treatments and refusals, but the chart lacked documentation of why he refused and lacked documentation that the doctor was notified. The facility policy required wound information to be recorded, including refusals and the reason why, and required staff to notify the supervisor if the resident refused wound care.
Failure to Provide Ordered ROM and Restorative Nursing Services
Penalty
Summary
The facility failed to provide ROM services to a resident with limited ROM to prevent further decrease in ROM or development of contractures. Resident #10 had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia, with impairment in bilateral upper and lower extremity ROM. The resident’s care plan identified altered musculoskeletal status related to C-5 paralysis injury and contractures of the BUE and BLE, with goals related to remaining free of complications from contracture formation and tolerating PROM exercises as written in the individualized restorative programs. The resident’s EMR showed restorative PROM tasks for the lower extremities and for bilateral shoulders, elbows, forearms, wrists, and finger digits, but the documented services were not consistently provided. The record showed the resident received the lower extremity PROM task 12 times, with the last service on 9/19/25, and the upper extremity PROM task 13 times, with the last service on 10/27/25. On 12/1/25, the resident stated he had not been receiving PROM for the upper and lower extremities, that ROM had stopped when OT stopped working with him, and that he had not been receiving restorative nursing services for quite some time. Staff interviews showed confusion and inconsistency regarding who wrote, documented, and oversaw restorative nursing services. The DON stated therapy wrote the restorative programs and that the restorative aide worked 5 days a week, while the RNA stated she completed her own paper documentation because she could not document in the EMR and that the resident had not been on restorative nursing services since she returned in 6/25. The PTA/DOR stated she did not know the process for residents transitioning to restorative nursing and had not written a restorative nursing program for the resident, and the OTR/L stated she was not familiar with the resident and had not written a restorative nursing program for him. The DON and Administrator also stated the restorative nursing programs were in the EMR, while the RNA stated she wrote the programs she was completing and that they were not documented in POC.
Failure to Complete Ordered Catheter Care
Penalty
Summary
The facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 1 residents reviewed, Resident #10. Resident #10 had a BIMS score of 15/15 indicating normal cognition and diagnoses including traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia. The resident had an indwelling, supra pubic catheter, and the care plan focused on managing the catheter appropriately and preventing signs of infection or urethral trauma, with interventions to provide catheter care per facility policy, change the catheter as ordered, and monitor and document intake and output. The MAR/TAR for November 2025 showed an order for Acetic Acid Irrigation Solution 0.25% to be used at bedtime for flushing with catheter care, but there was no documentation that the order was followed on 11/11 and 11/13/25. The resident’s point-of-care output documentation from 8/3/25 through 12/3/25 showed multiple days with limited or no output entries, including 5 days with no entries, 28 days with 1 entry, 55 days with 2 entries, 25 days with 3 entries, and 3 days with 4 entries. The DON stated that a blank on the MAR/TAR would indicate the treatment or medication was not given and expected catheter cares to be managed as ordered and/or as indicated on the care plan. The facility’s Catheter Care Policy did not provide guidance for the frequency of emptying a catheter bag.
Unnecessary Tramadol Stored and Narcotic Counts Did Not Match
Penalty
Summary
The facility failed to ensure that unnecessary narcotics were not stored and failed to maintain an accurate accounting of narcotics for Resident #38. Resident #38 had a BIMS score of 14, was independent in all care areas, and received scheduled pain medications. His care plan identified him as at risk for pain/discomfort and directed staff to administer pain medications as ordered. However, the medication carts contained three separate blister pack cards of PRN tramadol 50 mg for the resident, all labeled from the same February order, with 30 tablets, 29 tablets, and 3 tablets remaining when observed. The pharmacy representative stated that three separate cards of 30 tablets each had been delivered on three different dates. The CDA records and MAR did not match: the CDA showed different numbers of administrations than the MAR in August and September, and one CDA document showed tramadol last used with 3 tablets remaining. Staff also stated that the extra narcotic packs should not have remained in the drawer and that two of the three cards were destroyed after the issue was identified. The DON stated the narcotics in the drawer should have been destroyed a long time ago and that the facility was working on a process to review narcotics weekly.
Incomplete Resident Inventory Documentation on Admission
Penalty
Summary
The facility failed to maintain complete and accurately documented resident records when Resident #19 did not have a resident inventory list completed upon admission. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment. Review of the EHR showed only an inventory list dated 7/7/23, while other records documented the resident’s admission to the facility on 5/19/25 after discharge from the hospital. During interview, Staff Y from Social Services stated that a friend took the resident to the emergency room and that the resident was admitted to the facility on 5/19/25, and Staff Y acknowledged that an inventory list should have been completed at that time but was not. The Administrator also stated that the facility’s expectation was for an inventory list to be completed upon admission, and no policy for resident inventory lists was provided.
Failure to Provide Scheduled Baths or Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled baths or showers to three out of four residents reviewed, despite care plans and facility protocols indicating the required frequency. Electronic Health Record (EHR) reviews showed that one resident, who was cognitively intact and required substantial assistance, was scheduled for three baths per week but only received 30 out of 48 expected baths over a four-month period. Staff interviews confirmed that baths were sometimes missed due to staffing shortages, and there was no documentation of resident refusals for the missed baths in the EHR or on bath sheets, despite staff claims that refusals would be recorded. Another resident, also cognitively intact and dependent on staff for bathing, received only 8 out of 18 scheduled baths over a two-month period, with no refusals documented in the EHR. A third resident, similarly dependent, received 17 out of 33 scheduled baths over a four-month period, with only one refusal documented. The facility's policy required that residents be assisted with bathing according to their care plans and preferences, but the records and interviews indicated that this standard was not consistently met. The Director of Nursing (DON) and other staff acknowledged that baths were missed and that the facility had identified this as a concern. The DON confirmed that the expectation was for residents to receive at least two baths per week, and that the documentation did not reflect refusals for the missed baths. The administrator also acknowledged the issue, stating that resident preferences were considered in care planning, but that the scheduled baths were not consistently provided as required.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to medication administration errors. Resident #2, who had no cognitive impairment, did not receive her diabetes medication, Mounjaro, on a specified date, and her antihypertensive medication, Hydralazine, was administered outside the ordered parameters. Additionally, her weekly weight monitoring was not completed as ordered. There were no progress notes documenting the reasons for these discrepancies. Resident #2 reported that the Assistant Director of Nursing (ADON) did not administer medications to several residents, including herself, on a particular day, and there was a discrepancy in the administration of her insulin, Tresiba. Resident #3, also without cognitive impairment, did not receive his insulin as per the sliding scale order, and there were no notes explaining the deviation. On another occasion, the ADON documented that Resident #3 refused his morning medications, which he stated was due to the late administration time, advised by his doctor. Staff confirmed that Resident #3 had never refused his medications before, indicating a possible error in documentation or communication. Resident #6's medication, Oxycodone, was destroyed without obtaining a discontinuation order from the physician. The medication had not been used for several months, and there was no documentation explaining the destruction. The Director of Nursing was unsure why the medication was destroyed without an order. The facility's policy on medication administration was not followed, as medications were not signed out immediately after administration, and parameters for holding medications were not adhered to.
Deficiencies in Fall and Infection Assessment Protocols
Penalty
Summary
The facility failed to adequately assess and respond to an unwitnessed fall involving Resident #5, who had severe cognitive impairment and a history of falls. On 2/12/2025, Resident #5 was found on the floor next to her bed without her fall mat in place, and no call light was activated. The Interim Administrator, who was not a licensed nurse, conducted an initial assessment and assisted the resident into a wheelchair without using a gait belt. Neurological checks were not initiated immediately, and the first set of vitals was delayed by 30 minutes. The facility's protocol for neurological assessments following an unwitnessed fall was not followed, as confirmed by staff interviews and the Director of Nursing. Additionally, the facility failed to conduct appropriate assessments for residents who tested positive for COVID-19 and Influenza A. Residents #1, #8, #11, #12, #13, and #14, who tested positive for COVID-19, did not receive consistent respiratory assessments every shift as required. Their clinical records lacked documentation of regular COVID-19 Observation assessments and vital signs monitoring. Similarly, Resident #9, who tested positive for Influenza A, did not have consistent vital signs and respiratory assessments documented in their clinical record. The facility's failure to adhere to established protocols for post-fall assessments and monitoring of residents with infectious diseases highlights significant lapses in care. The lack of timely and thorough assessments, as well as the absence of consistent documentation, contributed to the deficiencies identified during the survey. These actions and inactions demonstrate a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week, as evidenced by the review of nursing schedules, staffing sheets, and Payroll Based Journal (PBJ) reports. Specific dates in January and February 2025, as well as several dates in late 2024, were identified where the facility did not have the necessary RN coverage. Interviews with staff, including Licensed Practical Nurses (LPNs) and Certified Medication Aides (CMAs), revealed that the facility struggled with consistent RN coverage, often relying on the Director of Nursing (DON) and a part-time RN who worked weekends. However, the DON's frequent absences due to vacation, illness, or hospitalization further exacerbated the issue. Staff interviews highlighted a lack of communication and coordination in scheduling RNs, with some RNs expressing difficulty in picking up shifts due to unresponsive management. The facility's assessment claimed to maintain 24-hour licensed nurse coverage, but the reality, as reported by staff, was inconsistent and insufficient. The DON and Assistant Director of Nursing (ADON) were often unavailable, and agency staff were sometimes used to fill gaps, but this did not ensure the required coverage. The deficiency was further underscored by staff laughter and comments about the ongoing issue, indicating a lack of confidence in the facility's ability to meet regulatory requirements for RN coverage.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily with accurate and updated details for residents and visitors to see. Observations on multiple dates revealed that the daily staff postings were not updated consistently. On February 13, 2025, the postings were dated February 11, 2025, and on February 19, 2025, the postings were dated February 18, 2025. The Director of Nursing (DON) stated that night nurses were responsible for filling out the staff postings. The facility reported a census of 37 residents at the time of the survey.
Staffing and Management Deficiencies Lead to Unsafe Conditions
Penalty
Summary
The deficiency report highlights a significant lapse in staffing and management at the facility, which led to a period where no licensed nurse was present to care for the residents. On the day in question, the facility was left without a nurse for approximately three hours due to a combination of staff illness, weather conditions, and scheduling issues. During this time, the Administrator, who is not currently licensed to practice as a nurse, attempted to fill the gap by overseeing the medication cart and assessing a resident who had fallen. However, this was not sufficient to meet the facility's needs, as the absence of a licensed nurse left the staff feeling unsupported and concerned for resident safety. The report details an incident involving a resident who fell out of bed during the period without a nurse. The resident was assessed by the Administrator, who determined there were no injuries, but the assessment was not conducted by a licensed nurse, and proper protocols, such as using a gait belt for lifting, were not followed. Additionally, neurological assessments were not initiated despite the fall being unwitnessed. This incident underscores the facility's failure to ensure adequate staffing and appropriate care for residents, as the Administrator's actions, while well-intentioned, did not comply with standard nursing practices. The report also reveals a broader issue of poor management and a toxic work environment, as staff members expressed frustration with the lack of support from the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON and ADON were reported to have remained in their offices rather than assisting with resident care, contributing to a hostile work environment. Staff members reported feeling unsupported and retaliated against for raising concerns, further exacerbating the facility's challenges in maintaining a safe and effective care environment.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified in multiple surveys. The Department of Inspections, Appeals and Licensing (DIAL) website revealed that the facility had a history of deficiencies, including insufficient nursing staff, inadequate quality of care, issues with resident records, and infection control problems. These deficiencies were noted across several surveys, including complaint surveys and the annual recertification survey, indicating a pattern of non-compliance with regulatory standards. The facility's QAPI plan, revised in January 2025, aimed to foster a culture of proactive leadership and systematic improvement. However, the plan's implementation appeared ineffective, as evidenced by the recurrence of deficiencies. The administrator acknowledged that after surveys, results are shared with the management team to develop a plan of correction. However, the approach to preventing recurrence seemed inconsistent, relying on actions such as staff demotion, audits, and training, which may not have been sufficient to address the underlying issues. The repeated deficiencies suggest that the facility's QAPI efforts were not adequately addressing the root causes of the problems identified in the surveys.
Infection Control and Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during an outbreak status, as observed by surveyors. Despite a sign on the front entrance indicating that masks were required, masks were not readily available at the entrance, and staff, including the Administrator and Director of Nursing (DON), were frequently observed without masks. This non-compliance with mask-wearing protocols was consistent across multiple days and involved various staff members, including the Activity Director and Transportation staff, who were seen with masks improperly worn or not worn at all. The facility was in outbreak status due to COVID-19, with several staff and residents testing positive, yet routine testing and mask enforcement were not adequately implemented. Additionally, the facility failed to adhere to proper procedures for obtaining blood sugar levels and administering insulin to residents. Multiple residents reported that Staff A did not use alcohol wipes before performing finger sticks for blood sugar checks or before administering insulin injections. This was corroborated by other staff members who were aware of the issue but did not take corrective action. Residents expressed concern over this practice, which was contrary to the facility's established procedures for blood sampling and insulin administration. The facility's COVID-19 policy guidelines and procedures for blood sampling and insulin administration were not followed, leading to deficiencies in infection control and resident care. Staff interviews revealed a lack of consistent testing and mask-wearing, with some staff unaware of the current protocols. The DON acknowledged the issues but did not ensure compliance with the facility's policies, contributing to the ongoing deficiencies during the outbreak status.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in their care. Resident #4, who had no cognitive impairment, was documented to have an indwelling catheter, ostomy, and received tracheostomy care. However, the care plan, last revised in November 2024, did not reflect these medical devices or provide directives for their care. This oversight was confirmed by staff observations and record reviews, indicating a lack of necessary updates to the resident's care plan to address their current medical needs. Resident #5, with severe cognitive impairment, had a history of falls and required a fall mat when in bed. Despite this, the care plan did not instruct staff to use a fall mat, and staff interviews confirmed that the mat was not in place during a recent fall. The Director of Nursing acknowledged the oversight, noting that the care plan should have included the use of a fall mat. The facility's policy requires care plans to be revised with significant changes in a resident's condition, but this was not adhered to, resulting in inadequate care planning for the residents involved.
Failure to Complete Ordered Treatments for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to complete treatments as ordered for a resident with pressure ulcers, as observed through clinical record reviews, resident and staff interviews, and facility policy review. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was at risk for developing pressure ulcers and had existing stage two pressure ulcers and venous and arterial ulcers. Despite having a care plan that directed staff to follow doctor's orders for treatment and to monitor and document the location, size, and treatment of skin injuries, the facility did not consistently complete these tasks. The resident's treatment administration records (TAR) for December 2024, January 2025, and February 2025 showed multiple instances where orders for wound care and skin assessments were not signed out as completed. This included the application of dressings, ointments, and other treatments, as well as weekly skin assessments and the elevation of the resident's legs. The resident reported that while treatments generally got done, there were times when nurses skipped them, sometimes for two days at a time, depending on which staff were working. The Director of Nursing (DON) stated that measurements were not obtained during weekly skin assessments because they were done monthly at the wound clinic. However, the facility's protocol required full assessment and documentation of pressure sores, including measurements. The DON also mentioned that the resident often refused treatments, although this was not documented as required by the facility's procedures. The facility's failure to consistently follow treatment orders and document assessments and refusals contributed to the deficiency.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt for a resident with severe cognitive impairment and physical limitations during a transfer after a fall. The resident, who had a history of stroke, dementia, and other medical conditions, required extensive assistance for transfers. On the day of the incident, the resident fell out of bed, and the staff, including the Administrator, assisted the resident back into a wheelchair without using a gait belt, contrary to the facility's policy. The resident's fall was unwitnessed, and although the Administrator assessed the resident for pain and injuries, no neurological assessments were conducted. Staff interviews revealed confusion regarding the facility's policy on lifting residents, with some staff unsure if a mechanical lift was required. The Director of Nursing acknowledged that a gait belt should have been used during the transfer. The facility's policy on safe lifting and movement of residents emphasized the use of appropriate techniques and devices, including gait belts, to ensure resident safety and comfort. However, the staff did not adhere to this policy during the incident, leading to the deficiency.
Nursing Coverage Lapse in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing coverage on a specific date, resulting in a period from approximately 1:30 PM to 4:30 PM where no licensed nurse was present in the building. This occurred after an LPN, who had been working extended hours due to another staff member calling in sick, was advised by the Administrator to leave the facility to rest and retrieve her medications. The absence of a licensed nurse during this time left the facility without the necessary medical oversight, despite the presence of high-risk residents, including one with complex medical needs such as a tracheostomy, indwelling catheter, and a history of frequent hospitalizations. During the period without nursing coverage, the facility had several CNAs and CMAs on duty, but no licensed nurse to oversee care or respond to medical emergencies. The Administrator, who was not currently licensed as a nurse, assumed some responsibilities, including taking charge of the medication cart keys and assessing a resident who had fallen. However, the lack of a licensed nurse meant that certain medical protocols, such as neurological assessments following an unwitnessed fall, were not completed. Staff interviews revealed that this situation was unprecedented in the facility, causing concern and anxiety among the staff. The facility's staffing plan and contingency measures were insufficient to address the sudden shortage, despite having partnerships with staffing agencies. The Administrator's actions, including advising the LPN to leave and attempting to fill the gap himself, were inadequate to meet regulatory requirements for nursing coverage. The absence of a licensed nurse during this critical period posed a significant risk to resident safety, particularly for those with complex medical needs and those in isolation due to infectious diseases.
Inadequate Staffing and Competency in Resident Care
Penalty
Summary
The facility failed to ensure that licensed staff were competent to complete an assessment after a resident experienced an unwitnessed fall. The resident, who had severe cognitive impairment and required extensive assistance for transfers due to a history of stroke and other medical conditions, fell out of bed when there was no licensed nurse present in the building. The Administrator, who was a former nurse but did not have an active license, assessed the resident for pain and injuries and assisted in transferring her to a wheelchair without using a gait belt. During the time of the incident, the facility was without a licensed nurse for approximately three hours. Staff members, including a Certified Medication Aide, were present but were not licensed to perform the necessary assessments. The Administrator, who was aware of the situation, instructed a nurse to take a break due to exhaustion, leaving the facility without proper nursing coverage. The Director of Nursing eventually arrived later in the afternoon. The incident highlighted a lapse in staffing and competency, as the necessary neurological assessments were not conducted following the unwitnessed fall. Additionally, the transfer of the resident was performed without the use of a gait belt, which is against standard protocol for ensuring resident safety during transfers. The facility's failure to maintain adequate licensed nursing staff and ensure proper assessment and transfer procedures contributed to the deficiency.
Unnecessary Administration of PRN Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically the administration of a PRN narcotic pain medication, Oxycodone, without clear evidence of pain. The resident, who had severe cognitive impairment and a history of stroke, cancer, heart failure, and dementia, was documented to have received the narcotic on several occasions despite staff observations that he did not appear to be in pain. The resident's care plan included directives to administer analgesic medications as ordered and to anticipate and respond to his pain needs, but there was no consistent evidence of pain that justified the frequent administration of the narcotic. Staff interviews revealed discrepancies in the administration of the PRN narcotic. Several staff members, including LPNs and CNAs, reported that the resident often moaned and groaned but did not exhibit behaviors consistent with significant pain. Some staff indicated that the narcotic was given to help the resident sleep, despite the resident being on a sleeping pill, and one staff member admitted to administering the medication to ensure a quieter night shift. The resident's Medication Administration Record (MAR) showed frequent administration of the narcotic by a specific LPN, raising concerns about the necessity of the medication. The facility's policy on administering medications required re-evaluation of frequent PRN medication use by the attending physician and care team, with input from a consultant pharmacist. However, there was no documentation of such re-evaluation or clinical justification for the frequent use of the narcotic. The Director of Nursing and other staff members acknowledged the resident's behaviors were more related to agitation than pain, further questioning the appropriateness of the narcotic administration.
Failure to Properly Store Delivered Medications
Penalty
Summary
The facility failed to appropriately store medications after they were delivered from the pharmacy, as observed on two separate occasions. On February 13, 2025, a blue plastic bag containing medication cards for sertraline, oseltamivir, Lisinopril, pyridostigmine, Eliquis, and metoprolol was found opened and unattended on the counter at the nurse's station for 30 minutes. This was contrary to the facility's policy, which requires medications to be stored in locked compartments. Staff interviews revealed that medications are usually delivered in white or blue bags and should be put away immediately by the nurse or Certified Medication Aide (CMA) present at the time of delivery. The Director of Nursing (DON) confirmed the procedure for handling delivered medications, which involves checking the packing slip, signing forms, and storing the medications in the cart. However, the incident on February 13, 2025, indicated a lapse in this procedure, as the medications were left unattended on the counter. Staff members, including a Licensed Practical Nurse (LPN) and a CMA, acknowledged that medications should not be left on the counter unattended, highlighting a failure in adhering to the facility's medication storage policy.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. Resident #5, who had severe cognitive impairment and a history of falls, experienced an unwitnessed fall that was not properly documented or assessed. The incident report for the fall was delayed, and a post-fall assessment was not conducted immediately. The Administrator, who was present during the fall, did not perform a neurological assessment, and the Director of Nursing acknowledged the delay in completing the incident report due to her absence from the facility. Additionally, the facility did not document positive test results for Influenza A and COVID-19 for Residents #9 and #10, respectively, in their medical records. Both residents were placed in isolation due to their positive test results, but the documentation in their progress notes was incomplete. The Director of Nursing admitted that the staff failed to chart these test results, which was contrary to the facility's policy guidelines that required all test results to be recorded in the residents' permanent medical records.
Failure to Prevent Abuse of Residents by CNA
Penalty
Summary
The facility failed to prevent physical and verbal abuse of two residents, identified as Resident #2 and Resident #5, by a Certified Nursing Assistant (CNA) known as Staff U. The abuse was witnessed by another CNA and involved both physical and verbal aggression. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found with bruises on her chest that resembled fingerprints. These bruises were discovered during a skin assessment conducted by a Licensed Practical Nurse (LPN). Staff interviews revealed that Staff U had a history of being rough with Resident #2, including pushing her down into a chair and using derogatory language. Resident #5, also with severe cognitive impairment and a BIMS score of 6, was similarly subjected to rough handling and verbal abuse by Staff U. Witnesses reported that Staff U aggressively moved Resident #5 by grabbing his feet and pulling him up by his arms. Staff U was also reported to have used offensive language towards Resident #5, threatening to hit him. Multiple staff members corroborated these incidents, indicating a pattern of abusive behavior by Staff U towards both residents. The facility's administration acknowledged that the abuse incidents were not reported to the state agency as required. The Administrator admitted that the facility's expectation was for all possible abuse to be reported, but this did not occur. The investigation revealed that Staff U's negative attitude and rough handling of residents were known issues, yet she was not immediately separated from resident care. This oversight allowed the abuse to continue, resulting in an Immediate Jeopardy situation for the residents involved.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse conducted.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone number/contact for reporting has been placed conspicuously in the facility.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. On August 26, 2024, between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abusing two residents. Despite reporting the incident to a nurse, neither the CNA nor the nurse reported the abuse to the state agency or the administration. This failure resulted in residents being exposed to actual abuse and the potential for further abuse, creating an Immediate Jeopardy to their health, safety, and security. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found to have three bruises on her chest, which were documented by a Licensed Practical Nurse (LPN) during a skin assessment on August 27, 2024. The bruises were consistent with fingerprint marks, suggesting physical abuse. Additionally, Resident #5, also severely cognitively impaired with a BIMS score of 6, was dependent on staff for dressing and toileting. Staff interviews revealed that the same CNA had a history of verbally and physically abusing these residents, but these allegations were not reported. The investigation uncovered that multiple staff members had witnessed or were aware of the abusive behavior by the CNA, identified as Staff U, but failed to report it due to fear of retaliation or a belief that nothing would be done. The facility's policy required immediate reporting of suspected abuse to the Administrator and Director of Nursing, but this protocol was not followed. The Administrator acknowledged that the allegations should have been reported to the state agency and that Staff U should have been immediately separated from resident care, which did not occur.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for 24/7 reporting has been placed conspicuously in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shenandoah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Shenandoah | 0.4 mi | ★★★★★ | 16 | 0 |
| The Ambassador Sidney Inc | 13.9 mi | ★★★★★ | 6 | 0 |
| Azria Health Clarinda | 17.7 mi | ★★★★★ | 0 | 0 |
| Tabor Manor Care Center | 18 mi | ★★★★★ | 22 | 0 |
| Red Oak Rehab And Care Center | 19.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.