Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony House Health Care Center during CMS and state inspections, most recent first.
Cold food and milk were not kept at safe temperatures or served promptly. A cook placed room trays on a half wall with the food exposed to open air and left a half-gallon of milk out without ice; a CNA then poured and served the milk to a resident even though it later measured 53 degrees. A resident who received one of the trays said breakfast was cold, and the Administrator stated the milk was not at the correct temperature and should not have been served.
Unsanitary food handling and storage practices: A cook licked her thumb, failed to perform hand hygiene, and served bacon with her hands instead of tongs while preparing resident meals. Kitchen observations also found dirty dry storage floors, food particles on bins, and food boxes stored on the floor, with staff and the Administrator acknowledging the improper handling and storage practices.
Infection control and EBP were not consistently followed during wound care and incontinent care for multiple residents. An agency RN and CNA handling a resident with severe cognitive impairment and multiple pressure ulcers repeatedly touched wound supplies with contaminated gloves, changed gloves without consistent hand hygiene, and used a wipe multiple times during bowel care; an agency LPN caring for a resident with a stage 4 pressure ulcer used unclean scissors and did not perform hand hygiene between glove changes; and a CNA caring for a ventilator-dependent resident wore a gown incorrectly during personal care.
A resident who was NPO with all nutrition provided via enteral tube feeding experienced significant, unexplained weight loss while the facility failed to follow care plan interventions and its change-in-condition policy. The resident had multiple chronic conditions, including muscular dystrophy, diabetes, and malnutrition, and was ordered tube feedings several times per day, but frequently refused scheduled feedings without consistent notification to the physician or RD as expected. The facility reduced the tube feeding frequency from five times to two times per day, substantially lowering daily intake, without documented physician orders or indication and without informing the RD. Weight records showed a marked decline over time, while the RD later reported not being notified of the refusals or the feeding reduction, and the facility’s policy requiring consultation and notification for significant status changes and treatment alterations was not followed.
The facility failed to respond promptly to resident call lights and an essential medical alarm, resulting in repeated, prolonged delays in assistance. One resident with impaired cognition, myotonic muscular dystrophy, diabetes, and malnutrition experienced multiple call light waits ranging from about 18 minutes to over an hour, despite a care plan requiring assistance with ADLs and ready access to the call light. Another cognitively intact resident, dependent for toileting and transfers and diagnosed with DM2, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, reported staff turned off her call light and left after she had waited over an hour, and call light logs showed numerous waits of 30–50+ minutes, including one lasting nearly 2 hours. A third cognitively intact resident with DM, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, at risk for falls and with bladder incontinence, reported having a call light on for 2 hours without response and needing a roommate to press the call light because hers was out of reach; logs showed waits of 36 and 51 minutes. Additionally, a resident dependent on tube feeding had a feeding pump alarm sounding continuously for close to an hour while multiple staff, including housekeeping, other staff, the DON, and an LPN, did not respond until prompted by a surveyor, and the facility lacked a written policy on timely call light response.
Staff failed to consistently communicate with residents in a dignified and respectful manner. One resident with a tracheostomy and intact cognition reported that an RT performed suctioning roughly, instilled saline while he was talking causing choking and gagging, and then spoke in a mocking way about his complaint in the hallway within his hearing. Another resident with myotonic muscular dystrophy and chronic respiratory failure, who used a communication board, was not care planned for impaired communication and was brought to tears when an RT entered the room and spoke in a rude tone asking what was wanted. A third resident with severe cognitive impairment and traumatic brain injury was observed waiting in a wheelchair for a bath when a staff member mimicked his exhalation and made sarcastic remarks about how terrible life was, rather than interacting respectfully.
A cognitively intact resident with paraplegia, seizure disorder, respiratory failure, malnutrition, MDD, antisocial personality disorder, and PTSD alleged physical abuse by a respiratory therapist. Although staff reported promptly notifying leadership and obtaining written statements, the facility’s investigation file contained only limited, unsigned statements and lacked the original witness and resident statements, as well as documentation of additional resident and staff interviews that were later identified. Despite concluding there was no evidence to support the allegation, the facility failed to maintain complete, signed documentation and supporting materials as required for a thorough abuse investigation under its own policy.
The facility failed to ensure medications were administered and documented as ordered for multiple residents with complex neurological, respiratory, and systemic conditions. One resident with a seizure disorder and tube feeding had repeated undocumented or missed doses of Keppra, Baclofen, and famotidine over two months, confirmed by MAR gaps and medication event reports. Another resident with TBI, quadriplegia, and a trach had missing documentation for scheduled ipratropium‑albuterol treatments and was found with morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they were not given by agency staff. A third resident with myotonic muscular dystrophy, diabetes, and malnutrition had MAR entries showing bedtime medications as given, but staff later discovered Midodrine, Eliquis, escitalopram, and quetiapine doses still in the card. Staff interviews and documentation confirmed that nurses found medications not given on prior shifts, and leadership acknowledged MAR gaps and the absence of a policy guiding medication administration.
The facility failed to ensure that dependent residents received regular baths or showers as outlined in their care plans and facility policy. One cognitively intact resident with multiple serious medical conditions reported not receiving showers for a week, and records for the month showed only one documented shower and one refusal. Another resident with impaired decision-making, myotonic muscular dystrophy, diabetes, and malnutrition had only one shower documented for the month, with several days left blank and several days noted as no shower given, despite a care plan requiring assistance with bathing and a stated preference for bed baths. Staff interviews linked missed showers to reduced staffing ratios, and the DON acknowledged that completion of baths and showers needed improvement, despite an expectation of twice-weekly bathing and a policy requiring EHR documentation.
Two residents experienced significant changes in condition that were not promptly recognized or reported to a provider. One resident with atrial fibrillation and functional dependence returned from a CT scan, after which the guardian reported possible lung blood clots; a nurse documented low pulse ox requiring O2 but did not immediately notify a provider, and treatment for a confirmed PE was delayed for two days. Another resident with paraplegia, seizure disorder, CAD, and respiratory failure had two prolonged unresponsive episodes with abnormal respirations during transfers, followed by recurrent dizziness and a BP of 60/40 with position changes; these events were not documented by nursing, no timely physician notification occurred, and the care plan lacked interventions for orthostatic hypotension or unresponsive episodes.
A resident with intact cognition but a history of TBI, aphasia, and seizure disorder was care planned as a dependent smoker requiring staff assistance to designated smoking areas and supervision while smoking, and had an elopement risk score indicating a risk to wander. The facility failed to complete required annual updates to the resident’s smoking and elopement risk assessments and did not perform any additional assessments after the initial ones. On one occasion, a nurse took the resident outside, lit a cigarette, and then left the resident unattended, contrary to the Care Plan and the facility’s smoking policy, which required supervision for dependent smokers. The incident was reported via a grievance, but there was no corresponding documentation in the resident’s EHR describing the occurrence.
The facility failed to follow physician orders and ensure complete documentation for tube feeding care for two residents. One resident with neurological impairments and dysphagia, dependent on G-tube feeding and NPO, had multiple undocumented enteral feedings, water flushes, residual checks, and pre- and post-medication water administrations across several shifts, with staff acknowledging awareness of missed feedings and incomplete audits. Another resident dependent on tube feeding for hydration had no ordered water flush amount on the MAR for medication administration; during an observed med pass, an RN relied on the DON’s statement of a "standard" 60 cc flush before and after medications, despite no written order and no clear facility policy guiding medication administration via feeding tube.
A resident with intact cognition, multiple medical and psychiatric diagnoses, and a history of substance overuse was admitted to hospice with an order for lorazepam concentrate 2 mg/mL at 0.25 mL every 2 hours PRN for anxiety or restlessness. An MDS coordinator, who was also working as a floor nurse, transcribed the order into the EHR as 0.5 mL every 2 hours PRN without a second-nurse double-check and later administered 0.5 mL, which was later identified as an incorrect dose. The MAR showed multiple administrations of lorazepam under this incorrect order by various staff, and the facility could not produce a controlled substance log for the lorazepam, despite leadership expectations that such a log be initiated and completed with each administration and the absence of formal written medication administration policies beyond the general "6 rights."
A resident on hospice with paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia had comfort-medication orders for low-dose morphine and lorazepam concentrates. When these orders were entered into the EHR, the morphine dose was incorrectly transcribed as 2 mL q2h PRN instead of 0.25 mL, and the lorazepam dose was doubled to 0.5 mL q2h PRN. Nursing staff then administered morphine and lorazepam according to the erroneous MAR, including a documented 2 mL morphine dose and multiple 0.5 mL lorazepam doses, while a narcotic log for lorazepam was not found. One RN reported feeling rushed and not having a second nurse double-check the transcription, and another RN administered the higher morphine dose without first verifying against the controlled substance log, discovering the discrepancy only after the medication was given.
A resident with moderate cognitive impairment and anticoagulant use reported that staff grabbed his arms and pulled him from bed, leaving dark bruises on both forearms. Staff observed the bruising, but the allegation was not documented or escalated to the Administrator, and the report was not made to the State agency within the required timeframe. The Administrator stated she was not informed of the claim, and the facility’s abuse policy required immediate reporting of alleged abuse and bodily injury.
Failure to Thoroughly Investigate Alleged Abuse: A resident with moderate cognitive impairment, mobility dependence, and anticoagulant use reported that staff grabbed his arms and caused bruising to both forearms. Staff gave inconsistent accounts, the administrator was not initially informed, and the resident later stated the staff had done it again and that he feared the staff who transferred him.
A resident with hemiplegia and limited mobility, who communicated needs by moving his right foot, did not have his call light within reach as required by facility policy. Observations and staff interviews confirmed the call light was not consistently positioned by the resident's right foot, and care documentation lacked instructions for proper placement.
Two residents were not properly notified when their Medicare Part A SNF coverage ended and they remained in the facility, as the required SNF Advance Beneficiary Notice of Non-Coverage (ABN) was not provided. Although the NOMNC was given, documentation and staff interviews confirmed that residents were not informed of their financial responsibility for continued services, and the facility lacked a policy for such notifications.
Respectful Care and Resident Dignity Not Maintained: Staff told one resident with intact cognition to leave the dining room while she was talking with another resident and used disrespectful language when she asked for help. Staff also directed another resident with moderate cognitive impairment to get out of bed and go to the meal despite his refusal, and the resident reported being pulled from bed and having bruises on both forearms. Interviews showed inconsistent staff understanding of the resident’s rights and transfer guidance.
Failure to Prevent Abuse During Resident Transfers: A resident with moderate cognitive impairment, dependence for transfers, and anticoagulant use reported that staff pulled him from bed by his arms during transfers, causing bruising to both forearms and wrists. Therapy had directed use of a standing mechanical lift with 2 staff for all transfers, but staff interviews showed inconsistent understanding of the transfer method and no clear explanation for the resident’s multiple bruises and skin tears. The resident stated he feared the staff involved and said they did it again after he told them not to.
A resident with an existing positive PASRR Level 1 later received a new bipolar dx, but the facility did not resubmit PASRR for review. The SSD said she was unaware of the new dx, and the facility’s PASRR policy stated that new or updated dxs and psychotropic med changes should be discussed in daily IDT mtgs and that SS would update PASRRs as needed.
Failure to Follow Positioning and Splinting Care Plans: Two residents with significant mobility and cognitive impairments were observed without ordered splints, braces, or a chest harness during scheduled use. One resident’s OT-directed splints and braces were repeatedly not in place despite care plan instructions and posted reminders, while the other resident’s chest harness was missing or not applied properly on multiple occasions, with staff expressing uncertainty about the required use and a recent wheelchair fall documented.
A resident with moderate cognitive impairment, COPD, and gait/mobility deficits had a care plan that was not updated to reflect PT/OT transfer recommendations. Staff used an outdated paper resident list that identified him as a 1-assist for cares and transfers, while other staff described using a gait belt or stand-and-pivot methods instead of the standing mechanical lift recommended for all transfers. The resident reported staff pulled him from bed by his arms and showed bruising to his forearms and wrists.
A CNA repositioned a resident with intact cognition and significant mobility impairment when the resident’s head struck the siderail. The resident later reported a headache, and the LPN said she did not learn of the incident until hours later when the resident called the facility and told the DON herself. Staff interviews showed the CNA did not promptly report the event to the nurse, which delayed the resident’s assessment.
Failure to maintain heel offloading and secure dressing: A resident with paraplegia, diabetes, and a stage 3 L heel pressure ulcer was observed sitting in a wheelchair without the ordered pressure-relieving boot and with the heel resting on the wheelchair calf support. The resident also had an unsecured heel bandage at times. Staff interviews confirmed the boot was not consistently applied, despite the care plan and MD order for heel floating and continuous use of the pressure-relieving boot until healed.
A resident with moderate cognitive impairment, cerebral palsy, mild ID, and a manual wheelchair fell when staff adjusted the recline of the wheelchair while the resident was not wearing the ordered chest harness. Therapy repeatedly documented the resident seated without the harness, noted the strap was missing, and nursing staff were aware of the issue. Staff interviews showed confusion about whether the harness was required, and the incident note documented the wheelchair tipped forward and the resident slid to the floor without injury.
Infection control failures occurred during peri care, wound care, and blood exposure cleanup. A CNA changed gloves during peri care for a resident with an indwelling catheter but did not perform hand hygiene, an RN placed scissors on bed linen and then used them for wound dressing care without disinfecting them, and staff moved a mechanical lift and shower chair out of a room after they were contaminated with blood without sanitizing the equipment. Blood-contaminated items were also placed into clear bags and sent to regular trash and laundry carts.
The facility did not consistently answer call lights within the expected timeframe, as shown by call light system data and resident interviews. Several residents, including those with both intact and impaired cognition, experienced significant delays—sometimes over an hour—before staff responded to their requests for assistance, despite facility policy requiring timely response.
A cook at the facility was observed preparing and serving food without washing hands and using the same glove to handle multiple food items, contrary to FDA 2022 Food Code guidelines. This improper technique affected several residents during meal service. The CDM expected staff to use tongs and avoid touching food with contaminated gloves, but the facility lacked a specific food handling policy.
A facility failed to provide adequate PPE for a resident in COVID-19 isolation, leading to improper use by staff. A resident with severe cognitive loss and multiple health conditions was placed in isolation, but staff lacked sufficient face shields, resulting in inadequate eye protection. Staff interviews revealed inconsistencies in PPE protocol understanding. Additionally, clean laundry was transported uncovered, and a contaminated fan blew onto clean clothes, indicating gaps in infection control practices.
The facility failed to treat residents with respect and dignity, as evidenced by a resident being left without sheets and staff using loud voices and profanity in the presence of residents. A CNA initially dismissed a resident's concern about missing sheets, later assisting without further communication. Additionally, staff were reported to have used profanity near residents, making them uncomfortable.
The facility did not ensure that a Registered Nurse held a current and valid license, as required by state laws. Staff F continued to work in nursing roles after their license expired, which was not detected due to an oversight in the facility's license tracking system. The Administrator and DON acknowledged the lapse, and Staff F admitted to missing the renewal notification.
Cold food and milk served without proper temperature control
Penalty
Summary
The facility failed to ensure cold food items were maintained at or below 40 degrees Fahrenheit and served immediately. On 5/12/26, Staff A, Cook, dished up four room trays and placed them on a dining room half wall in front of the steam table. The trays were on foam plates with another foam plate used as a cover, leaving the sides of the food exposed to open air. A half-gallon of milk was also left next to the trays without an ice bath or other temperature control. Staff A instructed a nurse to call staff to pick up the room trays, and at 8:47 AM Staff B, CNA, poured a glass of milk from the half-gallon and took it with a tray to a resident's room. At 8:48 AM, Staff A checked the milk temperature and found it was 53 degrees Fahrenheit, and stated the milk should not have been used. An observation at 9:10 AM showed the last room tray being delivered to Resident #13's room. At 9:15 AM, Resident #13 stated the breakfast was cold, but it usually is, so it wasn't the best. Staff A later stated room trays are to be announced to CNAs, plated, placed on the half wall, and then delivered right away, with milk kept on ice to maintain temperature. The Administrator also stated the milk was not at the correct temperature and should not have been served. The facility policy revised January 2024 directed that cold items be maintained at 40 degrees Fahrenheit or below.
Unsanitary food handling and storage practices
Penalty
Summary
The facility failed to maintain a sanitary kitchen and failed to serve and prepare food in accordance with professional standards for food safety. During observation on 5/12/26, Staff A, a cook, licked the thumb of her hand and then served food without performing hand hygiene. She also picked up bacon with her hands and placed it on a plate for residents, and later touched her food-soiled apron with her hands, picked up bacon with her hands again, and did not use the tongs on the steam table. A kitchen walkthrough on 5/12/26 found the dry storage area floor with dried leaves, dried liquid, and food particles, and a box of soups sitting on the floor. In the refrigerator, a liquid eggs box and a sliced ham box were stored on the floor. The flour and sugar bins in the kitchen were covered in flour and food particles. On 5/13/26, Staff A acknowledged she had served the bacon with her hands and licked her thumb, and the Administrator acknowledged the bacon should have been handled with tongs and that the dry storage floors remained dirty and food supplies were still stored on the floor. The facility's policies directed staff to store food properly and use clean utensils, and stated cross-contamination can occur when microorganisms are transferred to food by hands.
Infection Control and EBP Failures During Wound and Incontinence Care
Penalty
Summary
The facility failed to implement standard infection control practices and Enhanced Barrier Precautions during wound care and incontinent care for three residents, and it also failed to review its infection policy yearly. Resident #15 had severe cognitive impairment, chronic respiratory failure, antibiotic resistance, dependence for toileting, personal hygiene, and bed mobility, and multiple pressure ulcers. During continuous observation of wound care, an agency RN and CNA both wore gowns, gloves, and masks, but the RN repeatedly handled wound cleanser bottles, bulk gauze packages, and dressings with the same gloves used to clean wounds, set the wound cleanser bottle on the bed without a barrier, and changed gloves without consistent hand hygiene. The RN also handled the resident’s catheter after it fell to the floor and placed it on clean bedding. During bowel care, the CNA used the same wipe multiple times and did not always wipe front to back. The ADON observed these practices and acknowledged concerns with hand hygiene, glove changes, touching supplies with dirty gloves, and repeated use of the wipe. Resident #24 had intact cognition and a stage 4 pressure ulcer. During wound treatment, an agency LPN wore a gown and gloves and kept supplies on a bedside table, but pulled bandage scissors from a scrub pocket and used them without cleaning them first. The LPN repeatedly changed gloves but did not perform hand hygiene between glove changes. The LPN used bulk gauze packages during cleansing of multiple wounds, dampened gauze with wound cleanser, Vashe, and Dakin’s solution, and continued wound care without cleaning the scissors before use. The ADON later acknowledged that hand hygiene should have been performed with each glove change and that the scissors should have been cleaned before use. Resident #4 had intact cognition, was dependent for toileting, and had respiratory failure with ventilator dependence. During observed care, two CNAs checked and changed the resident. One CNA wore a gown and gloves, while the other wore a gown incorrectly, with his arms not in the armholes and the gown only around his neck. The CNA with the incorrect gown used the wipe only once and wiped front to back, changed gloves from dirty to clean, and performed hand hygiene between glove changes. After the resident was cleaned, the CNA removed the gown and gloves and washed his hands. The CNA later stated he forgot to put his arms in the gown and was not wearing it correctly.
Failure to Maintain Nutritional Status and Notify Physician/RD of Significant Weight Loss and Tube Feeding Changes
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s nutritional status and follow care plan interventions and policy regarding significant weight changes and treatment alterations. The resident had moderately impaired cognitive skills and diagnoses including myotonic muscular dystrophy, diabetes mellitus, and malnutrition, and was NPO with all nutrition provided via enteral tube feeding. The care plan directed staff to provide the ordered NPO diet, monitor weights, and notify the physician and Dietitian of significant weight changes, and identified that the resident had tube feedings related to gastrostomy status with a goal to tolerate feedings and remain free of complications. An intervention noted that the resident might refuse feedings. The Dietitian’s nutrition assessment documented that the resident’s enteral feeding provided all nutrition and recommended increasing the feeding volume from 240 mL to 250 mL five times per day and increasing water flushes due to the resident being below estimated needs. The MAR for February showed an order for enteral feedings of 250 mL five times daily with water flushes, which was discontinued later in the month. During that period, the resident refused multiple scheduled tube feedings, particularly at the 10:00 AM, 6:00 PM, and 10:00 PM times. Despite these frequent refusals, there was no documented notification to the physician or Dietitian as required by the care plan and as expected by the DON when refusals occurred more than twice. On 2/26, the enteral feeding regimen was reduced to 300 mL twice daily, significantly decreasing the total daily volume, and this order was later discontinued and then restarted in March, without documentation of a physician’s order or indication for the reduction. The resident’s recorded weights showed a decline from 130 pounds in early January to 121.1 pounds in mid-February and 119.5 pounds in late March, representing a significant, unexplained weight loss. The Dietitian reported not being informed of the frequent refusals of tube feedings in February or of the reduction in feedings to twice per day, and could not find an order or indication from the physician for this change. The facility’s policy on Notification for Change in Condition required immediate consultation with the physician and notification of significant changes in status and significant alterations in treatment, but this was not followed in relation to the resident’s weight loss and feeding regimen changes.
Failure to Respond Timely to Call Lights and Tube Feeding Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely responses to resident call lights and alarms, resulting in prolonged wait times for assistance. For one resident with moderately impaired cognition, myotonic muscular dystrophy, diabetes mellitus, and malnutrition, the care plan required assistance with ADLs and keeping the call light within reach due to fall risk. Despite this, call light log data showed multiple instances where this resident’s calls were not answered for extended periods, including waits of 46 minutes, 37 minutes, 27 minutes, 18–19 minutes, and one episode lasting 1 hour and 21 minutes. The resident reported that it took up to 2 hours for someone to answer her call light, and a CNA reported observing this resident’s call light on for over an hour during an overnight shift without staff notifying the nurse on duty. Another resident, cognitively intact but dependent on staff for toileting hygiene, bed mobility, and transfers, with diagnoses including type 2 diabetes mellitus, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, also experienced prolonged call light response times. This resident’s care plan required assistance with ADLs and keeping the call light within reach due to fall risk. The grievance log documented that the resident reported staff refused to lay her down, turned off the call light, and left, after she had her call light on for over an hour. Call light logs showed multiple delays for this resident, including waits of approximately 33 minutes, 56 minutes, 32–33 minutes, 31 minutes, 20 minutes, 29 minutes, and one episode of 1 hour and 47 minutes before the call was answered. A third cognitively intact resident with diabetes, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, who was at risk for falls and had occasional bladder incontinence, also reported unaddressed call lights. This resident’s care plan required that the call light be kept within reach. The grievance log recorded that from 1:00 AM to 3:00 AM the resident had her call light on and no one answered, and that she had to ask her roommate to press the call light because her own was not within reach. Call light logs for this resident showed waits of 51 minutes and 36 minutes. In addition, a resident with paraplegia, seizure disorder, CAD, respiratory failure, malnutrition, and dependence on a feeding tube for more than half of daily calories and fluids had a tube feeding pump alarm sounding continuously for nearly an hour. Multiple staff, including housekeeping, another staff member, the DON, and an LPN, passed by or were present in the hallway without responding to the audible alarm until the surveyor alerted the LPN, who then identified an occlusion-related cassette error on the pump. The facility did not have a written policy to ensure timely call light response, and the DON acknowledged that residents had complained about call light wait times and that some documented waits were too long.
Failure to Ensure Dignified and Respectful Communication With Residents
Penalty
Summary
The deficiency involves failures to honor residents’ rights to dignity, respectful communication, and self-determination. One resident with intact cognition, paraplegia, respiratory failure, seizure disorder, malnutrition, and significant psychosocial diagnoses (MDD, antisocial personality disorder, PTSD) reported that a respiratory therapist (Staff G) suctioned his tracheostomy in a way he perceived as rough and distressing. He stated that Staff G instilled a large amount of saline into his tracheostomy tube while he was talking, causing choking, coughing, and gagging, and that it felt as though she was trying to “shut him up” and “drown” him. After leaving his room, he reported hearing Staff G in the hallway, within his hearing distance, laughing and mocking his concern by repeating that he said she was going to drown him. Another respiratory therapist (Staff H) recalled the resident’s report that Staff G laughed with another staff member in the hallway about his concern, and an LPN (Staff A) confirmed that Staff G told her in the hallway that the resident had accused her of trying to drown or kill him, after which the resident began banging on the wall and yelling. A second resident with moderately impaired decision-making, myotonic muscular dystrophy, chronic respiratory failure with hypoxia, anxiety disorder, and MDD used a communication board but did not have this communication need or intervention identified in the care plan. When asked about concerns with Staff G, this resident nodded yes and spelled out “rude” on the communication board. A CNA (Staff J) reported witnessing Staff G enter this resident’s room and say, in a rude tone, “what do you want? As they were just in there,” which made the resident cry. The lack of care plan identification of the resident’s impaired communication and use of a communication board, combined with Staff G’s rude verbal interaction, demonstrated a failure to support and respect the resident’s communication needs and emotional well-being. A third resident with severe cognitive impairment (BIMS score of 4), traumatic brain injury, seizure disorder, and depression had a care plan noting impaired cognitive function and frustration when unable to express words, leading to cussing and yelling. During observation, this resident was seated in a wheelchair outside the shower room awaiting assistance for a bath and made a loud exhaling noise. A staff member at a nearby medication cart repeated the sound in a mocking manner and said to the resident, “life is so tough isn’t it, it’s so terrible.” The resident did not respond. These interactions, including mocking comments and conversations about residents within their hearing distance, were inconsistent with the facility’s policy requiring residents to be treated with dignity and respect and not to be laughed at or talked about within hearing distance.
Failure to Thoroughly Document and Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse made by Resident #3 against a respiratory therapist (Staff G). Resident #3 had intact cognition with a BIMS score of 15 and multiple diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, and PTSD. The resident’s care plan emphasized psychosocial well-being, including interventions to assist the resident in processing feelings, verbalizing concerns, and validating and resolving complaints. Despite this, when Resident #3 alleged physical abuse by Staff G, the facility’s subsequent investigation did not fully document all relevant information and interviews. The facility’s self-reported incident documentation stated that, after completing interviews with Resident #3 and staff, there was no evidence to support the allegation and that Resident #3 reported feeling safe with Staff G and denied that Staff G was physically rough or provided care without explanation. However, the investigation file contained only limited written statements dated 2/22/26: an interview by Staff F (MDS coordinator) with Resident #3, an interview with Staff H that lacked Staff H’s signature, and an interview with Staff G by the DON that lacked Staff G’s signature. The investigation documentation omitted written witness statements that Staff H reported having written, as well as the original statement Staff H helped Resident #3 write, which Staff F reportedly took. The investigation also lacked documentation of interviews with three additional residents and three additional staff members whose names were later provided by the DON. Interviews with staff further highlighted gaps in the investigation record. Staff H confirmed that on the date of the incident they were working with Resident #3, received the abuse allegation against Staff G, immediately notified the administrator and Staff F, and wrote a witness statement before assisting Resident #3 in writing a statement with an LPN present. Staff F confirmed being notified of the allegation, coming into the facility, speaking with Staff H, the LPN, and Resident #3, and using Staff H’s written statement to write statements for both Staff H and Resident #3. Staff G confirmed being contacted by the DON about the alleged incident but reported no further contact from the facility. The facility’s abuse policy required timely, thorough, and objective investigations with documentation of the allegation and collection of supporting documents, but the investigation file lacked complete, signed statements and documentation of all resident and staff interviews referenced by the facility, resulting in a failure to maintain evidence that the allegation was thoroughly investigated.
Failure to Administer and Document Medications as Ordered for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered and failed to document administration for multiple residents. One resident with a history of traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dependence on tube feeding had multiple omissions or undocumented doses of famotidine, Keppra, and Baclofen across January and February. The Medication Administration Records (MARs) for this resident showed missing documentation for several scheduled doses of these medications on specific dates and times, and incident reports documented that staff discovered missed doses of Baclofen and Keppra for an evening shift and additional missed doses later in the month. Another resident with traumatic brain injury, traumatic brain dysfunction, quadriplegia, and severe cognitive impairment had missing documentation on the March MAR for ordered ipratropium‑albuterol nebulizer treatments via trach four times daily. A progress note documented that evening shift staff found the morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they had not been given by agency staff. An incident report further documented that the facility attempted to contact the resident’s representative to update them about the missed medications. Staff interviews confirmed that nurses had found medications not given on prior shifts. A third resident with myotonic muscular dystrophy, diabetes mellitus, and malnutrition had a February MAR that indicated all bedtime medications were given on two consecutive days, but a subsequent health status note documented that staff later found evening and bedtime doses from one of those days still in the medication card. The missed medications included Midodrine, Eliquis, escitalopram, and quetiapine. An incident report described this as a medication event/missing medication. During interviews, the MDS coordinator acknowledged awareness that one resident had missed medications, and the DON acknowledged gaps on the MARs and stated that the facility followed the six rights of medication administration but lacked a policy directing staff how to administer medications.
Failure to Provide and Document Regular Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document weekly bathing or showers for dependent residents, as required by resident care plans and facility policy. One resident with intact cognition, respiratory failure, heart failure, morbid obesity with hypoventilation, and an MRSA infection required partial to moderate staff assistance with bathing and had a care plan directing staff to assist with baths or showers per schedule. This resident filed a grievance stating she was not getting showers and reported not having received one in a week. Electronic health records for the month reviewed showed only one documented shower and one refusal, with no other baths or showers recorded, despite the resident’s expressed concerns. Another resident with moderately impaired decision-making, myotonic muscular dystrophy, diabetes mellitus, and malnutrition also required assistance with ADLs and had a care plan directing staff to assist with scheduled baths or showers, later updated to note a preference for bed baths while still requiring staff to offer showers. For this resident, documentation for the month showed only one shower provided, multiple refusals, several days left blank, and several days explicitly documented as no shower given. Staff interviews revealed that since a decreased staff-to-resident ratio was implemented, residents had not been receiving showers, and staff reported residents going a week or more without a shower. The DON acknowledged that completion of resident baths and showers needed improvement and stated the expectation was two baths or showers per week, while facility policy required staff to document completed baths and showers in the EHR.
Failure to Recognize and Report Significant Changes in Condition for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on significant changes in condition requiring timely physician notification for two residents. For one resident with atrial fibrillation, mild intellectual disability, and dependence on staff for ADLs and transfers, the resident was sent out for a CT scan and returned the same day. Progress notes documented that the paperwork from the scan could not be printed and that staff planned to follow up in a few days for faxed dictation. Later that day, the resident’s guardian called the facility reporting possible abnormal blood clot results in the lungs and requested an update. A nurse assessed the resident, found a low pulse oximetry reading, placed the resident on oxygen until the saturation normalized, and documented that the resident denied breathing or pain issues. The resident was then assisted to a wheelchair and taken to the dining room, with no incident or concerns noted at that time. Despite the guardian’s report of possible blood clots in the lungs and the documented low pulse ox requiring supplemental oxygen, there was no documented immediate physician notification or initiation of treatment on that day. Two days later, the MDS coordinator received a call from a provider with CT scan results confirming a pulmonary embolism and an order to send the resident to the ED, after which the resident returned on anticoagulant therapy. The medical director later stated he expected the facility to notify the provider as soon as they knew of the pulmonary embolism and confirmed there was a delay in treatment. Staff interviews indicated that the nurse who assessed the resident after the guardian’s call believed he needed to wait for documentation of the PE or a provider call to validate the PE, and another staff member reported it took two days to obtain treatment orders, noting that the DON did not check her voicemail regularly. For a second resident with intact cognition and diagnoses including paraplegia, seizure disorder, CAD, respiratory failure, and malnutrition, the respiratory therapist documented two separate episodes of unresponsiveness and dizziness during transfers on the same day. In the morning, during a bed-to-wheelchair transfer, the resident reported dizziness, then developed a fixed gaze and became unresponsive to verbal stimuli for about eight minutes, with respirations of 12–14 per minute, before gradually returning to baseline. In the late afternoon, during another transfer with nursing staff present, the resident again developed a blank stare lasting over 15 minutes, with slowed respirations of 7–8 per minute, grayish lips, no response to sternum rub, and nonreactive pinpoint pupils, before suddenly awakening and reporting thirst, dizziness, and hunger. The EHR contained no nursing documentation, assessment, or physician notification related to these unresponsive episodes. Subsequently, the respiratory therapist discussed the unresponsive episodes with the DON and they agreed to track the resident’s blood pressure during episodes. Later, the therapist documented that the resident reported a history of low blood pressure treated with medication at another facility and experienced dizziness and near-syncope when the head of the bed was elevated, requiring lowering of the bed angle. A blood pressure of 60/40 was recorded after the resident became lightheaded with positional change. Despite this severely low blood pressure and repeated dizziness with position changes, the EHR still lacked nursing documentation, assessment, or physician notification of these events on that date. The care plan, initiated earlier, did not identify or include interventions for orthostatic hypotension or unresponsive episodes during position changes. The facility’s own policy required immediate physician consultation and notification of the resident and representative for significant changes in status, including loss of consciousness, but this was not followed in these instances.
Failure to Supervise Dependent Smoker and Maintain Updated Safety Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and maintain updated assessments for a resident identified as a dependent smoker with a risk of wandering. The resident’s MDS dated 1/20/26 showed a BIMS score of 15 (intact cognition) and diagnoses including traumatic brain injury, aphasia, and seizure disorder. A Care Plan focus initiated 10/21/24 documented that the resident used tobacco, with a goal to adhere to the smoking policy, and interventions specifying that a dependent smoker must be assisted to designated smoking areas at designated times and supervised while smoking. A smoking assessment dated 10/21/24 indicated the resident had cognitive loss and could not light a cigarette safely, and an elopement risk assessment on the same date showed a score of 9, indicating risk to wander. The electronic health record contained no additional smoking or elopement risk assessments after 10/21/24, despite the facility’s practice of completing these at admission and annually. On 1/4/26, a nurse took the resident outside to smoke, lit the cigarette, and then returned inside, leaving the resident unattended, contrary to the Care Plan directive that staff supervise the resident while smoking. A grievance reported to the Administrator on 1/5/26 described this event, and the Administrator and DON became aware that the resident had been left unsupervised while smoking. The facility’s grievance log referenced this concern, but the resident’s electronic health record lacked documentation related to the incident, such as a progress note or incident report, even though the DON stated staff must document any occurrence outside the resident’s plan of care. The facility’s smoking policy, revised January 2024, required determining whether a resident is an independent or dependent smoker before allowing smoking, and directed that dependent smokers be supervised while smoking and have their Care Plans updated with needed safety interventions, but the facility did not consistently follow these procedures for this resident.
Failure to Follow Tube Feeding Orders and Document Enteral Nutrition and Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide tube feeding care and related water flushes and residual checks according to physician orders and to ensure complete documentation for residents receiving enteral nutrition. For one resident with moderately impaired cognition, traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dysphagia requiring G-tube feeding and NPO status, the care plan directed enteral nutrition as ordered. The January and February MARs contained orders for Fibersource HN 375 ml four times daily as a nutritional supplement, 150 ml water flushes with each feeding, residual checks of 5–20 ml prior to every medication pass or feeding each shift, and 60 ml water before and after medications every shift. Surveyors found multiple instances across January and February where feedings, water flushes, residual checks, and pre- and post-medication water administrations were not documented as completed. The clinical record review showed specific missed documentation dates and times for this resident’s tube feedings and associated water flushes, including several lunch and hour-of-sleep doses in January and mid-afternoon and evening doses in February. Residual checks and 60 ml water flushes before and after medications were also not documented on multiple shifts. The Medical Director acknowledged awareness that the resident missed a few feedings and confirmed the expectation that staff follow provider orders as written. An LPN and the MDS Coordinator both reported knowing that the resident had missed some feedings, and the MDS Coordinator stated that if it is not documented, it is not done and that audits were not completed, confirming gaps in both performance and documentation of ordered enteral nutrition and hydration. For a second resident with intact cognition and diagnoses including stroke, heart failure, hypertension, diabetes mellitus, and dependence on tube feeding for nutrition and hydration, the care plan directed flushing the feeding tube as ordered. However, the March MAR did not specify the amount of water to flush the feeding tube before and after medication administration. During an observed medication pass, an RN asked the DON about the required flush amount; the DON left the room and returned stating that 60 cc of water should be used before and after medications, describing this as the standard amount, despite no corresponding order on the MAR. The RN and DON then administered 60 cc water flushes based on this verbal direction. The ADON confirmed she did not see an order for the water flush amount, and the DON acknowledged the lack of a policy directing staff on how to administer medications via tube feeding, while the existing enteral feeding policy only addressed verifying physician orders for formula, rate, and frequency.
Failure to Maintain Controlled Substance Records and Accurate Lorazepam Dosing
Penalty
Summary
The deficiency involves the facility’s failure to maintain required controlled substance records for lorazepam administered to one resident and to ensure accurate transcription and dosing of that medication. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, PTSD, and a history of substance overuse. The care plan directed staff to administer medications as ordered, remain non-judgmental, monitor for behavioral changes, increase supervision as needed, and conduct medication review with pharmacy per facility protocol. Hospice admission orders for lorazepam concentrate 2 mg/mL directed 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the order was entered into the EHR, it was transcribed as lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed, and this order remained active until it was discontinued several days later. The March MAR showed multiple administrations of lorazepam under the incorrectly transcribed order by various staff on several dates and times. The facility was unable to locate a controlled substance log for the resident’s lorazepam solution, despite the expectation that a controlled substance log be initiated and completed with each administration. The MDS Coordinator reported she transcribed the lorazepam order while working as a floor nurse, was in a rush, did not have another nurse double-check the order, and administered 0.5 mL of lorazepam, later identified as an incorrect dosage. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, and that a controlled substance log should be used for lorazepam. The Administrator reported there were no written policies and procedures for medication administration and that the facility followed the general “6 rights” of medication administration.
Transcription and Dosing Errors for Morphine and Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer physician orders for two controlled substances, morphine sulfate concentrate and lorazepam concentrate, resulting in a resident receiving significantly higher doses than ordered. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia. Hospice admission orders dated 3/6/26, noted by the facility on 3/7/26, specified morphine sulfate concentrate 20 mg/mL at 0.25 mL (5 mg) by mouth/sublingual every 2 hours as needed for pain or shortness of breath, and lorazepam concentrate 2 mg/mL at 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the orders were entered into the EHR on 3/7/26, the morphine order was transcribed as morphine sulfate concentrate 100 mg/5 mL with instructions to give 2 mL by mouth every 2 hours as needed, and the lorazepam order was transcribed as 0.5 mL every 2 hours as needed, doubling the intended lorazepam dose. The EHR and MAR reflected these incorrect orders, and nursing staff administered medications according to the erroneous entries. On 3/8/26 at 1:11 AM, a nurse (Staff A) documented administering morphine concentrate 100 mg/5 mL, 2 mL, for a reported pain level of 8. The controlled substance log for morphine showed that earlier doses had been logged as 0.25 mL, but at 1:12 AM on 3/8/26, 2 mL was dispensed, reducing the remaining amount from 29.5 mL to 27.5 mL. The resident’s MAR also showed multiple administrations of lorazepam oral concentrate 2 mg/mL at 0.5 mL every 2 hours as needed for anxiety or restlessness, which was twice the ordered 0.25 mL dose, and the facility was unable to locate a controlled substance log for the lorazepam solution. An encounter note later documented that, due to the transcription error, the MAR listed morphine as 2 mL every 2 hours as needed and that the resident received lorazepam 1 mg every 2 hours instead of the intended 0.5 mg. Staff interviews further clarified the actions and inactions that led to the medication errors. Staff F, the MDS Coordinator, stated she entered the morphine and lorazepam orders into the EHR on 3/7/26 and acknowledged that she felt pressured to enter the orders quickly while also working as a floor nurse, and no second nurse double-checked her work. Staff A reported that on the night of the incident, she checked the doctor’s orders and MAR, both of which showed a 2 mL morphine dose, and administered that dose without first checking the controlled substance log. She stated she questioned the high dose given the resident’s recent hospice admission and thin condition but could not locate the original hospice orders. Only after returning to sign out the narcotic in the controlled substance log did she notice that the previous dose had been 0.25 mL, revealing the error. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, while the Administrator reported there were no written policies and procedures for medication administration, and that the facility followed the general “6 rights” of medication administration.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Administrator and the State Survey Agency within the required 2-hour timeframe after Resident #51 reported that a staff member grabbed his arms, hurt him, and caused multiple dark purple bruises to his forearms. The report states this failure prevented an investigation into the incident and that the harm continued to occur. The deficiency was cited as Immediate Jeopardy to the resident’s health, safety, and security. Resident #51’s MDS identified a BIMS score of 9, indicating moderate cognitive impairment. He required maximal assistance for lying to sitting, was dependent on staff for all transfers, could not walk 10 feet, and had diagnoses including COPD, mild intellectual disabilities, cognitive communication deficit, and gait and mobility abnormalities. His care plan included use of a standing mechanical lift for all transfers, monitoring for bruising due to anticoagulant use, and approaches in a calm manner because he tended to refuse medications and showers. Resident #51 told staff that he had been pulled from bed and that it happened day and night, resulting in bruises to both forearms. He pointed out bruises about the size of half-dollar coins and said he had reported the issue because being pulled from bed was not good for him. The progress notes lacked documentation of the bruises and lacked documentation of notification to nursing staff, administration, family, or the physician. Staff interviews showed that some staff saw the bruising but did not know how it occurred, some said they reported it to a nurse, and others stated they were unaware of the allegation. The Administrator stated no one informed her about the claim. The facility’s abuse policy required immediate notification of the charge nurse and Abuse Coordinator, and stated allegations of abuse or bodily injury should be reported immediately and no later than 2 hours.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving a resident who reported that staff grabbed his arms, hurt him, and caused multiple dark purple bruises to both forearms. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and his MDS showed diagnoses including COPD, mild intellectual disabilities, cognitive communication deficit, and abnormalities of gait and mobility. He required maximal assistance for bed mobility, was dependent on staff for all transfers, could not walk 10 feet, and was prescribed Eliquis, which increased his risk for bruising. The resident told staff that he had been pulled from bed by his arms and that the pulling happened during both day and night shifts. He pointed out bruises to both forearms and stated he had reported the issue because being pulled from bed was not good for him. A CNA later confirmed that the resident reported a staff person had grabbed him too hard by the arm to get him out of bed and that dark bruises were visible on his arms. The administrator stated she had not been informed of the allegation when it was reported. The facility’s investigation documented bruising and a skin tear to the resident’s arms and hands, but the resident later gave differing explanations, including that he bumped his arm getting out of bed and that two young black staff members assisted him from bed and grabbed his left arm. The investigation also reviewed staffing, behavioral documentation, and interviews, but staff gave inconsistent accounts and several staff members stated they were unaware of the allegation or bruising when it was reported. The resident later stated that the staff had done it again and that he feared the staff who transferred him, while the facility’s root cause analysis concluded there was no evidence of staff-inflicted injury and attributed the bruising to self-injury while attempting to get out of bed without assistance.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had their call light within reach at all times, as required by facility policy. The resident had a history of cerebral vascular accident (CVA) with hemiplegia affecting both sides, limited range of motion in all extremities, and was dependent on staff for bed mobility and transfers. The resident communicated basic needs by moving his right foot or leg, as documented in his care plan. However, the care plan and Kardex did not provide specific instructions regarding the use or placement of an adaptive call light for this resident. Observations revealed that the resident's call light was not consistently placed within his reach. On one occasion, the call light was found on the resident's lower left side, out of reach, and the resident was observed to be cold but unable to call for assistance. Staff interviews confirmed that the call light should have been positioned next to the resident's right foot, which was his method of communication. The Director of Nursing also verified that the Kardex lacked information about the call light placement, and the facility's policy required call lights to be within reach for residents who could use them.
Failure to Provide Required Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to notify residents or their responsible parties when there was a change in their level of care and services, specifically when Medicare Part A skilled nursing facility (SNF) coverage ended and the residents remained in the facility. For two residents, the facility initiated discharge from Medicare Part A services while benefit days remained, but did not provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). Although the Notice of Medicare Non-Coverage (NOMNC) was provided, there was no documentation that the SNF ABN was given to inform the residents of their financial responsibility for continued services. Staff interviews revealed that the person responsible for providing these notifications had not received proper training and was under the impression that the SNF ABN was not necessary if the resident had Medicaid as a payor source. Additionally, the facility was unable to provide a policy related to the notification of services to residents or their representatives. Facility records and progress notes lacked documentation that the required notifications were given, resulting in residents not being properly informed of their potential liability for services not covered by Medicare.
Respectful Care and Resident Dignity Not Maintained
Penalty
Summary
The facility failed to ensure residents were treated respectfully and with dignity for 2 of 3 residents reviewed. For one resident with intact cognition, quadriplegia, anxiety, depression, PTSD, and dependence on staff for eating and all ADLs, staff told her to leave the dining room while she was talking with another resident. The resident reported that a CNA slammed her snack down, told her someone else would have to feed her, and said she could not be in the dining room while others ate because of a rule. The resident also reported that staff were disrespectful when she asked for help and that she did not want those staff providing her care. The Administrator later acknowledged the dining room incident as a dignity concern and stated there was no rule preventing the resident from being in the dining room. For the second resident, who had a BIMS score of 9, moderate cognitive impairment, COPD, mild intellectual disabilities, cognitive communication deficit, gait and mobility abnormalities, and required extensive assistance with transfers, staff did not honor his refusal to get out of bed for the evening meal. The resident reported that staff pulled him from bed day and night and that he had bruises on both forearms. During observation, several bruises were noted on both forearms. Therapy guidance directed staff to use a standing mechanical lift for all transfers and to allow time for setup, while the care plan noted the resident tended to refuse medications and showers and staff should approach him calmly and respect his rights to make his own lifestyle choices. Interviews showed conflicting staff practices and expectations around the resident’s care. One CNA stated she was directed to get him up with a gait belt, stand him, and pivot him to the wheelchair after he said no, while another CNA stated staff were taught to use his preferred items and that if he absolutely said no, it was a no. A charge nurse directed staff to get him to the dining room anyway after he refused to get up. The facility’s abuse prevention and resident rights policies required a supportive, safe environment and respectful care, but the events described showed staff directing the resident to leave the dining room and physically getting him up despite his refusal.
Failure to Prevent Abuse During Resident Transfers
Penalty
Summary
The facility failed to prevent abuse when Resident #51 reported that staff pulled him from bed by his arms during transfers, and the resident later identified visible bruising to both forearms and wrists. Resident #51 had a BIMS score of 9, indicating moderate cognitive impairment, and his MDS showed he was dependent on staff for transfers, unable to walk 10 feet, and required maximal assistance for bed mobility. His diagnoses included COPD, mild intellectual disabilities, cognitive communication deficit, and gait and mobility abnormalities. He was also receiving Eliquis for atrial fibrillation, which was documented as increasing his risk for bruising. The care plan and therapy recommendation directed staff to use a standing mechanical lift with 2 staff for all transfers, and the therapy document also instructed staff to explain tasks to the resident and assist him to safely grip the handle because he needed time to set up in the lift. Despite this, the resident told staff and the surveyor that he was being pulled from bed, that it happened day and night, and that it caused bruises to his forearms. He pointed out bruises on both forearms, and later told the surveyor that he feared the staff who transferred him and that they had done it again after he told them not to. The record also showed multiple skin injuries and bruising documented during the investigation period, including bruising to the left elbow, right hand, right forearm, left hand, and left posterior forearm, along with a skin tear to the left posterior forearm. Staff interviews showed inconsistent knowledge of how the injuries occurred, with some staff stating they did not know the cause, some attributing the bruising to a prior fall, and others stating the resident resisted care or used a gait belt and stand-pivot transfers instead of the standing mechanical lift. The facility’s own investigation concluded there was no evidence of staff-inflicted injury and suggested the bruises likely resulted from self-injury while attempting to get out of bed without assistance, but the progress notes lacked documentation of falls or attempted transfers causing self-injury during the period reviewed.
Failure to Resubmit PASRR After New Bipolar Diagnosis
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) after Resident #31 received a new diagnosis of bipolar disorder. Resident #31 was admitted on 8/15/24, and his PASRR Level 1 completed on 6/5/24 documented a positive Level 1 PASRR with no status change, indicating he did not require further evaluation at that time. A medical diagnosis review showed bipolar disorder was added on 3/27/25, but the facility did not resubmit PASRR for review after that new diagnosis was entered. The care plan identified a PASRR baseline care plan and directed staff to follow PASRR recommendations as applicable. On 7/30/25, the SSD stated she was not aware of the resident's new diagnosis and said she had discussed with the team the need to notify her when new diagnoses are added so she can resubmit PASRR accordingly. The facility's PASRR process policy stated that psychotropic medication changes and new or updated diagnoses should be discussed in daily IDT meetings and that social services would update PASRRs as necessary.
Failure to Follow Positioning and Splinting Care Plans
Penalty
Summary
The facility failed to implement care plan interventions for positioning for 2 residents reviewed. Resident #22 had a BIMS score of 9 and diagnoses including hemiplegia, traumatic brain injury, stroke, and stiffness of an unspecified joint. The MDS identified the resident as dependent for multiple ADLs and noted use of a manual wheelchair. OT documentation dated 5/29/25 directed that splints be applied when the resident woke up, removed at lunch, reapplied at 2:30 PM, and removed at dinner, including an elbow extension splint, palm protectors or towel rolls, and a cervical cushion or towel roll on the right side of the neck. Resident #22’s care plan directed staff to use a left hand splint, right palm protector, and right elbow splint on after breakfast, remove for lunch, reapply after lunch, and remove before supper. However, on multiple observations the resident was seen in the dining area, hallway, and common area without splints and/or braces in place. On one observation, the resident’s left hand was in a fist over the seatbelt buckle without a splint. Another observation showed the resident with a splint/brace on the right arm and towel rolls in each hand. Staff interviews confirmed the resident had splints/braces, that reminders were posted above the bed, and that staff had observed the resident without the devices during the scheduled times they were to be worn. Resident #26 had a BIMS score of 9 and diagnoses including cerebral palsy, mild intellectual disabilities, and type II diabetes mellitus without complications. The resident was dependent for multiple ADLs and used a manual wheelchair. Therapy documentation identified repeated concerns with the resident’s chest strap being absent or not applied properly during wheelchair use, and staff were educated on proper application. The resident’s orders required a seatbelt when in the wheelchair and a chest harness when up in the wheelchair for positioning, with removal every 2 hours for 10 minutes. The care plan directed staff to use pillows/positioning devices as needed and follow therapy recommendations as applicable. Despite these directions, the resident was observed on multiple occasions in the wheelchair without the chest harness in place, including while seated in the common area and dining area. Staff interviews showed confusion about whether the chest harness was required at all times when the resident was in the wheelchair, and the ADON acknowledged the resident needed the chest harness when in the wheelchair. The record also documented that the resident recently fell from the wheelchair, and staff reported they did not know what interventions had been implemented after the fall.
Care Plan Not Updated to Reflect Transfer Needs
Penalty
Summary
The facility failed to revise the Comprehensive Care Plan for one resident to reflect individualized care needs and current therapy recommendations. Resident #51’s MDS identified a BIMS score of 9, indicating moderate cognitive impairment, along with diagnoses including COPD, mild intellectual disabilities, cognitive communication deficit, and abnormalities of gait and mobility. The care plan identified a fall risk and a tendency to refuse medications and showers, but staff were observed and interviewed using outdated resident care information from a paper list at the nurses’ station rather than the current care plan in the EHR. A PT/OT recommendation document directed staff to use a standing mechanical lift for all transfers and to allow the resident time to set up in the lift, but those details were not added to the care plan. Instead, multiple staff described transferring the resident in different ways, including with a gait belt, stand-and-pivot, or with 2 staff assistance, and some staff said they followed the paper resident list that identified him as a 1-assist for all cares and transfers. Staff also reported that the resident had been difficult to work with at times and that they learned his preferences through verbal direction from other staff. During interview and observation, the resident reported that staff pulled him from bed by his arms day and night and that this caused bruises to his forearms and wrists. He pointed out bruises on both forearms, and later stated he was fearful of the staff who transferred him and that they had done it again. Staff interviews confirmed that bruising had been seen on his arms, but the resident care information being used by staff remained inconsistent with the therapy recommendation and the current care plan.
Failure to Report Resident Head Injury Promptly
Penalty
Summary
The facility failed to report an incident at the time it occurred, which delayed assessment for one resident. Resident #4 had a BIMS score of 15, indicating intact cognition, and was dependent on staff for bed mobility due to quadriplegia, anxiety, PTSD, and arthrogryposis multiplex congenita with impaired mobility in both arms and legs. The care plan identified that the resident required assistance from 1 to 2 staff members for bed mobility. According to the record and interviews, Staff B, a CNA, was repositioning Resident #4 in bed when the resident’s head struck the siderail. The resident later reported that she had a headache for about 3 days, but denied a concussion. The incident note documented that when the resident reported the event during evening cares, the nurse initiated neuro checks and found no noted injury to the head. Staff B stated she apologized after the resident said “ow” and saw no red mark when she rolled the resident back over. Staff L, the covering LPN, stated she did not learn of the incident until hours later when the resident called the facility and reported it herself to the DON. Staff L stated she did not receive the report from Staff B or Staff N and that the delay prevented an immediate assessment. Staff N stated the resident later told her that Staff B pushed her head into the railing, and Staff M stated the resident had told her about the event days later. The DON stated staff were expected to report incidents immediately, and an email from the DON stated the facility did not have a policy for when a CNA should report such events to the nurse, though it was standard practice to report anything abnormal as soon as it happened.
Failure to Maintain Heel Offloading and Secure Dressing
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with a stage 3 pressure wound to the left heel. Resident #19 had a BIMS of 15, used a wheelchair for mobility, and had diagnoses including paraplegia, lumbar spina bifida without hydrocephalus, a left heel pressure ulcer, and type II diabetes mellitus with hyperglycemia. The care plan directed staff to apply bilateral heel protectors as indicated, apply tubi grip in the morning and remove it in the evening, and use a pressure reducing device on the chair. The physician order required heels to be floated at all times and a pressure relieving boot to the left foot at all times every shift until healed. Observations showed Resident #19 sitting in her wheelchair with her left heel resting on the calf support pad, with a pillow under her calves but no pressure relieving boot on her foot. On another observation, she again had no boot on and had an unsecured bandage on the left heel. Later, she was observed with a pressure relieving boot on the left foot, and she stated staff could not figure out what she needed for her foot and that she had not had the boot on for a while. Staff interviews confirmed inconsistent use of the boot; one CNA stated the resident usually did not have anything on her feet and they never put pressure relieving boots on her feet, while another CNA said she saw the resident with and without the boot. The RN/Infection Preventionist also acknowledged seeing the resident without the pressure relieving boots on a number of occasions.
Failure to Use Ordered Chest Harness Before Wheelchair Adjustment
Penalty
Summary
The facility failed to prevent a fall for Resident #26 by not ensuring the resident wore the chest strap ordered by the physician, recommended by therapy, and included in the care plan while the resident was in the wheelchair. Resident #26 had a BIMS score of 9, indicating moderate cognitive impairment, and was dependent for multiple activities of daily living. The resident also had cerebral palsy, mild intellectual disabilities, and type II diabetes mellitus without complications, and used a manual wheelchair. Therapy documentation showed repeated concerns that Resident #26 was seated in the wheelchair without the chest strap in place. On multiple encounters, the COTA found the resident without the strap, applied it for safety and proper seated positioning, and discussed the missing strap with nursing staff. The COTA also documented that the strap was lost and later could not be reassembled because parts were missing. The care plan did not include documentation related to falls, although it did direct staff to use pillows/positioning devices as needed and follow therapy recommendations as applicable. On 7/28/25, while Resident #26 was seated reclined in the dining room wheelchair, staff attempted to move the wheelchair to an upright position and the wheelchair tipped forward, causing the resident to slide to the floor. The incident note documented no injuries and baseline range of motion, and the resident was assisted back to the wheelchair with a mechanical lift and two staff. Interviews with CNA and nursing staff showed confusion about whether the chest harness was required and acknowledged that the resident had been observed in the wheelchair without it. The ADON confirmed the resident needed the chest harness when in the wheelchair, and the Administrator stated the facility lacked a policy for positioning devices.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to provide services in accordance with acceptable infection control practices during care for three residents. During perineal care for a resident with a BIMS score of 9, an indwelling catheter, and diagnoses including epilepsy, chronic kidney disease, and bipolar disease, staff donned gown and gloves for enhanced barrier precautions, provided groin and catheter care, removed dirty gloves, and then applied clean gloves without performing hand hygiene. The same staff also failed to wash the resident’s hips during the care. The DON and the staff member both acknowledged that hand hygiene was not completed between glove changes, and another staff member reported observing the same omission. During wound care for a resident with paraplegia, spina bifida, diabetes, and a stage 3 pressure ulcer of the left heel, a nurse set up a barrier and supplies but placed scissors directly on the bed linen rather than on the barrier. The nurse then used the same scissors to cut a wound dressing cover without sanitizing or disinfecting them first. The scissors were used to cut the Prisma pad for the heel wound after being placed on the bed, and the nurse acknowledged the scissors should have been sanitized or disinfected before use. The DON and Infection Preventionist stated that scissors were expected to be disinfected and kept on a barrier, and the facility’s dressing change policy directed staff to disinfect scissors before and after use. During transfer and bathing-related care for a resident with severely impaired cognition, total dependence for toileting, showering, and dressing, and diagnoses including anemia, stroke with right-sided involvement, and diabetes, staff used a mechanical lift and shower chair while the resident was bleeding. Blood spilled onto the shower chair and floor, and the chair was rolled through the blood. Staff removed the mechanical lift and shower chair from the room without sanitizing them after contact with blood. The resident’s blood-contaminated items were placed into clear bags and sent to regular trash and laundry carts, and staff also continued care while wearing contaminated PPE. The facility’s exposure control plan directed staff to clean and decontaminate equipment and place regulated waste in appropriate secondary containers.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to consistently answer resident call lights in a timely manner, as required by policy and regulatory standards. Multiple resident interviews revealed that call lights were often not answered within 15 minutes, with one resident reporting frequent delays and another stating they had to wait over an hour for assistance while on the commode. Call light system reports for several rooms over a one-week period documented numerous instances where response times exceeded 15 minutes, with some calls going unanswered for over an hour. The average response times for certain rooms ranged from 11 minutes to over 1.5 hours, far exceeding the facility's expectations for timely response. Residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others moderate impairment. Staff interviews confirmed that call lights should be answered promptly and that staff are expected to monitor call light notifications on their mobile devices. Facility policy requires call lights to be answered in a timely manner, but documented response times and resident reports indicate this standard was not consistently met during the review period.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined by the FDA 2022 Food Code, resulting in a deficiency. During an observation, Staff A, a cook, was seen preparing and serving food without washing her hands and using the same glove to handle multiple food items. Specifically, Staff A used her right gloved hand to touch a bun, scoop macaroni salad, and prepare fish sandwiches for residents. This improper technique was used to serve four residents, identified as Residents #9, #13, #22, and #31, in the main dining room. Additionally, Staff A had already served fish sandwiches to residents in the A wing dining room before being corrected by the Certified Dietary Manager (CDM). The CDM later reported that she expected dietary staff to use tongs and avoid touching food with gloves that had contacted other items. Despite this expectation, the facility did not have a specific food handling policy in place, relying instead on the most up-to-date food code. The FDA 2022 Food Code specifies that food employees must wash their hands and use suitable utensils to prevent contamination from hands. The incident highlights a lapse in following these guidelines, as observed during the meal service.
Inadequate PPE and Laundry Handling in COVID-19 Isolation
Penalty
Summary
The facility failed to maintain an adequate supply of personal protective equipment (PPE) for a resident in COVID-19 isolation, leading to improper use of PPE by staff. Resident #146, who had severe cognitive loss and multiple health conditions, tested positive for COVID-19 and was placed in isolation. However, the facility did not provide sufficient face shields for staff entering the isolation room, resulting in staff using inadequate eye protection. The Administrator acknowledged the shortage and mentioned that more face shields were on order, but did not provide guidance on whether existing shields should be sanitized or disposed of. Staff interviews revealed inconsistencies in understanding and implementing PPE protocols. A Certified Nurse Aide (CNA) entered the isolation room wearing only prescription glasses without additional eye protection, contrary to the facility's policy requiring a face shield or goggles. The CNA admitted to not wearing a face shield due to the lack of availability in the isolation bin. Other staff members also demonstrated a lack of clarity regarding the correct PPE requirements, with some believing that prescription glasses sufficed as eye protection. Additionally, the facility failed to ensure proper handling and transport of laundry, which could lead to cross-contamination. Observations showed that clean laundry was transported uncovered through resident areas, and a fan in the laundry room was heavily contaminated with dust and lint, blowing directly onto clean clothes. The facility lacked specific policies for laundry handling and fan cleaning, and staff did not document fan cleaning, indicating a gap in infection control practices.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by two specific incidents involving residents. In the first incident, a resident was observed without sheets on their bed. When the resident informed a CNA about the missing sheets, the CNA initially dismissed the concern by stating the sheet was stained but acceptable. After a brief pause, the CNA returned with linens and assisted the resident in making the bed without further communication. This interaction demonstrated a lack of respect and dignity towards the resident's needs and concerns. In another incident, staff members were reported to have used loud voices and profanity in the presence of residents. A specific event in July involved a CNA becoming loud and using profanity at the Nurse's Station, which was near the dining room where residents were present. Both an LPN and an RN confirmed the incident, noting that they attempted to deescalate the situation while addressing an acute resident concern. A resident also reported that staff sometimes became too loud and used profanity, which made him feel uncomfortable. These incidents highlight the facility's failure to maintain a respectful and dignified environment for its residents.
Failure to Ensure Valid Nursing Licenses
Penalty
Summary
The facility failed to ensure that professional nursing staff held current and valid licenses, as required by state laws. Specifically, the employee file of Staff F, a Registered Nurse, contained a license verification from Nursys indicating that their license had expired. Despite this, Staff F continued to work in the roles of floor nurse and Health Services Supervisor for a period of time after the expiration date. The job descriptions for both positions, which Staff F had signed, required a current and active license. During interviews, Staff F admitted to missing the renewal email from the Board of Nursing, and the Administrator acknowledged that Staff F was overlooked in their system for tracking professional licenses. The Director of Nursing expressed an expectation that all nurses maintain a valid license.
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 150 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Specialty Care | 3.4 mi | ★★★★★ | 6 | 0 |
| The Suites At Western Home Communities | 3.5 mi | ★★★★★ | 1 | 0 |
| Harmony Waterloo | 3.5 mi | ★★★★★ | 17 | 1 |
| Friendship Village Retirement | 3.6 mi | ★★★★★ | 4 | 0 |
| Ravenwood Specialty Care | 3.9 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.