Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Red Oak during CMS and state inspections, most recent first.
Two residents with significant cardiopulmonary conditions did not receive timely assessment and intervention when experiencing respiratory compromise and possible bleeding. One resident with chronic respiratory failure, COPD, sleep apnea, and atrial fibrillation had documented low O2 saturations, complaints of shortness of breath, weakness, and hallucinations, yet staff did not complete or document a comprehensive respiratory assessment, did not administer or document PRN respiratory treatments, did not document oxygen adjustments and follow‑up vitals, and did not clearly communicate critically low O2 readings to the provider. The resident ultimately called 911, and EMS found severe hypoxia and respiratory distress requiring CPAP and ED transfer for suspected pneumonia and CHF exacerbation. Another resident with COPD and on apixaban for atrial fibrillation had care plans directing staff to monitor for respiratory distress and hemoptysis and to report bleeding‑related signs, but when the resident reportedly coughed or spat up blood, staff did not complete appropriate assessment or intervention consistent with those care plans and physician orders.
Failure to post daily nurse staffing information: The facility did not keep the staffing sheet updated in a prominent location for residents, staff, and visitors. Survey observations showed the sheet remained dated Saturday while the DON said the overnight nurse was responsible for updating it and later found the nurse did not have access to complete the form. The Administrator acknowledged the sheet should have been updated, and the facility's policy required daily posting of the current date, census, and actual hours for RNs, LPNs, CNAs, and CMAs.
Food items were found undated, unlabeled, and improperly stored in the kitchen and dry storage areas, including opened containers and bags of food and items placed on the freezer and dry goods room floors. During meal service, multiple CNAs and other staff moved between residents and assisted with feeding without hand hygiene, and one staff member handled spilled food from the floor, touched a resident’s plate and glass, and continued assisting without sanitizing hands. The DON and Administrator confirmed the expected hand hygiene and food storage practices.
Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents, and document vaccination status. Review of records and staff interviews showed 5 residents did not receive the 2025 COVID-19 vaccine, with immunization offers last documented in prior years or not at all for one resident. The RN/IP and DON stated the vaccine was not given unless requested, and the DON said the facility did not administer the vaccine for the year due to formulary and guidance issues, despite policy calling for vaccination per CDC guidance.
Psychotropic consent forms were incomplete for 3 residents receiving antianxiety, antidepressant, and antipsychotic medications. The forms documented medication education and side effects, but did not consistently identify the target behaviors or non-pharmacological interventions attempted. Staff, including the Social Services Coordinator, MDS Coordinator, and DON, acknowledged the forms were not completed in full as required by policy.
Soiled body pillow case left in use: A cognitively intact resident with stroke, hemiplegia, and hemiparesis used a large u-shaped body pillow because she feared falling out of bed. Surveyors observed yellow and brown discoloration on the pillow case on consecutive days, and staff later found two soiled pillow cases on the pillow before replacing them with a clean one. Staff said the pillow case was supposed to be changed weekly or when visibly dirty, and the DON said it should be changed on shower day and if soiled between shower days.
Failure to Document Behavior Triggers and Non-Pharmacologic Interventions for Psychotropic Medication Use The facility failed to consistently document resident-specific behaviors and attempted non-pharmacologic interventions for 3 residents receiving psychotropic meds. Records showed psychotropic orders for anxiety, depression, and psychosis-related symptoms, but the consent forms, care plans, progress notes, and TARs often did not identify the target behaviors or the non-pharmacologic alternatives attempted. One resident had intact cognition and orders for an antianxiety med and an antidepressant; another had severe cognitive impairment and multiple psychotropic orders; and a third had intact cognition with anxiety and PRN antianxiety use. Staff interviews showed some awareness that target behaviors and interventions should be documented, but the required behavior details were not consistently recorded.
Incomplete Discharge Summary: The facility failed to complete a discharge summary for a resident with a BIMS of 15. The EHR showed the discharge summary lacked a recapitulation of stay, a final status summary, and reconciliation of pre- and post-discharge meds. The DON acknowledged the required discharge summary elements were not completed after the resident's discharge.
Failure to update PASRR after new mental health diagnosis: A resident with dementia, depression, psychotic disorder, visual hallucinations, and delusional disorder had psychotropic meds including Risperdal, Sertraline, and PRN Lorazepam, but the PASRR on file still showed no MH dx, no MH services, and no MH meds. The DON, Social Services Director, and Administrator acknowledged the PASRR was not completed when the resident’s new MH dx and medications were initiated, despite facility policy requiring a new PASRR when a resident is diagnosed with a mental disorder.
Incomplete Care Plans for Residents Receiving Psychotropic Medications: The facility failed to include resident-specific target behaviors and nonpharmacological interventions in the care plans for 3 residents receiving psychotropic meds. One resident had intact cognition with anxiety and depression, another had severely impaired cognition with dementia, anxiety, and depression, and a third had intact cognition with anxiety and a communication deficit. Staff interviews showed uncertainty about care plan requirements, and the DON stated the target behaviors and interventions should have been included.
A resident with severe cognitive impairment and a care plan directing staff to cut up all meat was served a meal without her meat being cut, despite a family request for that assistance because her vision was deteriorating. During observation, kitchen staff placed the tray in front of her and walked away, the meat pieces were larger than bite-size, and the meal ticket did not show that the plate should be oriented or the meat cut. Interviews showed confusion among staff about who was responsible for meal setup and cutting food, even though the DON and Administrator said meal-related needs should be identified on the tray card or meal card.
A resident with severe cognitive impairment, bladder and bowel incontinence, and dependence for toileting hygiene did not receive appropriate toileting hygiene assistance. During observed toileting care, a CNA handled items in the resident's room and then provided peri care without changing gloves or performing hand hygiene, despite the resident's recent UTI and the facility's hand hygiene policy requiring hand hygiene before a clean task and after glove removal.
A resident with COPD and dependence on supplemental O2 was ordered continuous oxygen at 2 lpm via nasal cannula, but surveyors observed the concentrator set at 3 lpm on multiple occasions. The resident said his O2 order had recently changed to 3 lpm, while staff and the DON stated the setting should match the physician order and that the resident did not usually change it. The facility policy required oxygen to be administered only with a medical order and by trained staff.
Two cognitively impaired residents were observed by a CNA with their hands in each other's pants at the nurses’ station and were separated, with a nurse documenting the event and notifying the DON, social services, and the Administrator. The Administrator, after a phone discussion with the nurse and without directly interviewing the CNA or reviewing video, concluded the residents had only been holding hands in laps and decided the incident was not reportable, and no formal abuse investigation or state notification was made. The DON, who was on vacation and received only limited information, did not report the incident either. This response conflicted with the facility’s abuse policy, which required immediate reporting and investigation of all alleged or suspected abuse, including resident-to-resident incidents.
Two cognitively impaired residents were observed by a CNA with their hands down each other’s pants at the nurses’ station, after which they were separated and a nurse documented no trauma and notified leadership. The Administrator, relying on second-hand clarification that the residents were only holding hands in a lap and noting both had dementia, decided the incident was not reportable and did not initiate a formal investigation. The DON was not fully informed of the specific allegation, Social Services did not document the event, and no comprehensive abuse investigation consistent with the facility’s abuse/neglect policy was conducted, resulting in a failure to immediately and thoroughly investigate an allegation of potential abuse.
Two residents with cognitive impairment and a history of falls experienced repeated incidents due to the facility's failure to consistently implement and document fall prevention interventions, including not removing wheelchair pedals and not completing required assessments or care plan updates after falls. Staff interviews and record reviews confirmed lapses in supervision and adherence to facility policy.
Staff did not measure pureed foods before serving, resulting in incorrect portion sizes for residents requiring texture-modified diets. Despite facility policy and supervisory expectations to measure and divide pureed foods to ensure proper nutrition, pureed items were served without confirming correct serving sizes.
A staff member was observed handling food without proper hand hygiene, touching multiple surfaces and their own clothing before serving food with bare hands, and placing utensils on unclean surfaces between uses. These actions did not comply with the facility's infection control and hand hygiene policy.
Staff did not adhere to infection control protocols during care for three residents, including leaving an open pressure ulcer exposed during transfer and shower, failing to use gloves during enteral tube care, and not performing hand hygiene between glove changes or after catheter care. These lapses resulted in exposure of wounds to potential pathogens and improper handling of medical devices.
A resident with moderate cognitive impairment and total dependence on staff for personal hygiene did not receive oral care for at least 30 days, as shown by a lack of documentation and physical findings of poor oral hygiene upon hospital admission. Staff were unable to locate the resident's toothbrush, and there was uncertainty about oral care procedures and documentation, despite facility policy requiring both.
The facility did not ensure comprehensive care plans were developed and implemented for two residents: one who was a smoker and another with suicidal ideation. For the smoker, the care plan required cigarettes and a lighter to be stored at the nurse's station, but the resident kept the lighter in her pocket and staff were inconsistent about storage procedures. For the resident with depression and suicidal ideation, the care plan lacked documentation and interventions addressing her mental health crisis, even after an incident requiring emergency evaluation. The DON confirmed care plan interventions were not implemented for suicidal ideation.
A nurse left Nystatin suspension at a resident's bedside for self-administration without direct supervision, despite the resident not having an assessment, care plan, or provider order for self-administration. Facility policy required these steps, and the DON confirmed they were not completed.
A resident with a PEG tube received medications and water via a piston syringe using a slow push method, rather than by gravity as required by facility policy. The RN reported this was due to resistance in the tube and the resident's preference, but the method was not documented in the care plan. The DON confirmed the policy did not allow for pushing medications, resulting in a deficiency.
Two residents with significant cognitive and physical impairments did not receive proper pressure ulcer care, including missed or undocumented wound treatments, failure to apply ordered dressings, and lack of documentation and measurement of new skin breakdowns. Facility staff did not consistently follow wound care policies, resulting in inadequate treatment and monitoring of pressure injuries.
The facility failed to maintain sanitary conditions in food storage and preparation, as observed with improper food storage, undated items, and inadequate hand hygiene practices by staff. The kitchen's refrigerator had a black fuzzy area, and food items were found uncovered and undated. Staff did not follow proper glove use and handwashing protocols during meal preparation, contributing to the deficiency.
The facility failed to serve food at safe and appetizing temperatures to three residents. A resident reported that baked potatoes were served raw and food was not always warm. Observations showed room trays left on a cart for extended periods, resulting in food temperatures outside safety standards. Another resident reported food frequently served cold, and a third resident noted a pork sandwich was not hot and coleslaw was not cold. The facility's policy required periodic temperature checks, which were not followed.
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. A resident with an indwelling catheter had the drainage bag improperly positioned, and staff failed to perform hand hygiene during catheter care. Another resident with a supra pubic catheter experienced similar issues, with staff not adhering to hand hygiene protocols.
The facility did not update the daily nursing staffing data as required, with outdated information observed on two consecutive days. The DON identified an LPN as responsible for updating the staffing sheet, which was expected to be changed daily. The facility's policy mandates daily posting of current staffing data, including staff hours and resident census.
The facility failed to notify a resident's family when a large bruise developed on the resident's right thigh. Despite the resident's pain and the bruise being documented by staff, the family was not informed until the resident's condition declined the following day. Staff interviews revealed a lack of clear recollection and absence of a specific policy for family notification.
A facility failed to notify management in a timely manner when a resident was found to have a large, painful bruise on her right hip/thigh. The bruise was first documented by an RN, but management was not informed until the following day. The resident had a history of heart failure, stroke, hemiplegia, and depression, and required substantial assistance with mobility. Staff interviews revealed uncertainty about reporting the bruise, and the facility's policy on immediate reporting was not followed.
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. The resident, with severe cognitive impairment, was observed with TUMS on two occasions without an order for self-administration. The resident's son also reported finding multiple pills in a medication cup during his visits. The DON and Administrator acknowledged the issue, which had been a problem in past surveys.
A resident with no cognitive impairment and limited mobility due to a stroke reported pain and bruising, which was first documented by an RN but not followed up. The bruise was present for about a month before the resident's passing, and multiple CNAs reported it to nurses who did not document or assess it further. The DON and Administrator acknowledged that incidents should be reported and investigated promptly, but this protocol was not followed.
A facility failed to notify hospice when a resident with no cognitive impairment and requiring substantial assistance was found with a large, painful bruise on her right thigh. Despite documentation and family-provided photos showing extensive bruising, there was no record of hospice being informed. Staff interviews revealed a lack of communication regarding the resident's condition, contrary to the facility's agreement with the hospice provider.
Failure to Assess and Intervene for Respiratory Distress and Hemoptysis
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment and intervention for residents experiencing significant respiratory changes and possible bleeding while on anticoagulant therapy. For Resident #16, who had chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, atrial fibrillation, and sleep‑related hypoventilation, the care plan directed staff to monitor for signs and symptoms of respiratory distress and to report changes to the provider as needed. Physician orders included PRN albuterol nebulizer, PRN albuterol‑budesonide inhaler, and oxygen at 2 L/min via nasal cannula to maintain oxygen saturation above 92%, with documentation of oxygen saturation, pulse, respirations, and lung sounds pre‑ and post‑administration when PRN treatments were used. The April MAR/TAR showed no documentation that PRN respiratory medications were administered, and the electronic record for 4/15/26 contained only a weekly skin assessment and an infection assessment, with no documented respiratory assessment despite multiple indications of respiratory compromise. On 4/15/26, Resident #16’s oxygen saturation readings included 96% on room air at 4:29 AM and 90% on BiPAP at 8:11 AM, with later readings of 93% on BiPAP. Staff G, the RN caring for the resident that morning, reported that when therapy sat the resident on the side of the bed, she could not get enough air and her oxygen saturation was 68%, prompting staff to put her back on BiPAP, after which the saturation reportedly increased to 94%. Staff G stated she completed an assessment, repeatedly checked oxygen saturation, and listened to lung sounds, but she did not document these assessments or the subsequent oxygen readings. She also stated she increased oxygen to 2.5 L when the saturation was 90%, but did not document the change or obtain a corresponding physician order, despite saying she notified the physician. The clinic nurse later stated she was not told about an oxygen saturation of 68% and that, had she known, the physician would likely have ordered ED evaluation. The DON acknowledged that Staff G noted a low oxygen level of 68% and applied BiPAP but did not document interventions or use of PRN albuterol as expected. Throughout the day, Resident #16 and her husband reported that she felt ill for several days, complained of fluid overload, shortness of breath, and difficulty breathing, and that she was gasping for air during therapy. The husband and resident both stated that staff did not appear concerned, did not perform assessments when she reported feeling ill, did not offer PRN breathing treatments, and did not increase oxygen. Staff D, a CNA, confirmed that during an attempted transfer with therapy, the resident said she could not breathe, took long deep breaths between words, seemed weak and tired, and insisted on lying back down; he recalled that her oxygen was low but did not remember the exact number. Despite these reports, there was no documented comprehensive respiratory assessment on 4/15/26. Later that evening, the resident called 911 herself, reporting someone nearby was having a stroke. EMS found her pale, cool, confused, and hallucinating, with oxygen saturation in the high 60s to low 70s and respirations of 36. EMS documented rales bilaterally, initiated CPAP with escalating PEEP due to persistent respiratory distress, and transported her to the ED, where she was diagnosed with possible pneumonia and CHF exacerbation. The primary care physician stated he was not informed of oxygen saturations in the 60s or 70s and that such values would have warranted notification and ED evaluation. For Resident #41, the report identifies another failure to follow care plan directives related to respiratory status and anticoagulant use. This resident had intact cognition, diagnoses including hypertension, pneumonia, COPD, and atrial fibrillation, and was receiving apixaban 5 mg twice daily. The care plan for altered respiratory status directed staff to monitor for and report signs and symptoms of respiratory distress, including hemoptysis, and the anticoagulant care plan directed staff to report blood‑tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. The report notes that this resident was reviewed in the context of coughing/spitting up blood while on an anticoagulant, indicating that staff did not complete appropriate assessment or intervention in response to hemoptysis as required by the care plan and physician orders. Specific details of the communication to the physician are referenced in a fax communication dated 3/30/26, but the excerpt provided ends before the content of that fax is fully described, leaving the documented deficiency focused on the failure to adequately assess and respond to the resident’s reported coughing/spitting up blood. Collectively, the findings show that for two of three residents reviewed, staff did not complete timely, comprehensive assessments or implement ordered or care‑planned interventions when residents exhibited low oxygen saturation or hemoptysis. For Resident #16, this included lack of documented respiratory assessments, failure to use or document PRN respiratory medications, failure to document oxygen adjustments and subsequent vital signs, and failure to communicate critical oxygen saturation values to the physician or clinic nurse. For Resident #41, this included failure to follow care plan directives to assess and report hemoptysis in the context of COPD and anticoagulant therapy. These actions and omissions occurred despite clear care plan instructions and physician orders directing staff to monitor for and respond to respiratory changes and bleeding‑related signs and symptoms.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place readily available to residents, staff, and visitors, including the total number of RNs, LPNs, CNAs, and CMAs, the actual hours worked by each staff category, and the resident census. The facility reported a census of 34 residents. Survey observations on 4/19/26 at 9:20 AM, 3:00 PM, and 4:30 PM, and on 4/20/26 at 7:10 AM showed the posted staffing sheet was still dated Saturday, 4/18/26. The sheet was not observed updated until 4/20/26 at 9:25 AM, when it was dated Monday, 4/20/26. The DON stated the overnight nurse was responsible for updating the staffing sheet and that on 4/20/26 mid-morning she discovered it had not been updated because the overnight nurse did not have access to complete the staffing form. The Administrator acknowledged the staffing sheet should have been updated on 4/19/26. The facility's Nursing Staff Daily Posting Requirements stated the document would be posted daily at the beginning of each shift and updated as appropriate with the location name, current date, resident census, and total number and actual hours for RNs, LPNs, CNAs, and CMAs.
Food Storage and Hand Hygiene Lapses During Meal Service
Penalty
Summary
Food was not stored and handled in accordance with professional standards in the kitchen and dry storage areas. During an initial kitchen tour, surveyors observed an undated previously opened bottle of ranch dressing, an undated previously opened carton of liquid eggs, three opened undated and unlabeled clear bags of breaded meat products, two undated plastic cereal containers, a box of squash, sliced bread loaves, french fries, and potato taters stored on the freezer floor, and a case of six cans of chili con carne stored in the delivery carton on the floor in the dry goods storage room. The facility’s food storage policy stated that opened or prepared foods are to be enclosed, dated, labeled, and stored properly, and that all food and supply items are to be stored six inches off the floor. Meal service observations showed multiple staff members moving between residents and assisting with feeding without completing hand hygiene. During one dining room observation, staff assisted several residents at different tables, cut food, provided total feeding assistance, and moved from resident to resident without sanitizing or washing hands between contacts. One staff member picked up spilled food from the floor and placed it back on a resident’s plate, wiped the floor, touched the resident’s plate, and then assisted the resident with a drink by holding the glass by the rim. Another staff member entered the dining room and assisted residents after touching clothing, glasses, silverware, and other items without hand hygiene. A housekeeping/CNA also entered the dining room and sat at an assisted table without completing hand hygiene. Staff interviews and policy review confirmed the expectations for hand hygiene and food handling. The DON stated staff should label, date, and stock items correctly, and that staff should complete hand hygiene when moving between residents and after assisting with cleanup. The Administrator concurred that hand hygiene should be performed between residents. The facility’s hand hygiene policy stated that hand hygiene includes sanitizer or handwashing and is routinely monitored in patient care areas, and that it is the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document vaccination status. Clinical record review, policy review, pharmacist interview, and staff interviews showed that 5 of 5 residents reviewed did not receive COVID-19 immunizations for the 2025 year. Resident #9, Resident #10, Resident #12, Resident #14, and Resident #15 all had immunization records showing the last COVID-19 vaccine offer occurred in prior years or, for one resident, had not been offered since admission. The census was 34 residents. Resident records showed varying cognitive status, including severe and moderate impairment for several residents and no impairment for one resident. Staff V, the RN/IP, stated the facility usually offered the vaccine yearly, but could not find a declination or consent for Resident #9 and said COVID-19 vaccines were not given to residents unless they specifically requested them. Staff V also stated the facility did not get the 2025 guidelines and that the vaccine formulation had changed. The DON stated the facility did not administer the COVID-19 vaccine at all for 2025, explaining the vaccine was in-between formulary and that the pharmacy could not get the new vaccine. The DON acknowledged the vaccine should have been offered yearly if available. The facility policy stated residents should receive COVID-19 vaccination per CDC guidelines, and the CDC website cited in the report stated the 2025-2026 vaccine was especially important for adults age 65 and older, those at high risk for severe COVID-19, or those who had never received a COVID-19 vaccine.
Psychotropic Consent Forms Missing Behaviors and Non-Pharmacological Alternatives
Penalty
Summary
The facility failed to fully inform residents and/or their representatives of alternative psychotropic medication options by not identifying target behaviors or non-pharmacological interventions on psychotropic medication consent forms for 3 of 5 residents reviewed. The deficiency involved residents #4, #7, and #30, all of whom had psychotropic medications ordered and documented in the EHR, but whose consent forms did not consistently include the behaviors prompting the medications or the non-pharmacological alternatives attempted. Resident #4 had diagnoses of anxiety and depression, a BIMS score of 15 out of 15, and physician orders for an antianxiety medication three times daily and an antidepressant daily. The consent form documented education about the medications and side effects, but did not include the resident’s anxiety or depression-related behaviors or any attempted non-pharmacological alternatives. Resident #7 had severely impaired cognition, diagnoses of non-Alzheimer’s dementia, anxiety, and depression, and received antianxiety, antidepressant, and antipsychotic medications during the look-back period. Multiple psychotropic medication orders were documented, but the related consent forms did not include the resident’s sadness, depression, anxiety, or psychosis-related behaviors, nor the facility’s attempted non-pharmacological alternatives. Resident #30 had a BIMS score of 15 out of 15, diagnoses of anxiety and cognitive communication deficit, and orders for antidepressant and antianxiety medications. The consent forms documented education about the medications and side effects, but did not include the resident’s anxiety-related behavior or the facility’s attempted non-pharmacological alternatives. Staff interviews showed the Social Services Coordinator and MDS Coordinator were not aware that behaviors and attempted non-pharmacological alternatives had to be listed on the consent form, and the DON stated staff should have completed the consent form in its entirety. The facility policy required documentation of observations of mood, symptoms, or behaviors causing distress and/or endangering the resident or others, along with non-pharmacological interventions reflected in the care plan.
Soiled body pillow case left in use
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident who had an admission date of 7/31/20, a BIMS score of 15, and diagnoses of stroke, hemiplegia, and hemiparesis. The resident used a large u-shaped body pillow in bed because she was afraid she would fall out of bed. On 4/20/26, surveyors observed the pillow case on the body pillow had yellow and brown discoloration on both bottom sections, and the same discoloration was observed again on 4/21/26. During the 4/21/26 observation, staff turned the body pillow over and found discoloration on the other side of the pillow case as well. A CNA/CMA and the Environmental Service Director then removed a first pillow case that also had yellow and brown discoloration, revealing a second soiled pillow case underneath before a clean white pillow case was placed on the pillow. The resident stated she had not seen the pillow case removed and washed, and said staff moved the body pillow into her recliner when making the bed and then placed it back on the bed after linen changes. Staff stated the pillow case was supposed to be changed weekly with bed linens or when visibly dirty, and the DON stated it should be changed on shower day and if soiled between shower days. The facility policy required clean bed linens and removal of soiled linen from the resident's bed.
Failure to Document Behavior Triggers and Non-Pharmacologic Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 residents who received psychotropic medications. For Resident #4, the record showed diagnoses of anxiety and depression, intact cognition with a BIMS score of 15/15, and orders for an antianxiety medication three times daily and an antidepressant daily. The psychotropic medication consent form documented education about the medications and side effects, but it did not include the resident’s anxiety or depression-related behaviors or any attempted non-pharmacological alternatives. The care plan directed staff to attempt resident-specific nonpharmacological interventions, but it did not identify the resident’s behaviors for staff to monitor, and the progress notes and TAR documentation also did not identify the behaviors observed or the non-pharmacological interventions attempted. For Resident #7, the record showed severely impaired cognition with a BIMS score of 03/15, diagnoses of non-Alzheimer’s dementia, anxiety, and depression, and use of antianxiety, antidepressant, and antipsychotic medications in the look-back period. The chart included multiple psychotropic medication orders, including an antidepressant, an increased antidepressant dose, PRN antianxiety medication for restlessness, and an antipsychotic at bedtime. The consent forms documented education about the medications and side effects, but they did not include the resident’s sadness, depression, anxiety, or psychosis-related behaviors, nor did they document attempted non-pharmacological alternatives. The care plan included psychotropic medication use and directed staff to attempt nonpharmacological interventions for psychosis and depression, but it did not include anxiety behaviors, and the progress note for agitation/anxiety did not document attempted non-pharmacological interventions. For Resident #30, the record showed intact cognition with a BIMS score of 15/15, diagnoses of anxiety and cognitive communication deficit, and antidepressant use in the look-back period. The chart also included PRN antianxiety medication orders for agitation and anxiety. The psychotropic medication consent forms documented education about the medications and side effects, but they did not include the resident’s anxiety or depression-related behaviors or attempted non-pharmacological alternatives. The care plan included antidepressant medication use but did not identify anxiety-related behaviors or nonpharmacological interventions, and the progress notes and April 2026 TAR did not identify the behaviors to monitor or staff attempted non-pharmacological interventions. Staff interviews reflected that the Social Services Coordinator and MDS Coordinator were not aware that behaviors and attempted non-pharmacological alternatives had to be listed on the consent form, while nursing staff and the DON stated target behaviors and non-pharmacological interventions should be documented in the care plan and TAR.
Incomplete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for Resident #40 that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications. Resident #40's MDS documented a BIMS score of 15, indicating no cognitive impairment. Review of the EHR showed the discharge summary dated 2/20/26 did not contain the required recapitulation of stay, final status summary, or medication reconciliation. A faxed document dated 2/20/26 at 3:37 PM documented that the physician signed the discharge summary on 2/20/26, with the resident discharged at 1:00 PM. The DON stated on 4/23/26 that she expected the discharge summary to be completed after the resident's discharge and acknowledged that it was not completed with the required elements.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a PASRR for Resident #33 after the resident developed new mental health diagnoses and was receiving psychotropic medications. The resident’s clinical record showed diagnoses including non-Alzheimer’s dementia, depression, psychotic disorder, visual hallucinations, major depressive disorder, delusional disorder, and vascular dementia with mood disturbance. The record also showed orders for Risperdal, Sertraline, and PRN Lorazepam, and the care plan addressed hallucinations, accusations of missing items, and monitoring for antipsychotic medication side effects. The facility’s PASRR on file, completed on 10/4/22, identified no mental health diagnoses, no mental health services, no mental health medications, and no Level II requirement. Survey interviews confirmed staff knew the resident had current mental health diagnoses and psychotropic medications, and they acknowledged a new PASRR should have been completed when those diagnoses or medications were initiated. The DON stated the Social Services Director completed PASRRs, and the Social Services Director acknowledged she completed PASRRs when required but agreed the resident’s existing PASRR did not reflect the current mental health diagnoses or medications. The Administrator also acknowledged the facility did not complete a PASRR when a resident had a new mental health diagnosis and/or medication when the resident did not previously have one. The facility policy stated a new PASRR evaluation must be initiated when a resident is diagnosed with a mental disorder and that the state-designated mental health authority should be notified promptly when a resident experiences a significant change.
Incomplete Care Plans for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to develop personalized care plans that included resident-specific target behaviors and non-pharmacological interventions for 3 of 5 residents who received psychotropic medications. Resident #4 had diagnoses of anxiety and depression, a BIMS score of 15/15 indicating intact cognition, and orders for an antidepressant and an antianxiety medication. Although the care plan noted psychotropic medication use and directed staff to attempt resident-specific nonpharmacological interventions, it did not identify the resident’s anxiety or depression-related behaviors for staff to monitor or specify anxiety-related interventions. The April 2026 MAR showed the resident continued to receive both medications. Resident #7 had a BIMS score of 03/15, diagnoses of non-Alzheimer’s dementia, anxiety, and depression, and orders for an antidepressant, an antianxiety medication PRN, and an antipsychotic at bedtime. The care plan identified psychosis-related target behaviors and included psychosis and depression interventions, but it did not identify depression or anxiety-related target behaviors and did not include anxiety interventions. Resident #30 had a BIMS score of 15/15, diagnoses of anxiety and cognitive communication deficit, and an order for an antidepressant at bedtime for generalized anxiety. The care plan included antidepressant use but did not identify anxiety-related target behaviors or nonpharmacological interventions. Staff interviews reflected uncertainty about whether target behaviors and nonpharmacological interventions belonged in the care plan, and the DON stated they should have been included.
Failure to Cut Meat as Requested for a Resident Needing Meal Assistance
Penalty
Summary
The facility failed to ensure Resident #28’s ADL abilities were maintained or improved when staff did not cut the resident’s meat prior to serving, despite the resident’s care plan and family request. The resident’s MDS identified severe cognitive impairment with a BIMS of 4/16, independence with eating, and no upper or lower extremity range of motion limitations. The care plan directed staff to feed the resident after set up and to cut up all meat, and a care conference note documented the family’s request that the resident receive more assistance in the morning and night and that her meat be cut up at meals. During the noon meal observation, kitchen staff served the resident’s tray and walked away after placing the entree and dessert in front of her, without verbal interaction. The resident did not attempt to cut her meat, and the meat pieces on the plate were larger than 1.5 cm x 1.5 cm. The meal ticket did not reflect orienting the plate or cutting the meat before serving. Interviews showed the family member had requested the meat be cut because the resident’s vision was deteriorating, while the CDM, CNA, DON, and Administrator gave differing accounts of who was responsible for cutting food and orienting plates, and the DON and Administrator stated these meal-related needs should be identified on the tray card or meal card.
Failure to Perform Hand Hygiene During Toileting Care
Penalty
Summary
Appropriate toileting hygiene assistance was not provided for Resident #7, who had severely impaired cognition with a BIMS score of 03 out of 15 and diagnoses including non-Alzheimer's dementia, anxiety, diabetes mellitus, and need for assistance with personal care. The resident was frequently incontinent of bladder and bowel, required maximal assistance with toileting transfers, and was dependent with toileting hygiene. The care plan identified bladder incontinence and directed staff to assist with changing as needed or as requested, and it also noted the resident had a UTI on 4/02/26 and directed staff to assist with handwashing after toileting and before and after meals. During observation, a CNA transported the resident to the room, assisted her to the toilet, and while the resident urinated, handled a periwipe packet and paper towels. After the resident finished, the CNA wiped the resident's perineal area one time from behind and helped her dress, but did not perform hand hygiene or change gloves after touching objects in the resident's room and before wiping the resident's perineal area. The CNA stated she had received annual infection prevention education and acknowledged she may have needed to change gloves and perform hand hygiene after touching the resident's belongings and before providing peri care. The DON stated staff should have followed the policy, and the facility's hand hygiene policy required hand hygiene at key moments including before a clean task and after glove removal.
Oxygen Concentrator Set Above Ordered Flow Rate
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for Resident #14, who had diabetes mellitus, COPD, dependence on supplemental oxygen, shortness of breath with exertion, and shortness of breath when lying flat. The MDS showed the resident used oxygen while in the facility and during the last 14 days of the assessment period. The care plan directed staff to apply oxygen therapy at 2 lpm via nasal cannula continuously and to monitor for changes in orientation, increased restlessness, anxiety, and air hunger related to hypoxia. The physician's orders also directed oxygen via nasal cannula at 2 lpm continuous for dyspnea and hypoxia. During observations, Resident #14 was seen lying in bed or sleeping with oxygen via nasal cannula while the concentrator was set at 3 lpm on three separate occasions. The resident stated his oxygen order had recently changed from 2 lpm to 3 lpm. Staff interviews indicated the resident did not usually change his oxygen settings, and the DON stated the concentrator should be set at the lpm ordered by the physician and changed if it did not match the order. The facility's oxygen policy stated oxygen administration is carried out only with a medical order and that trained staff are responsible for proper administration of oxygen.
Failure to Report Alleged Resident-to-Resident Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents who were observed inappropriately touching each other. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer's disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with behavioral disturbance. On 12/20/26, a CNA (Staff H) observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other's pants. Staff H separated the residents, assisted Resident #2 back to his room, and reported the incident to the nurse (Staff A) and another nurse (Staff I). A progress note entered by Staff A documented that both residents were assessed for trauma and none was observed, and that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident. The Administrator later stated that he determined the incident was not reportable because both residents had documented dementia. He reported that, after speaking with Staff A, he understood the situation as the residents holding hands in each other's laps rather than having hands down each other's pants, and on that basis decided not to report the incident to the state agency or conduct a formal investigation. The Administrator acknowledged that he did not interview the CNA or nurse directly at the time and did not review available camera footage from the lobby for the date of the incident. The DON stated she was on vacation at the time, was only told there was an “incident” without details, and believed the Administrator handled the situation. She also stated she was not aware that Resident #2 had his hands down another resident’s pants and therefore did not report the incident to the state agency. Staff H consistently described the event as both residents having their hands in each other's pants or waistbands, possibly with Resident #1 holding Resident #2’s penis, and stated she knew it needed to be reported to the nurse for safety reasons. Staff G recalled being informed that Resident #2 was reaching toward Resident #1 but did not document the incident and did not convey specific details such as “hands in pants” to the DON. A subsequent progress note on the same day documented Resident #2 reaching to touch another resident and becoming combative when redirected. Both residents later told surveyors they felt safe, were treated with dignity and respect, and denied inappropriate touching, though both had cognitive impairment. Family members of both residents reported being notified of an incident in December involving inappropriate touching or hands in waistbands, but did not recall being told it was considered abuse. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be immediately reported to the Administrator and designated agencies within specified time frames, but the allegation involving Residents #1 and #2 was not reported to the state survey agency as required. The facility’s written policy on abuse and neglect specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be promptly reported and investigated, and that designated agencies, including the State Survey and Certification Agency, must be notified in accordance with state law. The policy further required immediate reporting of allegations of abuse or serious bodily injury, and reporting within 24 hours for other allegations, as well as documentation of notifications and review of incidents by an investigation team. Despite this policy, the Administrator and DON did not initiate or complete a formal abuse investigation or report the allegation to the appropriate state agency after being made aware, at least in part, of the incident between Resident #1 and Resident #2. This failure to follow the facility’s own abuse reporting and investigation procedures led to the deficiency for not timely reporting suspected abuse to the proper authorities.
Failure to Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately and comprehensively investigate an allegation of potential resident‑to‑resident sexual abuse involving two cognitively impaired residents. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer’s disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with other behavioral disturbance. On 12/20/26, a CNA (Staff H) reported to nursing staff that she observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other’s pants. The residents were separated, Resident #2 was taken to his room, and a nurse (Staff A, RN) documented that both residents were assessed for trauma with none observed. The RN’s progress notes also documented that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident, and that the Administrator stated the incident was not reportable because both residents had documented dementia. Additional documentation in Resident #2’s record on the same date showed that later that day Resident #2 was observed reaching to touch another resident and had to be redirected by a CNA, after which he hit staff and told them to leave him alone. Interviews with the involved CNA confirmed that she had seen the two residents with their hands in each other’s pants and that she believed Resident #1 might have been holding Resident #2’s penis, although she did not see movement. She reported that she separated the residents and informed the RN and an LPN. She also stated she did not see the nurses complete an assessment at that time and that she reported the incident to the nurse because of safety concerns and the possibility that Resident #2 might repeat the behavior. The Social Services Director recalled being informed of an incident involving Resident #2 reaching toward Resident #1 around the time before Christmas but stated she did not document the incident, did not clearly report that there were hands in pants, and could not recall the exact wording used when she notified the DON. The DON stated in interview that she had not been made aware that Resident #2 had his hands down another resident’s pants and acknowledged she had not completed an investigation into the reported incident documented on 12/20/25 between Resident #1 and Resident #2. She indicated that if she had been notified of such behavior, she would have come in and completed an investigation, including talking to residents and staff, and that she should have been informed. The Administrator reported that he spoke with the RN by phone and was told that the CNA initially thought the residents had their hands in each other’s pants but later believed they were holding hands in a lap, and based on that, he decided the situation did not warrant reporting or further investigation. He acknowledged that he did not interview the nurse or CNA in person, did not review available camera footage at the time of the incident, and concluded that no investigation was needed. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be reported immediately to the Administrator or designee, that the charge nurse complete an initial investigation, and that an investigation team review all incidents by the next working day. Despite this policy, no comprehensive investigation was initiated or completed in response to the CNA’s allegation that the two residents had their hands down each other’s pants. Interviews with both residents later indicated that each reported feeling safe at the facility, believed staff treated them with dignity and respect, and denied that other residents had touched them inappropriately or that they had touched others inappropriately. Family interviews showed that Resident #2’s son was informed of an incident of inappropriate touching between the two residents and considered it inappropriate but did not view it as abuse, and Resident #1’s daughter recalled being told of an incident described as the residents holding hands or having hands in each other’s waistbands. However, these later perceptions and characterizations did not change the fact that the original CNA report described hands down each other’s pants and that the facility’s own policy required immediate reporting and investigation of such allegations. The failure to follow the abuse policy, to fully clarify and document the allegation, to interview all involved staff promptly, and to conduct a comprehensive investigation into the reported incident constituted the deficiency. The facility’s written abuse and neglect policy, revised 7/6/23, specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be reported immediately to the Administrator and, in the Administrator’s absence, to designated leaders such as the DON or Social Services Director. The policy required the charge nurse to assess the situation, determine if emergency treatment or action was required, complete an initial investigation, and ensure that any potential for further abuse was eliminated. It also required timely notification of designated agencies, the physician, and family, and mandated that an investigation team (social worker, Administrator, and DON) review all incidents no later than the next working day. In this case, despite a documented allegation that two residents with dementia were observed with their hands down each other’s pants, the DON was not fully informed, the Administrator decided the incident was not reportable without a thorough fact-finding process, and no formal investigation consistent with policy requirements was conducted. The DON later acknowledged that she should have been informed and that an investigation should have been started if such an incident occurred. The Administrator acknowledged that if the residents had indeed had their hands down each other’s pants, it would have been a different situation, but he relied on a second-hand clarification that the residents were only holding hands in a lap and did not pursue further inquiry. No contemporaneous documentation by Social Services was made, and there was no evidence that the investigation team convened or that a structured review of the incident occurred by the next working day. This sequence of actions and inactions—failure to clearly communicate the nature of the allegation up the chain of command, failure to follow the facility’s abuse reporting and investigation policy, and the Administrator’s decision not to investigate further—led to the deficiency for not completing a comprehensive investigation immediately when an allegation of abuse was reported for Resident #1.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to establish and implement effective interventions to prevent falls and injuries for two residents with known fall risks. One resident with severe cognitive impairment and a history of multiple falls experienced repeated incidents involving wheelchair pedals. Despite documentation in the care plan and fall scene huddle worksheet that the resident had tripped on wheelchair pedals, staff did not consistently remove the pedals when not in use, as was indicated as a corrective action. This resident suffered multiple falls, including one that resulted in a head injury and subsequent admission to hospice care due to traumatic cerebral hemorrhage. Observations and staff interviews confirmed that the pedals were left on the wheelchair, and staff were not always able to supervise or intervene in time to prevent falls. Another resident with moderately impaired cognition and a history of falls, including fractures, experienced a fall that was not properly documented or investigated. The care plan lacked documentation of the fall and any new interventions following the incident. Progress notes described the fall and the resident's uncooperative behavior, but there was no incident report, falls tool assessment, or fall scene huddle worksheet completed for this event. The DON acknowledged that the fall was missed in documentation and that the incident was not fully assessed or followed up according to facility policy. Facility policy required prompt assessment, documentation, and investigation of falls, including completion of a fall scene huddle worksheet, falls tool, and care plan updates with new interventions. In both cases, the facility did not follow its own policy for fall prevention and management, resulting in missed opportunities to identify root causes and implement effective interventions to prevent further accidents.
Failure to Measure and Portion Pureed Foods Correctly
Penalty
Summary
Staff failed to provide a well-balanced diet that meets the nutritional and special dietary needs of residents by not using correct serving size portions for meals. During meal preparation, staff pureed brownies, green beans, and ham and beans, adding thickener as required, but did not measure the pureed food before serving. The pureed items were placed into serving bowls or onto the steam table without determining the correct portion sizes. Staff A indicated that extra servings were made, but there was no measurement of the pureed food to ensure each resident received the appropriate amount. Interviews with the Food and Nutrition Supervisor and the Administrator confirmed that the expectation was for pureed foods to be measured after blending to ensure correct scoop sizes and portion control. Review of the facility's policy on textured-modified diets also specified that the total volume of pureed food should be measured and divided by the original number of portions to ensure accuracy. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Safe Food Handling and Hand Hygiene Practices
Penalty
Summary
Staff was observed failing to follow safe food handling practices during meal service. Specifically, one staff member touched various surfaces including plate warmer lids, menus, scoop handles, and their own clothing, then proceeded to handle food items in the warmers with bare hands. The staff member also placed the scoop on top of the lids of the warmer pans after use and touched multiple items between serving food from the steam table. Facility policy requires all employees to maintain adequate hand hygiene by adhering to specific infection control practices, which was not followed in this instance.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control practices for three residents. One resident with a stage 4 pressure ulcer on the sacral region was transferred using a mechanical lift sling after the dressing and packing were removed by CNAs, leaving the wound open and exposed. The wound bled during the transfer and soiled the sling, and the resident was taken to the shower with the wound still open and in contact with the soiled sling. The dressing was not dated and was soiled prior to removal. The wound was left open throughout the shower, and the sling remained soiled with blood. The treatment nurse later provided wound care but failed to perform hand hygiene after removing gloves and before leaving the room. Another resident with an enteral feeding tube received medication and water administration from an RN who initially performed hand hygiene and donned appropriate PPE. However, after changing the split sponge and removing gloves, the RN applied tape to the split sponge without gloves and only performed hand hygiene after removing the gown and leaving the room. The DON confirmed that gloves should have been used during all care involving the enteral tube. A third resident with a suprapubic catheter had care performed by two CNAs who did not cleanse the catheter tip before replacement and allowed the catheter bag to rest on the floor. During the care process, hand hygiene was not performed between glove changes or when moving from one area of the body to another. One CNA left the room and began care for another resident without performing hand hygiene. Facility policy required hand hygiene at specific moments, including after glove removal and when moving between contaminated and clean body sites.
Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident with moderate cognitive impairment and total dependence on staff for activities of daily living, including personal hygiene. According to the resident's care plan, staff assistance was required for oral care, shaving, and grooming. A review of the clinical record and Point of Care documentation over a 30-day period showed no evidence that oral care was provided to the resident during that time. Additionally, when the resident was admitted to the hospital, he was found to have crusty skin at the corners of his mouth and a yellow film buildup in his mouth and on his teeth. During an observation, staff were unable to locate the resident's toothbrush in the bathroom and only found one in a dresser drawer after searching. Staff interviews revealed uncertainty about the location of the resident's oral care supplies. The DON stated that staff were expected to set up the toothbrush and encourage the resident to brush his own teeth, with documentation required in the electronic medical record. Facility policy also required documentation of oral care in the electronic record.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident who was identified as a smoker with intact cognition, the care plan specified that cigarettes and a lighter should be stored at the nurse's station. However, observation revealed the resident kept the lighter in her pocket after smoking, and staff interviews indicated inconsistency in the storage of smoking materials, with some staff stating items should be kept in room lockboxes instead. The Director of Nursing expected the lighter to be stored at the nurse's station, but this was not consistently followed. For another resident with moderately impaired cognition and a history of depression, anxiety, and dementia, the care plan addressed antidepressant use but did not include documentation or interventions for suicidal ideation, despite a recent incident where the resident expressed a desire to kill herself and was sent to the emergency room for evaluation. Upon return, new medication orders were implemented, but the care plan was not updated to reflect interventions for suicidal ideation. The Director of Nursing confirmed that the care plan was not implemented for the interventions related to the resident's suicidal ideation.
Medication Left at Bedside Without Assessment or Order
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a prescribed medication, Nystatin mouth and throat suspension, at a resident's bedside for self-administration without direct supervision. The resident, who had no cognitive impairment as indicated by a BIMS score of 15 and received medications via an enteral feeding tube, was observed to have the medication left at the chair side table to take later. The nurse exited the room and closed the door, leaving the resident to self-administer the medication without nurse visualization. Review of the resident's records showed there was no assessment for self-administration of medications, no care plan reflecting permission for self-administration, and no provider order authorizing this practice. Facility policy required an interdisciplinary team assessment, a care plan, and a provider order for self-administration of medications, none of which were present in this case. The Director of Nursing confirmed that the required assessment and documentation were not completed for this resident.
Improper Administration of Enteral Medications via Feeding Tube
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the administration of medications via a feeding tube for a resident with a PEG tube. The resident, who was cognitively intact as indicated by a BIMS score of 15, required tube feeding and received medications through the enteral tube. During observation, a registered nurse used a piston syringe to slowly push medications and water into the resident's enteral tube, rather than administering them by gravity as outlined in the facility's policy. The nurse stated that medications were not given by gravity due to resistance in the tube, and that the resident preferred a light push during administration. The Director of Nursing confirmed that the facility's policy did not specify that pushing medications was acceptable practice and acknowledged that this method was not included in the resident's care plan. The policy reviewed indicated that medications should be administered slowly and steadily, with the flow rate determined by the elevation of the syringe, not by pushing. The deviation from policy and lack of care plan documentation for the resident's preferred method led to the deficiency.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents with significant skin integrity issues. One resident with moderate cognitive impairment and total dependence on staff for care had a Stage II pressure ulcer on the right buttocks and an unstageable ulcer on the left heel. Despite physician orders for a Mepilex dressing to be applied and changed every three days, the resident was observed without the required dressing, and staff acknowledged the omission. Documentation showed inconsistencies, with the treatment marked as completed earlier that day, but the dressing was not present during the observation. The resident's history included recent hospitalization for pneumonia, UTI, and pressure injuries, with conflicting accounts from facility staff regarding the presence of wounds prior to hospital transfer. Another resident, also with moderate cognitive impairment and multiple comorbidities including malnutrition and COPD, had a Stage IV pressure ulcer on the sacrum. This resident was bedfast, incontinent, and dependent on staff for all mobility and hygiene. During care observations, staff failed to document and measure three additional areas of skin breakdown on the resident's legs, and the primary wound dressing was found to be soiled, undated, and improperly removed by a CNA rather than a nurse. The wound was left open during a shower and exposed to a soiled lift sling, contrary to best practices. Review of treatment records revealed multiple missed or undocumented wound care treatments as ordered by the physician. Facility policy required daily and weekly wound documentation and monitoring for residents with impaired skin integrity, but this was not consistently followed. The lack of proper documentation, failure to apply and maintain ordered dressings, and missed wound care treatments contributed to the deficiency. The facility did not ensure that residents with pressure ulcers received necessary care to promote healing, prevent infection, and prevent new sores from developing, as required.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, distribution, and storage of food, as observed during a survey. On multiple occasions, the kitchen's refrigerator/freezer was found to have a black fuzzy area, and the refrigerator contained uncovered and undated food items, including a gallon of milk and packages of pizza. The walk-in dry goods pantry had empty cardboard boxes and condiment packages on the floor, and the walk-in refrigerator contained strawberries with a white fuzzy appearance. These observations indicate a lack of proper food storage and sanitation practices. Additionally, during meal preparation, staff failed to follow proper hand hygiene and glove use protocols. A cook was observed handling food with improper glove use, touching his face, and placing dirty gloves on the food preparation counter. The Dietary Manager acknowledged the issues with the refrigerator cleanliness and the improper handling of gloves, which contradicted the facility's policies on hand hygiene and general sanitation. These actions and inactions contributed to the deficiency in maintaining sanitary conditions in food preparation and storage areas.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to three residents, as identified through clinical record review, resident interviews, observations, staff interviews, and policy review. Resident #31, who was cognitively intact and independent with eating, reported that baked potatoes were served raw and food was not always warm. Observations on June 30, 2024, showed that room trays were left on a cart for extended periods before delivery, resulting in food temperatures that did not meet safety standards. Specifically, the coleslaw was served at 72.8 degrees and the pulled pork sandwich at 106 degrees, both outside the acceptable temperature range. The Dietary Manager acknowledged that room trays should not sit for over 10 minutes before delivery and suggested using Styrofoam containers to maintain cold food temperatures. Resident #30, also cognitively intact, reported that food was frequently served cold, at least once a week, and noted that she ate every meal in her room. Resident #40, with no cognitive impairment, stated that the pork sandwich was not hot and the coleslaw was not cold during lunch on June 30, 2024. The facility's policy on food temperature monitoring required that temperatures be retaken periodically throughout meal service to ensure food safety, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. In one instance, a resident with an indwelling catheter was observed with the catheter drainage bag improperly positioned on the wheelchair frame and the tubing lying on the floor. The resident, who had moderately impaired cognition and required supervision with toileting hygiene, relied on staff for catheter care. During a catheter care observation, staff members failed to perform hand hygiene and change gloves after emptying the urine collection bag, and one staff member placed alcohol wipe packets on the floor before use. In another instance, a resident with a surgically placed supra pubic catheter was observed during catheter care. Staff members failed to perform hand hygiene after glove removal and before resuming resident care tasks. The facility's hand hygiene policy required hand hygiene after glove removal, before and after resident care, and when entering or exiting a resident's room. However, staff did not adhere to these guidelines, as evidenced by one staff member who removed gloves, opened a door, and walked to the nurse's station before completing hand hygiene.
Failure to Update Daily Nursing Staffing Data
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a survey. On two consecutive days, the posted staffing information was outdated, displaying the date of June 29th, 2024, instead of the current date. This discrepancy was noted on June 30th and July 1st, 2024. The Director of Nursing (DON) acknowledged that the responsibility for updating the staffing sheet lay with Staff H, an LPN and Wound Nurse. The DON expressed an expectation that the Daily Staffing Form should be updated daily, with the possibility for overnight nurses to print it as well. The facility's policy, revised on February 28th, 2024, mandates the daily posting of current staffing data, including the number and hours worked by various nursing staff and the resident census, incorporating registry and pool staff members.
Failure to Notify Family of Resident's Bruise
Penalty
Summary
The facility failed to notify the family of a resident when a bruise developed. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. The resident required substantial staff assistance with bed mobility and used a repositioning/turn sheet. On 11/5/23, a large purple bruise was documented on the resident's right thigh by a registered nurse (RN). However, there was no documentation that the family was notified about the bruise at that time. The following day, a licensed practical nurse (LPN) noted the resident's condition had declined, and the resident's daughter was informed, but the initial bruise was not mentioned in the notification. Interviews with the resident's family revealed that they were aware of the resident's pain and possible bruising on 11/5/23, but they were not officially notified by the facility. Staff interviews indicated that the RN who documented the bruise could not recall notifying the family, and the LPN who noted the resident's decline also could not remember specific details about the notification process. The Director of Nursing (DON) confirmed that family should be notified of new skin concerns but acknowledged that the facility did not have a specific policy or procedure related to family notification.
Failure to Timely Report Bruising on Resident
Penalty
Summary
The facility failed to notify management in a timely manner when a resident was found to have a bruise on her right hip/thigh. The bruise was first documented by a Registered Nurse (RN) on 11/5/23 at 10:35 AM, but management was not notified until 11/6/23. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. She required substantial staff assistance with bed mobility and used a repositioning/turn sheet. The bruise was described as large, purple, and painful to touch. The family provided photos showing extensive bruising on the resident's right hip and thigh, which were taken on 11/6/23 at 8:33 AM. Staff interviews revealed that the Licensed Practical Nurse (LPN) who documented the resident's condition on 11/6/23 could not recall seeing the bruising earlier and was unsure if she had reported it to management. The RN who first documented the bruise suggested it might have been caused by the mechanical lift used for the resident. The Director of Nursing (DON) stated she was notified of the bruising on 11/6/23 but did not see it herself as the resident was being sent to the emergency room. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin to the Administrator or designated individuals, which was not followed in this case.
Failure to Supervise Medication Administration
Penalty
Summary
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. Resident #3, who had a BIMS score of 4 indicating severe cognitive impairment, was observed with a medication cup containing TUMS on two separate occasions. The resident's care plan did not include an order for self-administration of medications, and no Self-Administration of Medication assessment had been completed for her. The resident's son also reported finding multiple pills in a medication cup during his visits, which he brought to the attention of the DON, who assured him that she would address the issue with the staff. The DON confirmed that staff should watch residents take their medications unless there is an order for self-administration. Despite this, the DON acknowledged that she had not had issues with staff leaving medications in residents' rooms for them to take later, nor had she received complaints from family members. The Administrator also noted that while he had not noticed medications being left in resident rooms recently, it had been an issue in past surveys. The facility's policy on Resident Self-Administration of Medication outlines a detailed procedure to determine if a resident can safely self-administer medications, including obtaining a physician's order and documenting the process in the care plan. However, this procedure was not followed for Resident #3, leading to the deficiency observed by the surveyors.
Failure to Timely Assess and Intervene for Resident's Bruise
Penalty
Summary
The facility failed to assess and intervene timely for a bruise on a resident's right thigh. The resident, who had no cognitive impairment and was dependent on staff for mobility due to a stroke, reported pain and bruising to her family on a visit. The bruise was first documented by a Registered Nurse (RN) on 11/5/23, but there was no follow-up documentation or assessment of the bruise in the clinical records or hospice notes. The resident's condition declined, and she was sent to hospice care the following day, where significant bruising was noted by a Licensed Practical Nurse (LPN). The family provided photos showing extensive bruising of varying colors, indicating different stages of healing. Interviews with staff revealed that the bruise had been present for about a month before the resident's passing, and multiple Certified Nursing Assistants (CNAs) had reported the bruise to nurses, who did not document or assess it further. The Director of Nursing (DON) and the Administrator acknowledged that incidents should be reported and investigated promptly, and skin assessments should have been conducted regularly. However, this protocol was not followed, leading to a lack of timely intervention and documentation for the resident's bruise.
Failure to Notify Hospice of Resident's Bruising
Penalty
Summary
The facility failed to notify the hospice provider when they found a bruise on a resident's right hip and thigh. The resident, who had no cognitive impairment and required substantial assistance with mobility due to a stroke, was found to have a large purple bruise on her right thigh that was painful to touch. This bruise was documented by a registered nurse, but there was no subsequent documentation indicating that hospice was notified about the bruise. The resident's family provided photos of the bruising, which showed extensive discoloration on her hip and thigh. Despite the severity of the bruising, the hospice coordination notes revealed no record of the hospice being informed about the bruise. Interviews with staff and the hospice nurse indicated a lack of communication regarding the resident's condition. The hospice nurse was aware of bruising on the resident's lower leg but not on her hip or thigh. The registered nurse who documented the bruise suggested it might have been caused by the mechanical lift used for transfers but did not confirm notifying hospice. The Director of Nursing stated that hospice would not need to be notified if there was no change in the resident's condition. However, the facility's agreement with the hospice provider required regular and as-needed communication to ensure resident needs were met, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Red Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Red Oak Rehab And Care Center | 0.9 mi | ★★★★★ | 8 | 0 |
| Accura Healthcare Of Stanton | 7.4 mi | ★★★★★ | 1 | 0 |
| Good Samaritan - Villisca | 14.3 mi | ★★★★★ | 12 | 0 |
| Griswold Rehabilitation & Health Care Center | 15.5 mi | — | 0 | 0 |
| Accura Healthcare Of Shenandoah | 20 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.