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 August 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.
Failure to Hold and Document Care Plan Conferences: The facility did not hold or document Care Plan Conferences with the resident and/or representative for 4 reviewed residents. One resident with severe cognitive impairment and dementia had family repeatedly request a conference after being told it was needed due to behaviors, while another resident's POA was not involved in the conference and said he did not know what it was. Two other residents had no documented follow-up conferences after prior meetings, and staff reported care conferences were not being conducted after social services staffing changes.
A facility failed to complete wound care as ordered, documented treatments as done before they were actually provided, recorded medications as administered when they were not available, and gave antihypertensive meds despite BP readings below ordered hold parameters. Records and observations showed uncovered surgical wounds with drainage, missed or delayed wound care, missing MAR entries for blood glucose checks and insulin, and documentation that conflicted with staff interviews and pharmacy availability.
Failure to provide oral care was identified for four residents. Residents with varying levels of cognition and dependence had care plans directing staff assistance or encouragement for oral hygiene, yet toothbrushes, mouthwash, and toothpaste were observed unopened in basins, and staff and residents stated toothbrushing was not being completed as expected. A CNA acknowledged oral care was not getting done twice daily, and the DON stated oral care and toothbrushing should be completed twice a day or more depending on orders.
Delayed response to resident call lights. Several residents with significant care needs, including dependence for transfers, toileting, and bed mobility, reported waiting from 24 minutes to over an hour for call lights to be answered. One resident said overnight staffing was insufficient, another reported only 1 CNA and 1 CMA were available during evening care, and staff were observed briefly entering a room and leaving while the call light remained on. The DON stated call lights should be answered within 15 minutes or less.
A resident with moderate cognitive impairment kept prescribed lidocaine-prilocaine cream in his room even though he did not want to self-administer meds, and the cream was observed on a nightstand and later in a bedside drawer. In addition, an unlocked treatment cart containing insulin pens and needles was observed unattended in a hallway while staff and residents passed by; the DON stated meds should be stored in locked compartments and carts locked when not accompanied.
Failed QAPI Program and Repeated Deficiencies: The facility failed to maintain an effective QAPI program and had repeated deficient practices across multiple areas, including resident rights, reporting and investigating allegations, care planning, ADL care, quality of care, pressure ulcer prevention, staffing, pharmacy services, unnecessary drugs, nutrition, records confidentiality, and infection prevention and control. The Administrator stated QAPI meetings had occurred without his involvement and noted the facility had PIPs in place and planned additional plans due to repeat deficiencies.
Infection prevention measures were not followed during resident care. A resident on EBP with a wound was transferred by two CNAs wearing gloves only and no gowns, an RN changed gloves during wound care without hand hygiene for a resident with a surgical wound, and staff providing dependent ADL care for two residents repeatedly removed gloves and left the room without hand hygiene. Staff also used a dependent mechanical lift for one resident and did not disinfect it after use.
Failure to provide dignity and respect during resident interactions: A resident with normal cognition reported that overnight staff did not treat her with dignity and that she feared retaliation after raising concerns in Resident Council, while two other residents with normal cognition described disrespectful tones, lack of assistance, and feeling ignored by overnight CNAs. The DON stated residents should be treated with respect and not fear asking for assistance, and the facility policy stated residents have the right to be free from abuse and neglect.
A resident with CHF, renal failure, DM, chronic pain, and an amputation was receiving opioid pain medication when 54 tablets of Hydrocodone-Acetaminophen went missing after the order changed. A CMA removed the discontinued medication and count sheet from the cart and placed them at the nurses station for destruction, while an LPN assumed an incomplete order meant a dose decrease instead of clarifying it. An RN later found the count sheet in paperwork, and staff reported the missing tablets several days later but could not locate them.
Failure to timely report missing resident narcotics: A resident with chronic pain and multiple comorbidities had Hydrocodone-Acetaminophen ordered for PRN pain. Staff found discontinued opioid tablets still on the cart, placed them at the nurses’ station for destruction, and later discovered 54 tablets were missing. The DON and Administrator did not report the missing meds to police or the State Agency until days later, despite policy requiring immediate reporting of suspected misappropriation.
Failure to investigate missing controlled medications: A resident with chronic pain and multiple comorbidities had 54 tablets of Hydrocodone-Acetaminophen missing after a med order change. A CMA placed the discontinued narcotic and count sheet at the nurses’ station for destruction, but the meds were later found missing. Interviews showed the DON and admin were not notified in a timely manner, and the police and State Agency were not informed promptly, delaying the investigation.
A resident with cancer, anxiety disorder, and moderate cognitive impairment required substantial to maximal assistance for transfers and walking, and the care plan identified the resident as needing 1-staff assist with a walker. During observation, a CNA ambulated the resident to the dining room with a hand on the resident's lower back and no gait belt in use, despite staff and facility policy stating a gait belt was required for residents who need assistance with ambulation or transfers.
Failure to provide appropriate ostomy care occurred when staff did not consistently burp and empty a resident's ostomy appliance, leaving it repeatedly filled with air. The resident, who had an ileostomy, moderate cognitive impairment, and diagnoses including functional quadriplegia and Ogilvie syndrome, reported that staff are not always good about burping or draining the bag and that the appliance has blown out and spilled contents several times. Staff said the task should be done every 2 hours, but not all staff were completing it.
A resident with COPD and emphysema did not receive a timely PRN nebulizer treatment when he reported shortness of breath and audible wheezing. Staff heard his wheezing, observed him appearing short of breath, and a CMA said she had notified the nurse, but the resident stated he had already waited about 40 minutes after using his call light and that delays with breathing treatments happen frequently. The RN later assessed him and started the treatment.
A facility failed to provide individualized treatment and services for two residents with dementia and severe cognitive impairment. One resident with vascular dementia and agitation had care plans and physician orders that did not identify specific behaviors or 1:1 needs, yet was repeatedly observed sitting at the nurses’ station without activity or staff interaction, including one instance where urine was on the floor and the resident’s clothing was wet. Another resident with unspecified dementia was also repeatedly observed at the nurses’ station without activity or engagement, while the care plan did not address dementia-specific interventions. The DON stated staff needed more education on dementia interactions and activities, and the facility had no policy for dementia care and activities.
Failure to Provide Ordered Medications: The facility failed to ensure ordered meds were available and dispensed as prescribed for multiple residents with conditions including DM, HTN, TBI, depression, hypokalemia, hyperlipidemia, and hypothyroidism. Records showed potassium chloride, Wellbutrin XL, levothyroxine, atorvastatin, and lactobacillus were documented as unavailable at times, with missing documentation of physician notification and other required notifications. Staff and residents reported repeated episodes of meds not being available.
A resident with TBI and a history of substance abuse received PRN Tramadol for pain, but the chart did not include a current diagnosis of shingles to support the narcotic order. The record showed repeated PRN pain medication use, while progress notes lacked documentation of shingles treatment and the narcotic count sheets had discrepancies with the MAR. The DON stated she could not find signed pharmacy-driven GDR recommendations for the past year and acknowledged the documentation inconsistencies.
Failure to Provide Snacks at Requested Times: Residents with DM and other diagnoses did not consistently receive snacks outside scheduled meals. A resident with a physician order for a mid-afternoon snack reported not consistently getting snacks, especially in the evening. Another resident stated he was supposed to receive food 6 times daily but did not get morning, evening, or weekend snacks. A third resident reported evening snacks were inconsistent and sometimes had to obtain snacks from a hallway cart rather than staff delivery. Staff and the DON acknowledged problems with evening snack delivery, and the facility policy required snacks to be brought to the resident room and documented.
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.
Failure to Hold and Document Care Plan Conferences
Penalty
Summary
The facility failed to hold and document Care Plan Conferences that included the resident and/or the resident representative for 4 of 4 residents reviewed. Resident #6 had an MDS showing a BIMS score of 2/15 with diagnoses of Non-Alzheimer's Dementia and anxiety, and the care plan included multiple focus areas such as falls, diversional activity deficit, communication deficit, psychotropic medications, hospice, behaviors, impaired cognitive function, and self care. The clinical record did not show a Care Conference with the resident's family or representative, and the family stated they had been asking for a conference since shortly after admission after being told one was needed because of the resident's behaviors. Resident #11 had an MDS showing a BIMS score of 2/15 and diagnoses including DM, CVA, Non-Alzheimer's Dementia, anxiety, depression, and bipolar disorder. Although a Care Conference was documented with dietary, social services, activities, charge nurse, and the resident, the resident's representative was not present or involved, and there was no documentation of notification to the representative before the conference; the resident's POA stated he had not been involved and did not know what a Care Conference was. Resident #12 had a documented care conference on 1/13/26, but no additional conference was documented afterward, and Resident #16 had a documented care conference on 12/22/25, with no later conference documented. Staff interviews indicated social services had been responsible for setting up conferences, but staffing changes occurred and care conferences had not been conducted; the facility policy stated the resident and the resident's family and/or legal representative/guardian are encouraged to participate in care plan development and revision.
Failure to Provide Ordered Treatments, Accurate Documentation, and Medication Administration Within Parameters
Penalty
Summary
The facility failed to provide professional standards of care by not completing wound treatments as ordered, documenting treatments before they were actually completed, documenting medications as given when they were not available, and administering medications outside ordered parameters for several residents. The report identified deficiencies involving residents with diabetes, hypertension, amputations, and surgical wounds, and included findings from record review, observations, interviews, and policy review. For one resident with a recent below-the-knee amputation and a surgical wound, the treatment record showed ordered wound care was documented as completed even when observations showed dressings were missing, wounds were open, and drainage was present. Staff interviews indicated the wound had remained uncovered for hours, and one nurse later stated the wound area had been wrapped and would need to be done again. For another resident with a left below-the-knee amputation and wound dehiscence, the treatment record showed daily wound care documented as completed on days when staff later confirmed the treatment had not yet been done. Observations showed the incision site uncovered with stitches visible and yellowish-red drainage, and a nurse later completed the ordered wound care during the survey. For a resident with diabetes and hypertension, the MAR showed antihypertensive medications were administered even when blood pressure readings were below the physician-ordered hold parameter of systolic blood pressure less than 100. The record also showed Mounjaro was documented as given on dates when the pharmacy had not filled the medication, with progress notes stating the medication was waiting on prior authorization or not available. For another resident with diabetes and hypertension, the record showed missed documentation for ordered blood glucose checks, insulin coverage, and daily weights, along with missing documentation for some scheduled insulin administration. The facility’s policies stated that all services must be documented accurately and that care and services are to be provided according to accepted standards of clinical practice.
Failure to Provide Oral Care to Multiple Residents
Penalty
Summary
The facility failed to provide oral care for 4 of 4 residents reviewed. Resident #1 had a BIMS score of 15/15, diagnoses including atrial fibrillation, heart failure, and DM, and the care plan directed staff to assist with oral care. On observation, staff assisted the resident with personal care and transfer, but the resident’s toothbrush, mouthwash, and toothpaste remained sealed in the resident’s basin, and staff only asked if the resident wanted to brush teeth after the resident was already seated in a recliner. The resident stated she never brushed her teeth because the supplies were across the room. Resident #6 had severe cognitive impairment, was dependent on staff for oral care, and had a care plan calling for staff assistance with oral care. During observation, staff assisted with peri care, dressing, transfer, and hair care, but the resident’s basin also contained an unopened toothbrush, sealed mouthwash, and unused toothpaste. Staff acknowledged oral care should have been completed before the resident left the room. Resident #2 had intact cognition but was dependent for oral hygiene and had diagnoses including CAD, HF, renal insufficiency, DM, and blindness in the left eye; his care plan called for staff to encourage oral care, yet his toothbrush remained wrapped in plastic in the basin and he stated staff did not help brush his teeth or gums. Resident #12 had moderate cognitive impairment and required substantial assistance with oral hygiene, and his toothbrush was also observed still wrapped in plastic and unopened in the basin. A CNA stated toothbrushing was not getting completed twice a day, and the DON stated oral care and toothbrushing should be completed twice a day or more depending on orders. The facility policy stated oral care is to be provided to prevent and control plaque-associated oral diseases.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed. Resident #10, who had a BIMS score of 15/15, quadriplegia, an indwelling catheter, and was dependent on staff for all self-care activities, stated he had waited over an hour for his call light to be answered, especially later evenings and overnight. He also reported that on recent days there had been only 1 CNA and 1 CMA getting residents ready for bed, and that the CMA had to help with transfers, which could delay medications. Resident #19, who had normal cognition, spinal stenosis, and DM, stated his call light was turned on at about 3:00 AM and was not answered until after 6:00 AM when the next shift came on duty. Resident #21, who had a BIMS score of 15/15, stroke, paraplegia, anxiety, an indwelling catheter, and total dependence for toileting hygiene, transfers, dressing, and bed mobility, was observed with the call light on while staff briefly asked what he wanted and then left before returning with a Hoyer lift. Resident #1, who had normal cognition, atrial fibrillation, heart failure, DM, and dependence for toileting hygiene, transfers, and lower body dressing, stated she had waited up to an hour for her call light to be answered; during continuous observation, her call light remained on for 24 minutes while she waited by the door. The DON stated she would like to see call lights answered within 15 minutes or less, and the facility policy stated call lights will directly relay to a staff member to ensure appropriate response.
Unsecured resident medication and unlocked treatment cart
Penalty
Summary
The facility failed to properly secure and store medications to minimize loss or access when Resident #13’s lidocaine-prilocaine external cream was kept in the resident’s room instead of being secured. Resident #13 had a BIMS score of 12 indicating moderate cognitive impairment, and the EHR showed an order dated 3/10/26 for lidocaine-prilocaine external cream 2.5-2.5% to be applied topically to the right foot/ankle twice daily for pain. On 5/26/26, the cream was observed sitting on top of the bedside nightstand with no staff or residents around it, and on 5/27/26 it was observed in the top drawer of the bedside nightstand. Resident #13 stated he kept the cream next to his bed just in case he needed it. A facility self-administration medication assessment indicated that Resident #13 did not want to self-administer medications, and the DON stated she would expect the lidocaine to be stored in the medication cart unless there was an assessment and physician order for self-administration. The facility also failed to properly secure a treatment medication cart. Continuous observation on 6/1/26 showed the west hallway treatment medication cart was unlocked while it contained insulin pens and needles, and multiple nursing assistants, laundry staff, and residents passed by it during that time. Staff M, an LPN, later took the cart and stated she normally locks it when unattended and must have forgotten this time. The DON stated she would expect medication carts to be locked when not being accompanied. The facility policy titled Medication Storage stated that all drugs and biologicals will be stored in locked compartments and stored appropriately to ensure proper security.
Failed QAPI Program and Repeated Deficiencies
Penalty
Summary
The facility failed to maintain and implement an effective QAPI program and plan, and failed to make good faith attempts to correct repeated quality deficiencies. Based on facility record review, staff interview, and policy review, the facility had repeated deficient practices identified in CMS 2567 documents across 2025 and 2026, including deficiencies related to resident rights, reporting and investigating alleged violations, care planning, services meeting professional standards, ADL care, quality of care, pressure ulcer prevention and treatment, range of motion and mobility, accident hazards and supervision, respiratory/tracheostomy care, nursing staffing and competency, pharmacy services, unnecessary drugs, nutritive value and meal temperature, resident record confidentiality, infection prevention and control, and the QAPI program/plan itself. On 6/2/26 at 2:50 PM, the current Administrator stated the facility had held QAPI meetings in April and May that he had not been part of. He also stated the facility would be holding daily standup and standdown meetings for everyone in the building, the IDT would be meeting daily, and the Clinical Leadership Team would be meeting daily once the new ADON began. He stated the facility had PIPs in place and would be developing additional plans related to the current survey because there were repeat deficiencies. The facility's QAA Plan, updated on 1/2/2025, stated that the purpose of QAPI is to develop a culture of proactive leadership and ongoing plans for improvement leading to systemic changes that support exceptional health care to seniors.
Infection Prevention Failures During EBP, Wound Care, and ADL Assistance
Penalty
Summary
The facility failed to provide infection prevention measures by not using Enhanced Barrier Precautions (EBP) when required for a resident with a wound and MDRO history. Resident #15 had diagnoses including encounter for orthopedic aftercare following surgical amputation, MDRO, and diabetes, and was dependent on staff for toileting hygiene and transfers. The care plan stated EBP was required during high-contact activities because of the wound. During observation, two CNAs transferred the resident from bed to wheelchair with a mechanical lift while wearing gloves only and no gowns. One CNA stated she had just finished assisting the resident with a bedpan and acknowledged she should have worn a gown and that both staff should have worn gowns during the transfer because the resident was on EBP due to the wound. The facility also failed to perform hand hygiene during wound care for a resident with a surgical wound. Resident #2 had diagnoses including right below-the-knee amputation and diabetes, and the treatment record ordered wound cleansing and dressing changes three times weekly. During observation, an RN donned a gown and gloves, removed old dressings from the left below-the-knee amputation wound areas, cleansed the open wounds, then changed gloves without completing hand hygiene before applying the new wound treatment and dressing. The facility’s EBP policy identified chronic wounds as an indication for EBP and described gown and glove use during high-contact care activities, and the DON stated staff were expected to change gloves and complete hand hygiene before applying the new wound dressing. The facility further failed to maintain hand hygiene during dependent ADL care and did not disinfect a dependent mechanical lift after use. Resident #6 was severely cognitively impaired, dependent for all dressing, toileting hygiene, oral care, and transfers, and frequently incontinent of bladder; Resident #1 had normal cognition but was dependent for toilet hygiene, transfers, and dressing and was incontinent of bowel and bladder. During morning care for Resident #6, staff repeatedly removed gloves and left the room without hand hygiene, handled urine-contaminated items and the resident’s clothing, and performed peri care, brief care, and dressing assistance with glove changes and intermittent hand hygiene. During care for Resident #1, staff used a dependent mechanical lift to transfer the resident between bed and shower chair and later to a recliner, but the lift was left in the hallway and was not disinfected after use. The DON stated hand hygiene was expected with glove changes and that the dependent mechanical lift should be disinfected between residents, noting the wipe holder on the lift was empty.
Failure to Provide Dignity and Respect During Resident Interactions
Penalty
Summary
The facility failed to provide dignity and respect during interactions and care for three residents. Resident #8 had a BIMS score of 15/15, no behavioral symptoms, and no assistance needs for self-care or ambulation, yet stated that two overnight staff did not treat her with dignity and that she feared retaliation if she raised concerns about her care. She reported that concerns raised in Resident Council were shared by the prior Administrator with staff, including her name as the complainant, and that since then staff had not treated her the same, with changes in their mannerisms and care. Resident #18 also had a BIMS score of 15/15 and diagnoses of renal insufficiency and DM, with dependence on staff for toilet hygiene and transfers and substantial/maximal assistance for rolling. The resident stated that some overnight staff did not always assist with care and did not speak respectfully, describing their tone as disrespectful. Resident #20 had a BIMS score of 14/15, diagnoses of HTN and DM, and no assistance needs for self-care or ambulation, but stated there had been problems with two CNAs on the overnight shift, that staff had been notified of a concern raised during Resident Council, and that more recently staff had not been speaking to him and he felt ignored and hesitant to report concerns due to fear of retaliation. The DON stated residents should be treated with respect and not fear asking for assistance, and that staff education was needed regarding interactions with and/or in front of residents.
Missing Controlled Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when 54 tablets of Hydrocodone-Acetaminophen 10-325 mg became missing from the facility. Resident #2 had diagnoses including heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain, and the resident had been receiving opioid medication. The clinical record showed an order for Hydrocodone-Acetaminophen 10-325 mg as needed for increased pain, later changed to Hydrocodone-Acetaminophen 5-325 mg as needed for pain. A controlled drug record showed 54 tablets remaining on the narcotic count sheet, and the medication was later discontinued. Staff Q, a CMA, stated she removed the discontinued medication and the narcotic count sheet from the cart and placed them at the nurses station to be destroyed, but she did not hear anything for 3 days and later learned the medications were missing. Staff Q stated she had never been part of destroying medications as the facility requires 2 staff. Staff H, an LPN, stated a nurse practitioner had written an order for a frequency change on the Hydrocodone-Acetaminophen 10-325 mg without specifying the milligrams, and she assumed it was a dosage decrease to 5-325 mg instead of clarifying the order. Staff D, an RN, confirmed she was working when the medication went missing and later found the count sheet in a pile of paperwork. Staff S stated the missing medications were reported several days later, and staff searched for the tablets but could not locate the 54 missing tablets.
Failure to Timely Report Missing Resident Narcotics
Penalty
Summary
The facility failed to report suspected misappropriation of a resident’s medications in a timely manner. Resident #2 had diagnoses including heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain, and was receiving opioid pain medication. The record showed Hydrocodone-Acetaminophen 10-325 mg was ordered as needed for pain, then later changed to Hydrocodone-Acetaminophen 5-325 mg. A controlled drug record showed 54 tablets of Hydrocodone-Acetaminophen 10-325 mg were counted on the narcotic sheet, and the medication was later discontinued. A CMA stated she found the discontinued medication still on the cart, did not administer it because it did not match the current order, and placed the medication and narcotic count sheet at the nurses’ station to be destroyed. She then said she did not hear anything for 3 days and later learned the medications were missing. Staff interviews showed the medication could not be located and that the count sheet had been found in a pile of paperwork several days later. The previous Administrator stated the missing narcotics were not reported to him until 5/7/26 and that the facility then reported the matter to police and the State Agency on 5/8/26, 11 days after the medications went missing on 4/28/26. The DON at the time confirmed she did not report the missing narcotics to the appropriate persons until 5/7/26 and stated she should have reported within 24 hours. The facility policy required allegations of misappropriation to be reported immediately to the Administrator and reported to the appropriate state entity not later than 24 hours after the allegation when there was no serious bodily injury.
Failure to Investigate Missing Controlled Medications
Penalty
Summary
The facility failed to investigate the misappropriation of a resident’s medications after 54 tablets of Hydrocodone-Acetaminophen 10-325 mg went missing from the controlled drug record. Resident #2 had diagnoses including heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain, and the MDS indicated the resident was receiving opioid medications during the look-back period. The EHR showed the resident had been prescribed Hydrocodone-Acetaminophen 10-325 mg as needed for increased pain, later changed to Hydrocodone-Acetaminophen 5-325 mg as needed for pain. The controlled drug record showed a narcotic count sheet for the Hydrocodone-Acetaminophen 10-325 mg with 54 tablets remaining, and the medication was later discontinued. A CMA stated she found the discontinued medication still on the cart, did not administer it because it did not match the current order, and took the medication and count sheet to the nurses’ station to be destroyed. She stated she did not hear anything for 3 days and then learned the medications were missing, and no one found them. She also stated she had never been part of destroying medications as the facility requires 2 staff. Interviews showed the missing narcotics were not reported to the police or State Agency until 11 days after they went missing, and the police reported they were unable to complete their investigation because staff names and phone numbers were not initially provided. The former DON stated she was not notified until several days after the medications went missing and that she did not report the missing narcotics to the appropriate parties until the following day. The facility policy required the Administrator to be notified immediately when suspected abuse was reported or observed and required the investigation results to be forwarded to the Department within five days of the initial report.
Failure to Use Gait Belt During Assisted Ambulation
Penalty
Summary
The facility failed to provide safe ambulation and transfer techniques for a resident who required assistance. Resident #14 had diagnoses of cancer and anxiety disorder, and the MDS dated 5/12/26 identified the resident as requiring substantial to maximal assistance of staff for sit-to-stand, transfers, and walking. The MDS also noted occasional bladder and bowel incontinence and a BIMS score of 9, indicating moderate cognitive impairment for decision-making. Resident #14's care plan documented the resident as needing assistance of 1 staff with a front-wheeled walker and wheelchair, and also identified the resident as at risk for falls with interventions to use the call light and ask for assistance when transferring or ambulating. During observation on 5/14/26 at 7:30 AM, the resident walked down the hall and to the dining room with a wheeled walker and Staff C, CNA, with Staff C's hand on the resident's lower back and no gait belt in use. Staff E, CNA stated the resident's care plan required a gait belt for transfers or walking with the resident, and the facility's Use of Gait Belt Policy stated gait belts are to be used with residents who cannot independently ambulate or transfer. The DON stated staff were expected to use a gait belt for transfers and ambulating residents who need assistance and as documented in the care plan.
Failure to Provide Consistent Ostomy Burping and Emptying
Penalty
Summary
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services was not met when staff failed to release the buildup of gas in Resident #13's ostomy bag. Clinical record review showed Resident #13 had a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses including functional quadriplegia, ileostomy status, noninfective gastroenteritis, colitis, and Ogilvie syndrome. The care plan, revised 4/28/26, indicated Resident #13 required assistance from 1 staff member with colostomy care and emptying. Observation on 5/26/26 showed Resident #13's ostomy bag completely filled with air after bingo, and the resident stated staff are not always good about burping or draining the bag. The resident reported that when the bag is not burped, the appliance can blow out and spill its contents, and that this has happened several times. Another observation on 5/27/26 showed the ostomy appliance again full of air. Staff interviews indicated the bag should be burped every 2 hours, that outputs are charted twice a day, and that not all staff were completing the task. The DON stated staff would be expected to empty and burp ostomy appliances at the appropriate times. The facility policy stated residents requiring ostomy services will receive care consistent with professional standards of practice.
Delayed Nebulizer Treatment for Resident with COPD
Penalty
Summary
The facility failed to provide a timely respiratory treatment for a resident with panlobular emphysema and COPD who was identified by the MDS as having no cognitive impairment for decision-making. The resident’s care plan documented that he was at risk for shortness of breath, impaired breathing, and respiratory infections, with an intervention to administer medications/inhalers as ordered. The resident had an order for Ipratropium-Albuterol inhalation solution every 6 hours as needed for shortness of breath related to COPD. During observation, the resident was seen walking down the hall leaning on the wall and holding the hand rail, and staff could hear wheezing and see that he appeared short of breath. The resident stated he needed a nebulizer treatment immediately. A CMA told him she had notified the nurse because she was no longer able to do breathing treatments. The RN then came, walked with the resident to his room, listened to his lungs, and started the treatment. The resident later stated he had been waiting at least 40 minutes, had turned on his call light earlier, and had reported his need for a breathing treatment to staff who said they would tell the nurse, but no one returned. He stated this happens frequently and that he has waited over 15 minutes, and sometimes up to 2 hours, for breathing treatments.
Failure to Provide Individualized Dementia Care and Engagement
Penalty
Summary
The facility failed to provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of two residents diagnosed with dementia. Resident #6 had severe cognitive impairment with diagnoses including vascular dementia with agitation, anxiety, and non-Alzheimer's dementia. The care plan identified impaired cognitive function, fall risk, and a diversional activity deficit, but it did not identify the resident’s specific vascular dementia diagnosis or individualized interventions for behaviors, activities, or non-pharmacological behavior management. Physician orders directed staff to monitor behaviors each shift, but there was no order for 1:1 supervision and no individualized behavior plan documented. Observations showed Resident #6 repeatedly seated at the nurses’ station without activity or staff interaction, including times when the resident appeared restless and when urine was observed running onto the floor from the resident’s wet pants. Staff were not present at those times, and a visitor reported the resident had urinated on himself. Staff later stated Resident #6 was a 1:1, but the record did not identify the resident as requiring 1:1 supervision. Resident #11 had severe cognitive impairment with diagnoses including unspecified dementia, anxiety, depression, bipolar disorder, diabetes, and a history of stroke. The care plan addressed limited participation in activities and listed preferred activities such as cornhole, animal visits, and music, but it did not identify the resident’s dementia diagnosis or specific dementia-related interventions. Observations showed Resident #11 seated at the nurses’ station without activity or staff engagement on multiple occasions. The facility also lacked a full-time Activity Director, relying on a shared Activity Director present three days per week. The DON stated more education was needed for staff on interactions with residents with dementia and available activities, and stated that residents at the nurses’ station should have activities or stimuli available. The facility did not have a policy related to dementia care and activities.
Failure to Provide Ordered Medications
Penalty
Summary
The facility failed to order and dispense medications according to physician orders for 3 of 7 residents reviewed. Resident #1 had diagnoses including type 2 DM, hyperlipidemia, atrial fibrillation, heart failure, and hypokalemia, and the record showed ordered potassium chloride ER tablets were documented as not available on multiple dates. The clinical record included progress notes that the medication was on order or pharmacy was notified, but it lacked documentation of physician notification when the medication was unavailable. The resident stated there had been a couple of instances when all medications were not received because they were not available. Resident #16 had diagnoses including hypertension, TBI, and depression, and the care plan addressed pain/discomfort and increased risk for injury related to TBI and prior fractures. Although the record documented medications as dispensed as ordered, staff stated there had been multiple times when medications were not available for residents. Staff Q stated she had notified the previous regional clinical director about medications not being available and described a process using medication stickers and an ordering book. Staff Q also stated she had borrowed Wellbutrin from the day shift because the night shift was out. Resident #19 had diagnoses including DM with neuropathy, diabetic retinopathy, diverticulitis, hyperlipidemia, and hypothyroidism, and the care plan included interventions for DM, hypokalemia, and thyroid replacement therapy. The MAR showed levothyroxine, atorvastatin, and lactobacillus documented as not available on different dates, and the facility failed to document the medications not available, pharmacy notification, DON/charge nurse notification, and physician notification. The resident stated he had experienced episodes over the prior 2 months when medications were not available and was told by nursing staff during medication administration that the medications were unavailable. The current DON acknowledged there had been a problem with medication availability and stated the primary provider should be notified and documented when a prescribed medication was not available.
Unnecessary PRN narcotic use without current diagnosis
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by continuing a PRN narcotic order without a current diagnosis supporting its use. Resident #16 had intact cognition on the MDS and diagnoses including traumatic brain injury and other psychoactive substance abuse, uncomplicated. The clinical record showed a PRN order for Tramadol HCl 50 mg by mouth every 6 hours as needed for pain related to shingles, but the medical diagnoses section did not include a current diagnosis of shingles. Staff also stated the diagnosis needed to be current for the use of any medication. Resident #16’s record showed repeated use of Tramadol and Tylenol for pain complaints, including pain in the bilateral lower extremities, with progress notes documenting requests for PRN pain medication and observations of redness, discoloration, and edema in the legs and feet. However, the progress notes did not provide documentation related to treatment of shingles since 11/30/23, except for entries related to dispensing Tramadol. The physician visit note stated the resident was not a good candidate for pain medications because of a history of polysubstance abuse and that non-pharmaceutical pain management would be attempted. The narcotic count sheet and MAR also contained discrepancies, with several dates showing medication given on the count sheet but no corresponding MAR documentation. The DON stated she was unable to find signed pharmacy-driven GDR recommendations for the past year regarding Tramadol and acknowledged discrepancies between the narcotic count sheets and MARs. The facility’s policies required controlled substance count sheets to document the date, time, who administered the medication, and the number on hand, and required PRN orders to include the reason for administration.
Failure to Provide Snacks at Requested Times
Penalty
Summary
The facility failed to provide snacks to residents who wanted to eat at non-traditional times or outside scheduled meal service times. Based on clinical record review, resident interviews, staff interviews, and facility policy review, the deficiency involved 3 of 4 residents reviewed: Residents #8, #19, and #20. The facility reported a census of 32 residents. Resident #8 had diagnoses including anemia, HTN, and DM, with a BIMS score of 15/15 indicating normal cognition. The care plan included interventions for DM and stated snacks were allowed, and a physician order dated 10/4/23 directed a mid-afternoon snack at 3:30 PM. However, snack task documentation for the prior 30 days showed snacks were documented mainly in the morning and between meals, with no evening snacks documented. On 5/21/26, the resident stated she did not consistently get snacks as needed for blood sugar and diabetes management and said not receiving evening snacks was worse than missing afternoon snacks. Resident #19 had diagnoses including HTN, DM, hyperlipidemia, depression, diabetic neuropathy, and diverticulitis, and a BIMS score of 15/15. The care plan directed staff to provide snacks with meal times and to monitor for signs and symptoms of high and low blood sugars. Snack documentation for the prior 30 days showed snacks were documented in the morning and between meals, but no evening snacks were documented. On 5/21/26, the resident stated he was supposed to get food 6 times daily due to diabetes and diverticulitis, but he never got morning snacks between breakfast and lunch and did not receive evening snacks or weekend snacks. Resident #20 had diagnoses including HTN and DM, with a BIMS score of 14/15. The care plan included providing snacks with meal times and dietary restrictions. Snack documentation showed entries across the day, including evening snacks, but the resident stated on 5/21/26 that evening snacks were inconsistent, the snack cart might be left in the hallway, and he sometimes had to get snacks himself rather than staff delivering them. Staff interviews confirmed concerns about evening snack delivery, and the DON stated staff should be providing snacks in the afternoons and evenings, while the facility's meal schedule listed breakfast at 7:30 AM, lunch at 12:00 PM, and dinner at 5:30 PM.
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.
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 80 citations issued within 25 miles in the last 12 months — 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 | ★★★★★ | 0 | 0 |
| The Ambassador Sidney Inc | 13.9 mi | ★★★★★ | 6 | 0 |
| Azria Health Clarinda | 17.7 mi | ★★★★★ | 4 | 0 |
| Tabor Manor Care Center | 18 mi | ★★★★★ | 25 | 0 |
| Red Oak Rehab And Care Center | 19.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.