Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Heritage Specialty Care during CMS and state inspections, most recent first.
Food Preparation Not Performed Using Sanitary Practices: A Cook was observed preparing pureed meals while repeatedly touching bread, utensils, the robo coupe blade, and other nonfood surfaces with gloved hands before continuing food prep. The Cook also handled bread and pureed food with the same gloves, and both an LPN and the Regional Dietician stated these actions were not appropriate for sanitary food handling; the facility policy required proper hygiene and sanitary practices to prevent food borne illness.
The facility failed to notify the LTC Ombudsman of hospital transfers and discharges for 3 residents. EHR and progress note review showed that two residents were admitted to the hospital and one resident was sent to the ER for surgical opinion and later discharged, but the Notice of Transfer Form did not include these events. Staff and the Administrator acknowledged the omissions, and the facility lacked a policy for the notifications.
The facility failed to ensure MDS assessments accurately reflected resident condition for two residents. One resident’s MDS did not show the Level II PASRR outcome despite documentation that the resident needed NF services and specialized behavioral health/developmental services. Another resident had a PEG tube, tube feeding orders, and observed enteral feeding, but the MDS did not document the feeding tube even though the RN signed that the assessment was accurate.
Missed Dialysis Access Assessments: A resident receiving HD for ESRD with a LUE AV fistula did not consistently receive required fistula and post-dialysis assessments. The care plan and EMR directed staff to complete dialysis evaluations before dialysis, after dialysis, and on non-dialysis days, but records showed signed-off assessments with missing data on non-dialysis days and a missed post-treatment check on a dialysis day. The resident reported that staff often checked VS before dialysis but not afterward or on days without dialysis, and the DON acknowledged that post-dialysis checks did not always occur.
Failure to assess and care plan PTSD-related behaviors: A resident receiving prazosin for chronic PTSD with night terrors had no PTSD, trauma, nightmare, or medication-related focus in the care plan, and the MDS and EHR did not reflect the diagnosis. Staff documented crying, yelling, pushing, grabbing, and calling out, but the MAR lacked behavior monitoring and staff interviews showed they were unaware of the PTSD diagnosis, triggers, or any non-pharmacological interventions.
Failure to document staff COVID-19 vaccination education and status. The ADON/infection preventionist and DON could not produce records showing which staff received COVID education, whether staff were screened for vaccine eligibility, or whether vaccination status was documented. A CMA reported she was not asked about her vaccination status, was not offered the vaccine or told where to get it, and did not receive COVID education on paper or in person. The facility's training schedule did not list COVID education, and the Administrator's fact sheet did not show when, how, or to whom education was provided.
The facility failed to provide scheduled bathing assistance to several cognitively intact residents who required staff help with ADLs, including individuals with conditions such as heart failure, CKD, diabetes, COPD, stroke with hemiplegia, and epilepsy. Care plans and MDS assessments specified that each resident needed assistance from one staff member for bathing, and residents reported not receiving their twice-weekly showers as scheduled. Bathing records confirmed multiple missed showers over several months. A CNA reported that residents were not receiving baths as planned because CNAs were frequently pulled to cover other units when staff did not report to work, resulting in short staffing and missed hygiene care, contrary to the facility’s ADL policy.
A resident with diabetes and a left foot ulcer did not consistently receive ordered wound treatments and missed multiple wound clinic and infectious disease appointments. The care plan and physician orders required Iodoflex dressings to the left heel on a set schedule, but the TAR showed several missed treatment dates, and a CMA admitted to erroneously signing off all treatments one morning. Observations found undated dressings that remained in place from one day to the next, and an LPN/ADON later removed and changed an undated dressing. The wound clinic provider reported repeated no-shows and missed appointments due to lack of transportation and expressed concern that the resident’s wound care needs were not being met, while the resident stated that rides were sometimes not arranged or no staff were available to drive the van.
A resident with multiple chronic conditions, including CHF, CKD, and type 2 DM, who was cognitively intact and care planned for a low-sodium diet, reported that meals served in his room were frequently cold, late, and did not taste good. During a noon meal observation, residents waited in the dining room while staff struggled to plug in the hot cart and could not provide forks when requested. The resident’s tray was prepared from the hot cart and delivered to his room, where immediate temperature checks showed the meat and potatoes below appropriate hot-holding temperatures and milk near the upper cold-holding limit. Review of meal temperature logs revealed incomplete documentation for side items and reliance on recorded temperatures that did not match the food temperatures observed at the point of service, despite a policy requiring maintenance of proper hot and cold food temperatures.
Three residents dependent on staff for transfers experienced unsafe transfer practices, including the use of incorrect lift equipment, improper sling sizing, and failure to follow individualized care plans. These actions resulted in falls, injuries, and extensive bruising, with staff not consistently referencing lift sizing charts or facility policy.
Multiple residents, including those with a history of falls and mobility impairments, were found without accessible call lights, with devices placed out of reach on bedside stands, walls, floors, or in drawers. Some residents were unable to call for assistance and were found calling out or unaware of their call light's location, contrary to facility policy requiring call lights to be within easy reach.
Large, blackened, and worn carpet areas were observed in the main lobby and skilled unit entrance, with staff confirming that cleaning was ineffective and replacement was delayed. Additionally, a resident's visitor introduced bed bugs, leading to isolation and treatment of the affected room, but the facility's environment remained unclean and not homelike.
The facility did not effectively implement its QAPI and QAA processes to correct and prevent recurring deficiencies in medication administration, as issues identified in a previous survey were found again during a subsequent complaint investigation. Despite regular QAPI meetings and data collection, the same problems persisted, indicating insufficient follow-through on quality improvement activities.
The facility did not ensure that care and services provided met professional standards of quality, as observed through practices that did not align with established guidelines.
A resident with hemiplegia and a history of stroke, who required partial assistance and was at risk for falls, was left without access to a call light after care was provided, resulting in incontinence of bowel and bladder. The call light was placed out of reach, preventing the resident from requesting help, and the issue was discovered by a CNA during the next shift.
Two residents did not receive medications as ordered due to staff errors in medication administration. One resident was given another resident's medications after staff failed to properly identify the individual, resulting in hospitalization. Another resident received an incorrect insulin dose when a nurse did not follow the prescribed order and was unable to recall the correct amount, with the care plan lacking specific double-check instructions.
A resident with severe cognitive impairment and diabetes was given rapid-acting insulin before eating, without adequate follow-up to ensure meal consumption. Staff failed to monitor the resident after insulin administration, and the care plan lacked guidance on hypoglycemia observation and intervention. The resident was later found unresponsive with critically low blood glucose and required hospitalization.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
Surveyors found that kitchen staff did not consistently monitor the dishwasher's function or maintain adequate sanitation, as evidenced by dust and debris on equipment, lack of knowledge about required testing, and missing documentation of temperature and sanitizer checks. Facility policies requiring cleanliness and monitoring were not followed.
A resident with COPD and respiratory failure did not have their oxygen tubing changed or labeled according to facility policy, with observations showing outdated and unlabeled tubing on both the concentrator and portable tank. Staff and the DON confirmed that tubing should be changed and labeled weekly, but this was not done, resulting in a deficiency in respiratory care.
Staff did not follow the prescribed menu and portion sizes for residents on a pureed diet, resulting in incorrect serving sizes and omission of required food items such as whipped potatoes. The process for preparing and serving pureed meals was inconsistent, and there were no formal policies guiding staff in the preparation and portioning of pureed and mechanical soft diets.
A resident who had previously received a pneumococcal 23 vaccine was admitted and consented to receive an additional pneumococcal vaccination, with an active provider order in place. Despite pharmacy recommendations and updated CDC guidelines indicating eligibility for another pneumococcal vaccine, the vaccine was not administered due to unclear staff responsibilities and outdated facility policy.
A facility failed to conduct and document follow-up skin assessments for a resident at risk for pressure ulcers, despite a care plan requiring weekly documentation. The resident, with multiple health issues, had a bruise on the spine that was not properly assessed or documented upon admission. Staff interviews revealed inconsistencies in the assessment process, with some staff unaware of the bruise and others failing to document or notify emergency contacts. The facility's policy required regular skin assessments, but these were not consistently practiced, leading to the deficiency.
A resident with impaired cognition and mobility issues was transferred without a gait belt, contrary to the Care Plan and facility policy. The resident, who was non-weight bearing on the left lower extremity, was moved by two staff members using a bear hug technique due to her combativeness and pain. The Director of Nursing confirmed that the use of a gait belt is expected for all two-person transfers.
A resident with a history of fractures and dementia experienced unmanaged pain due to the facility's failure to complete pain assessments, update narcotic records, and follow up on ineffective interventions. Despite being on hospice care, the resident's pain was not adequately addressed, leading to concerns from family members and staff about the lack of timely and effective pain management.
The facility failed to maintain a clean and safe environment, with issues such as dust and food particles on tables, exposed insulation, and a hole in the wall caused by a resident's wheelchair. Additionally, a resident's room was left uncleaned after their transfer to the hospital, with food debris and a used Foley catheter found. Maintenance and housekeeping supervisors acknowledged these oversights, citing inadequate checks and coordination.
A resident with chronic lower leg ulcers did not receive daily dressing changes as ordered by the physician, with missed treatments on multiple days. The resident reported staff shortages as the reason, and a nurse admitted to not completing the task due to leaving early. The facility's policy for wound care was not adhered to, leading to this deficiency.
A resident with diabetes did not receive her noon insulin dose during an off-campus appointment because the nurse forgot to send it. The nurse was busy and working alone, leading to the oversight. The facility received a call from the adult day care center about the missing insulin, and a one-time order was made to hold the dose.
A resident with multiple health conditions, including COPD, was sent to an adult day care center without sufficient oxygen supply, leading to a drop in oxygen saturation levels and requiring emergency services. Facility staff were unaware of how long an oxygen tank would last, and the facility's policy lacked guidance on ensuring adequate oxygen for outings.
A resident with cognitive impairment and a history of falls did not receive wound care as prescribed by a physician. Observations showed that wound dressings on the resident's forearms were not changed according to the orders, with bandages dated several days prior. Documentation discrepancies were noted, and an LPN admitted to not performing the dressing change. The DON confirmed the failure to follow the physician's orders.
Two residents experienced significant delays in call light responses, with one waiting 23 minutes and another reporting a one-hour wait. The facility's staffing limitations contributed to these delays, impacting residents with conditions such as dementia and paraplegia who require timely assistance.
A resident with a history of cancer and a hip fracture experienced severe pain due to a delay in receiving a scheduled Fentanyl patch. Miscommunication between the pharmacy, facility staff, and hospice physician led to the patch not being applied for two days, despite the resident's reports of severe pain. The facility's pain management policy was not followed, resulting in inadequate pain management.
The facility failed to maintain a clean, homelike environment, with residents reporting unclean rooms and observations revealing dust, cobwebs, and unmade beds. A resident linked an eye infection to room dust, and another's bed had visible urine stains. Staff interviews showed inconsistencies in cleaning and bed-making practices, and facility policies were not followed.
A facility failed to follow physician orders for a resident's catheter care, resulting in the catheter not being changed as scheduled. The resident, who relied on staff for toileting due to a neurogenic bladder, reported the issue, but the facility's process for handling physician orders was ineffective. Despite a double-check system, the catheter change order was not executed, and staff interviews revealed a lack of clarity and accountability in implementing physician orders.
A resident with a Stage 4 pressure ulcer and an unstageable ulcer did not receive weekly assessments as required, from a visit to a wound clinic until an assessment at the facility over a month later. The resident, with a history of heart failure, cancer, and dementia, was dependent on staff for mobility and care. The facility acknowledged the lapse in conducting weekly measurements, despite the resident's complex medical needs and the importance of regular monitoring for pressure ulcer management.
A resident was observed smoking on the grounds of a smoke-free LTC facility, contrary to the facility's smoking policy. The resident, who was assessed as an independent smoker, wheeled herself to a sidewalk on the premises and smoked without staff supervision. The facility's policy requires residents to leave the grounds to smoke, which was not adhered to, leading to a deficiency.
A resident with intact cognition and specific dietary preferences for a vegetarian diet was repeatedly served meals containing meat and eggs, despite her clear communication of these preferences. The facility's failure to document and honor her dietary choices, compounded by a gap in the Dietary Services Manager position, resulted in inappropriate meal service. Staff were aware of the resident's requests, but the lack of proper documentation and communication led to this deficiency.
The facility failed to provide SNF Advanced Beneficiary Notice (ABN) forms 48 hours before the end of skilled services for two residents, as required by Federal Regulations. This deficiency was identified during a mock survey after the retirement of the long-term social worker, revealing that ABNs were not being completed correctly.
Food Preparation Not Performed Using Sanitary Practices
Penalty
Summary
The facility failed to prepare food in accordance with professional food safety standards. During observation of food preparation, Staff C washed her hands, used towels to remove pans of rice and pork stir fry from the convection oven, and placed the towels on the preparation table. She then scooped rice and pork stir fry for 7 pureed meals, wiped her hand on one of the towels, and proceeded to open a bread bag and don gloves while handling bread, utensils, and equipment during the preparation process. Staff C used gloved hands to place bread on a cutting board, operate the robo coupe, add liquid from the pork stir fry, remove additional bread from the bag, straighten stacked bread slices, and cut the bread while holding it with her gloved hand. She also touched the robo coupe blade and scraped the sides of the bowl with a rubber spatula, including using one hand to scrape food off the spatula. Staff C later stated she did not recall touching the bread or pureed mixture with gloved hands that had touched multiple nonfood surfaces, and Staff E and the Regional Dietician both reported that Staff C should not have touched the bread, pushed the robo coupe blade down, or scraped off the spatula with gloved hands that had contacted nonfood surfaces. The employee file showed Staff C was a Cook whose job description required sanitary food handling, and the facility policy directed staff to use proper hygiene and sanitary practices to prevent food borne illness.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of discharges for 3 of 6 residents reviewed: Resident #13, Resident #122, and Resident #126. Review of the electronic health record showed Resident #13 had hospital paid leave effective 3/28/26, and a progress note dated 3/29/26 documented that the resident had been admitted to the hospital. However, the Notice of Transfer Form to the LTC Ombudsman did not include this hospitalization. For Resident #122, the EHR showed hospital unpaid leave effective 3/26/26, and a progress note dated 3/26/26 documented admission to the hospital, but the Notice of Transfer Form lacked this hospitalization. For Resident #126, the EHR showed hospital paid leave effective 2/24/26 and stop billing effective 2/28/26. A progress note dated 2/24/26 documented the resident was sent to the emergency room for surgical opinion, and a progress note dated 2/27/26 documented the resident was being discharged. The Notice of Transfer Form to the LTC Ombudsman did not include the 2/24/26 hospitalization or the 2/28/26 discharge. During interview, Staff A, Interim Social Services, stated Residents #13 and #126 had not been included on the Notice of Transfer Form, and the Administrator acknowledged the facility lacked a policy and that both residents should have been included in the notifications.
MDS Assessments Did Not Accurately Reflect PASRR Status and Feeding Tube
Penalty
Summary
The facility failed to complete MDS assessments that accurately reflected resident condition for two residents. For one resident, the MDS dated 8/23/25 indicated the resident was not considered by the state Level II PASRR process to have serious mental illness, intellectual disability, or a related condition, even though the chart contained a Notice of PASRR Level II Outcome dated 3/27/25 stating the resident needed the level of services provided in a nursing facility and specialized services for behavioral health and/or developmental condition. The MDS Coordinator reviewed the record and confirmed the MDS failed to show the Level II PASRR outcome and did not accurately reflect the resident’s status. For another resident, the care plan identified tube feeding and directed staff to check placement and gastric contents/residual volume per facility protocol, and the resident’s hospital discharge summary documented a left PEG tube. Physician orders included enteral feeding, water flushes, and residual checks, and staff observed the resident receiving PEG tube feeding. However, the MDS assessment did not document a feeding tube in Section K, despite the RN who completed the section signing that the assessment accurately reflected resident information. The MDS Coordinator acknowledged the resident had a feeding tube since original admission and stated the MDS assessment was inaccurately coded.
Missed Dialysis Access Assessments
Penalty
Summary
The facility failed to ensure post-dialysis assessments and fistula assessments were consistently completed for a resident who received hemodialysis for end stage renal disease and had an AV fistula in the left upper extremity. The resident’s care plan directed staff to listen to and feel the dialysis site before dialysis, after dialysis, and on non-dialysis days, and the electronic record also directed completion of a dialysis evaluation before dialysis, after dialysis, and on non-dialysis days. The resident had intact cognition and reported that nurses often checked vital signs before dialysis but frequently did not check her afterward or on days without dialysis, and she stated that no one had checked her access site the previous day. Record review showed that on two non-dialysis days, staff signed off that the dialysis assessment was completed even though the actual evaluation data was missing. On a dialysis day, the facility failed to perform the required check after the resident returned from treatment. Staff confirmed that dialysis residents were expected to be evaluated every day, including assessment of the fistula for thrill and bruit and vital signs before and after dialysis appointments. The DON acknowledged that post-dialysis checks did not always happen and stated that daily checks on non-dialysis days only occurred if specifically ordered, with missed checks to be documented as refused or if the resident was out of the building.
Failure to Assess and Care Plan PTSD-Related Behaviors
Penalty
Summary
The facility failed to address a resident’s PTSD-related needs in the assessment and care planning process. Admission paperwork scanned into the facility documented that the resident took prazosin 1 mg at bedtime for chronic PTSD with trauma-related nightmares, but the admission care plan did not include focus areas, goals, or interventions for PTSD, nightmares, trauma, or prazosin. The MDS dated 3/08/2026 documented severe cognitive impairment, diagnoses of non-Alzheimer’s dementia, anxiety disorder, and depression, and did not check the PTSD box. A later provider visit note did not include PTSD in the past medical history, and the resident’s EHR did not contain a PTSD diagnosis until staff later located it on the admission orders. Behavior monitoring and symptom documentation were also incomplete. The EHR task section included monitoring behavior symptoms, and the 30-day look back documented episodes of crying, yelling, pushing, grabbing, and yelling/screaming, but the MAR for May 2026 did not include behavior monitoring even though it documented prazosin administration for chronic PTSD with night terrors. During observations, the resident was heard calling out, humming, and yelling in bed. Staff interviews showed they knew the resident sometimes yelled or screamed and called out, but they did not know the cause, were not aware of the PTSD diagnosis or nightmares/night terrors, and could not identify triggers or find documentation of a plan for non-pharmacological interventions.
Failure to Document Staff COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain documentation of staff screening and education regarding COVID-19 vaccination and failed to maintain records of staff vaccination status. During interviews, the Assistant Director of Nursing, who stated she was the infection preventionist, reported that the same provider who vaccinated residents could provide education to staff, but she did not have documentation showing which staff received that education. She also stated she would need to check the training platform or orientation records because she was not involved in all of the training processes. The Director of Nursing stated staff received COVID education through the facility's training provider, but directed surveyors back to the infection preventionist for documentation. Record review showed a 2026 Annual CNA Training Schedule updated 02/16/2026 that listed staff training by quarter but did not include COVID education. An email from the Administrator included a COVID-19 fact sheet dated 1/31/2025, which she identified as the facility's COVID education, but she did not provide information about when staff received it, who received it, how often it was provided, or how staff were screened. A Certified Medication Aide stated she had worked at the facility for about 2 years, was not asked for her vaccination status, was not offered the COVID vaccine or told where to get one, and did not receive COVID education on paper or in person. The infection preventionist later stated she could not say whether the facility had additional documentation showing staff were screened for vaccine eligibility, provided education, offered the vaccine, told where to get it, or vaccinated through the facility's vaccination partner. The facility policy stated eligible staff were strongly encouraged to receive the COVID-19 vaccine, consent would be documented in the employee health record, and staff would be provided a vaccine-specific fact sheet explaining risks, benefits, contraindications, and potential side effects.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing assistance to multiple residents who required staff help with activities of daily living (ADLs), specifically bathing. Resident #4, who had diagnoses including heart failure, chronic kidney disease, type 2 diabetes, COPD, and a left diabetic foot ulcer, was cognitively intact with a BIMS score of 15/15 and required moderate assistance of one staff member for bathing per the MDS and care plan. He reported not receiving a shower for an entire week, despite being scheduled for showers on Wednesdays and Saturdays, and stated staff told him there was not enough staff and that baths were not done on Sundays. Bathing records showed missed showers on multiple specific dates in December 2025, January 2026, and February 2026. Resident #2, with hemiplegia affecting the right side and a BIMS score of 15/15, also required assistance of one staff member for bathing per the MDS and care plan and reported not receiving twice-weekly baths. Her bathing records showed missed showers on identified dates in December 2025, January 2026, and February 2026. Resident #3, who had a history of stroke with left-side hemiplegia and epilepsy, was cognitively intact with a BIMS score of 15/15 and required assistance of one staff member for bathing per the MDS and care plan; he reported taking baths/showers on Tuesdays and Fridays, but records showed a missed shower on a specific date in January 2026. A CNA stated that residents were not getting their baths as scheduled because staff were pulled to cover other units when staff did not show up for work, leaving units short. This pattern of missed baths conflicted with the facility’s ADL policy, which stated that residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Failure to Provide Ordered Wound Care and Ensure Attendance at Wound Clinic Appointments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care as ordered and to ensure attendance at scheduled wound and infectious disease appointments for a resident with multiple comorbidities. The resident had diagnoses including heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer, and was cognitively intact with a BIMS score of 15/15. The care plan identified increased risk for skin impairments and required monitoring and documentation of skin injuries, weekly wound measurements, and continuous use of a wound vac to the left heel. Physician orders included application of Iodoflex iodine pads to the left lateral heel ulcer every other day, with a subsequent order specifying Iodoflex application every two days and use of betadine gauze once Iodoflex was unavailable. Review of the Treatment Administration Records showed that ordered wound treatments were not completed on multiple scheduled dates in January and February. Specifically, the Iodoflex iodine pad treatment ordered every other day was not completed on several listed dates, and the Iodoflex external pad ordered every two days was also missed on multiple dates. The podiatry wound clinic provider reported concerns that the resident’s wound care needs were not being met, including missed wound clinic and infectious disease appointments, and difficulty obtaining wound care supplies. The provider stated she wanted to see the resident weekly, but the resident was a no-show for several wound and infectious disease appointments, and additional appointments were missed due to lack of transportation. Observations and interviews further showed inconsistencies in wound care delivery and documentation. The resident reported having wound clinic appointments every other week and stated that appointments were missed when the facility forgot to arrange transportation or lacked staff to drive the van. On observation, the resident’s left foot dressing was in place without a date, and when the resident asked an LPN about a dressing change, he was told it had already been done, although the TAR showed it had been signed off by a CMA who later admitted she had accidentally signed off all treatments for the resident. On a subsequent day, the same dressing was still in place, again without a date, and was removed and changed by an LPN/Assistant DON. Facility wound care procedure required staff to verify physician orders, review the care plan, and document refusals and physician notification if a resident refused treatment, but the report documents missed treatments and missed appointments without indication of resident refusal.
Failure to Provide Palatable Food at Safe Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable food at safe and appetizing temperatures for one cognitively intact resident. The resident had multiple diagnoses, including heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer, and was care planned for a low sodium, regular texture diet with thin liquids, with staff directed to monitor diet tolerance. The resident reported eating all meals in his room and stated that his food was cold almost every meal, was often served later than scheduled, and did not taste very good. Surveyor observation of a noon meal service on Station 3 showed residents waiting in the dining room while beverages were passed and hot food was delayed as staff attempted to plug in the hot cart, which had to be moved due to a short power cord. Residents requested forks but were told none were available. The resident’s tray was prepared from the hot cart and delivered to his room, where food temperatures were immediately taken and showed the pork chop at 101.8°F, potatoes at 121.8°F, and milk at 45.4°F. Review of temperature logs for that meal showed the meat recorded at 189°F before service and 171°F after service, no temperatures recorded for the potatoes/starch, and milk temperatures of 34°F before and 39°F after service, despite facility policy requiring proper hot and cold temperatures during food service and discarding foods held in the temperature danger zone after four hours.
Failure to Ensure Safe Resident Transfers and Proper Sling Use
Penalty
Summary
The facility failed to provide safe transfers for three residents, resulting in accident hazards and inadequate supervision. One resident, with a history of stroke, heart failure, dementia, and on anticoagulation therapy, was dependent on staff for transfers and required a two-person assist with a stand lift as per her care plan. However, a CNA attempted to transfer her alone using the incorrect full body lift instead of the stand lift, leading to the resident falling from the lift, sustaining a head laceration that required staples, and being sent to the emergency department. Subsequent clinical notes documented extensive bruising and pain, with medical evaluations revealing hematomas and ecchymosis over multiple body areas. Observations and interviews indicated improper placement in the lift and ill-fitting slings contributed to repeated injuries during transfers. For another resident with atrial fibrillation, dementia, and multiple sclerosis, staff used a full body lift with an XXL sling for transfers, despite the resident's weight being below the recommended range for that sling size. Staff were observed to be unaware of the correct sling sizing, and the facility's lift sizing chart was not consistently referenced. The Assistant Director of Nursing confirmed that the wrong sling size was used for this resident, and staff required further education on proper sling selection based on weight and body size. A third resident, with coronary artery disease and severe cognitive impairment, was also transferred using an XXL sling, which was not appropriate for her weight. The facility's policy required individualized assessment for transfer assistance, including proper sling size and fit, but staff relied on judgment rather than established guidelines. The color-coded sling system and sizing chart were not consistently followed, leading to the use of slings that did not fit residents properly, increasing the risk of injury during transfers.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to multiple residents, as observed during staff and resident interviews, clinical record reviews, and direct observation. One resident with no cognitive impairment, a history of falls, and requiring moderate assistance for transfers was found with her call light out of reach on the bedside stand and her bed control on the floor. She confirmed she could not reach the call light and would have to yell for help if needed. Another resident, also with no memory impairment and a history of stroke and hemiplegia, was found calling out for assistance and rattling the bed rail because the call light was on the wall and out of reach. This resident was found incontinent of bowel and bladder and reported being unable to call for help due to the inaccessible call light. A facility-wide call light audit further revealed several instances where call lights were not accessible to residents in their rooms. Observations included call lights hanging on the wall, on the floor, or placed in drawers, all out of reach of residents who were in bed or in wheelchairs. In some cases, residents were unaware of the location of their call lights. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair, but this was not consistently followed.
Failure to Maintain Clean and Homelike Environment Due to Worn Carpet and Pest Issues
Penalty
Summary
The facility failed to provide a clean and homelike environment as evidenced by large, blackened, and worn areas of carpet in the main lobby and at the entrance of the skilled unit. Observations revealed that the carpet in these areas was significantly stained and darkened, with measurements provided for the affected spaces. Staff interviews confirmed that the carpet had been cleaned twice in the past six months, but the cleaning was not effective due to the carpet's worn condition. Housekeeping staff reported that the facility was planning to replace the carpet with laminate flooring, but no timeline had been established for completion, and the current state of the carpet persisted. Additionally, the facility experienced an incident involving bed bugs brought in by a resident's visitor. Staff followed facility policy by isolating and treating the affected room, laundering clothing, and working with a contracted pest control company. Despite these actions, the presence of bed bugs and the ongoing issues with the carpet contributed to an environment that was not clean or homelike, as required. Staff interviews indicated that the facility was aware of the problem and had plans for remediation, but the deficiency remained at the time of the survey.
Failure to Correct and Prevent Ongoing Medication Administration Deficiencies
Penalty
Summary
The facility failed to effectively carry out Quality Assurance activities to ensure that previously identified deficiencies, specifically related to medication administration, were corrected and did not persist. Despite the existence of a QAPI plan and regular meetings of the QAPI team, deficiencies in medication administration were identified during a prior survey and again during a subsequent complaint survey. The QAPI team collected data through various channels, including an online program, suggestion boxes, grievance forms, and state agency findings, and prioritized issues affecting residents' quality of life or rights. However, the facility continued to struggle with the same issues, indicating that the measures taken were not sufficient to resolve the deficiency. Interviews with the Administrator and the DON revealed that the QAPI team reviewed medication administration practices, including rights, refusals, and missed medications, and conducted ongoing audits following the previous survey. The QAPI plan outlined responsibilities for reviewing data and prioritizing improvement opportunities, but the recurrence of the same deficiency suggests that the process was not effective in preventing ongoing problems with medication administration. The report does not mention any specific residents or their medical conditions at the time of the deficiency.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff actions, or detailed events leading to the deficiency. No additional information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Provide Toileting Assistance and Maintain Call Light Accessibility
Penalty
Summary
A resident with a history of stroke and hemiplegia, who required partial assistance for transfers and was identified as a fall risk, was not provided with necessary toileting assistance. The resident's care plan directed staff to encourage the use of a call light and ensure it was within reach. However, on the morning in question, the resident was found calling out for help and rattling the bed rail, with the call light placed out of reach on the wall. The resident was incontinent of bowel and bladder at that time, despite normally being continent. Staff interviews and clinical record review confirmed that the night shift aide had failed to return the call light to an accessible position after providing care, leaving the resident unable to request assistance. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support, including assistance with elimination. The lack of a room-to-room report between shifts contributed to the oversight, as the day shift CNA discovered the resident's situation upon arrival. The incident was documented in the facility's incident report, and the resident confirmed the event occurred once, with no recall of the staff involved.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents, resulting in significant medication errors. In the first instance, a resident with multiple diagnoses including heart failure, coronary artery disease, wound infection, and diabetes mellitus, who was totally dependent on staff for several activities of daily living, was given another resident's medications in error. This occurred because the resident did not have a profile picture on file, no name tag on the door, and was responding to the other resident's name during the medication pass. The medications administered included several with potential for serious side effects, such as antipsychotics, anticonvulsants, and antihypertensives. Following the error, the resident became lethargic, developed increased confusion, and was ultimately sent to the hospital for further management after a decline in vital signs and mental status. The incident was attributed to human error and a failure to properly identify the resident prior to medication administration. Staff interviews revealed that the nurse responsible was overwhelmed by workload and distractions, leading to a lapse in following the required verification steps, such as confirming the resident's identity and cross-checking medications. The nurse admitted to not adhering to the 'five rights' of medication administration and acknowledged that the error could have been prevented by slowing down and double-checking the resident's identity. The Director of Nursing confirmed that the root cause was the failure to properly identify the correct resident. In a separate incident, another resident with a history of coronary artery disease, heart failure, and diabetes mellitus received the wrong dose of insulin during a medication pass. The nurse administered 12 units of Aspart insulin instead of the ordered 15 units plus an additional sliding scale dose, resulting in a total underdose. The nurse was unable to recall the correct dose and reported difficulty due to being assigned to different units during the shift. The care plan for this resident did not include specific instructions for staff to double-check insulin doses. The Director of Nursing verified that the resident should have received a higher total dose than was administered.
Failure to Monitor and Intervene After Insulin Administration Resulting in Hypoglycemic Event
Penalty
Summary
A resident with severe cognitive impairment, heart failure, urinary tract infection, and diabetes mellitus was dependent on staff for most activities of daily living except eating and oral hygiene. The resident had physician orders for scheduled and sliding scale insulin, with instructions to monitor blood glucose as ordered. However, the care plan did not include directions for staff to observe for signs of hypoglycemia or hyperglycemia, nor did it specify actions to take if such signs were present. On the day of the incident, the resident was administered rapid-acting insulin before consuming her meal. Staff placed the lunch tray in front of the resident and verbally prompted her to eat, but she did not touch her food. The nurse who administered the insulin did not check on the resident again after the administration, and there was no follow-up to ensure the meal was consumed. Several hours later, the resident was found unresponsive with a critically low blood glucose level (25 mg/dL), and emergency medical services were called. Documentation was incomplete, with missing entries regarding the initial blood glucose reading and the administration of Glucagon. Interviews with staff revealed inconsistent understanding and implementation of insulin administration protocols, particularly regarding the timing of insulin relative to meals and the need for post-administration monitoring. Staff acknowledged that the resident typically ate better when assisted to sit up in a chair, but this was not addressed in the care plan. The facility's policy required monitoring and documentation of blood glucose and resident status after insulin administration, but these steps were not followed, contributing to the resident's hypoglycemic event and subsequent hospitalization.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Maintain Kitchen Sanitation and Monitor Dishwasher Function
Penalty
Summary
Surveyors observed multiple sanitation and equipment monitoring deficiencies in the facility's kitchen. During an initial tour, a fan above the hand washing sink was found to be covered with mesh and a thick layer of dust, with the fan blowing toward the clean side of the dishwasher. The top of the dishwasher itself was covered with yellow debris, and the fire suppression system spigots had dust particles hanging from them. Staff responsible for dishwashing did not know how to test the dishwasher's function and had not performed the required test before washing breakfast dishes. Additionally, the Dietary Manager was unable to locate a log documenting dishwasher function tests. Review of the Dish Machine Temperature Log revealed missing documentation for required wash and rinse temperature and sanitizer concentration checks for several meals over multiple days. A follow-up visit confirmed that dust remained on both the fire suppression system spigots and the fan. Facility policies required food service areas to be kept clean and for dishwashing machine temperatures to be checked with each cycle, but these procedures were not consistently followed, as evidenced by the observations and lack of documentation.
Failure to Change and Label Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not changing the oxygen tubing as required for a resident with physician orders for oxygen therapy. The resident, who had diagnoses including COPD, respiratory failure, and anxiety, required moderate assistance with activities of daily living and utilized both an oxygen concentrator and a portable tank. Observations revealed that the tubing on the resident's oxygen tank was not labeled with the date it was last changed, and the tubing on the concentrator in the resident's room was last changed over two weeks prior, as indicated by the label dated 5/5/25. Interviews with nursing staff and the DON confirmed that facility policy requires oxygen tubing and cannulas to be changed weekly and labeled with the date and staff initials. Staff were unsure of the required frequency until reviewing the policy, which directs weekly changes. The failure to change and properly label the oxygen tubing for both the concentrator and the portable tank resulted in noncompliance with the facility's infection prevention policy.
Failure to Provide Correct Pureed Diet Portions and Menu Items
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received the correct portion sizes and food items as specified by the menu. During meal preparation, the Dietary Services Manager Assistant prepared pureed Salisbury steak by combining steaks, bread, and gravy, then adjusted the mixture to reach a total of 6 cups. He referenced the Pureed Diet Portion Sizes/Scoops chart, which directed the use of 2 #8 scoops per serving, but during meal service, a different staff member used a #6 scoop (5 1/3 ounces) instead of the specified portion size. Additionally, residents on a pureed diet were served Salisbury steak, carrots, and bread, but did not receive the required whipped potatoes, contrary to the menu instructions. Staff interviews revealed inconsistencies in following the established portion size chart and a lack of policies regarding the pureed and mechanical soft diet process. The Registered Dietician confirmed that residents on a pureed diet should have received mashed potatoes and that there were no formal policies guiding the puree process. The Dietary Manager also stated that staff should use the chart for scoop sizes and expected residents to receive the correct portions, indicating a failure to adhere to menu requirements and established procedures.
Failure to Administer Pneumococcal Vaccine per Updated CDC Guidelines
Penalty
Summary
The facility failed to follow the CDC 2025 Adult Immunization Schedule for pneumococcal vaccination for one resident. The resident was admitted to the facility and had previously received a pneumococcal 23 vaccination several years prior. Upon admission, the resident consented to receive the pneumococcal vaccine, and an active provider order was in place for administration if applicable. Pharmacy consultant notes recommended administration of Prevnar 20 and advised nursing to obtain consents and enter them into the EHR. However, the updated CDC guidelines indicated that the resident was eligible for an additional pneumococcal vaccine, which was not administered. Staff interviews revealed uncertainty regarding responsibility for reviewing pneumococcal vaccination status during the admission process. The facility's policy required assessment of vaccination eligibility within five working days of admission and offering the vaccine within thirty days if indicated, but did not specify who was responsible for this assessment. As a result, the resident did not receive the recommended pneumococcal vaccination according to the most recent guidelines.
Failure to Conduct and Document Skin Assessments
Penalty
Summary
The facility failed to conduct and document follow-up skin assessments for a resident who was at risk for pressure ulcers and had a history of skin tears. The resident, who had multiple diagnoses including anemia, congestive heart failure, and chronic kidney disease, required extensive assistance with daily activities and was on medications such as antidepressants and diuretics. Despite the care plan's requirement for weekly documentation of skin injuries, the facility did not complete an initial skin assessment upon the resident's admission or re-admission. The deficiency was further highlighted by the lack of documentation and follow-up on a bruise found on the resident's spine. Although a bruise was noted on admission, it was not measured or documented until several days later. Staff interviews revealed inconsistencies in the assessment process, with some staff unaware of the bruise and others failing to document or notify emergency contacts about the skin issue. The resident was also out of the facility for dialysis during some scheduled assessments, which contributed to the lack of timely evaluations. The facility's policy required comprehensive skin assessments upon admission and regular inspections during personal care activities. However, the staff did not adhere to these guidelines, resulting in missed assessments and documentation. The Director of Nursing acknowledged the expectation for weekly assessments and follow-ups when residents returned from appointments, but this was not consistently practiced, leading to the deficiency in care for the resident's skin condition.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as Resident #10, by not utilizing a gait belt during a two-person transfer as directed by the Care Plan. Resident #10 had moderately impaired cognition, was wheelchair dependent, and required maximum assistance with transfers. The Care Plan specified that the resident was to be non-weight bearing on the left lower extremity and required the assistance of two staff members for stand and pivot transfers. However, during an incident on February 23, 2025, staff members did not use a gait belt while transferring the resident, which was against the facility's policy and the Care Plan instructions. Interviews with staff and family members revealed that the resident was combative and in pain during the transfer, which involved moving her from the bed to a wheelchair, then to the toilet, and back. Staff D, a CNA, reported using a bear hug technique instead of a gait belt due to the resident's combativeness. The resident's daughter expressed concerns about the roughness of the transfer and the absence of a gait belt, noting that her mother was in significant pain during the process. The Director of Nursing confirmed that the expectation was for staff to use a gait belt for all two-person transfers if the resident allowed, as per the facility's policy on safe lifting and movement of residents.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, leading to a deficiency in care. Resident #10, who was admitted for aftercare following a left tibial plateau fracture and later moved to the Chronic Confusion or Dementing Illness Unit, experienced unmanaged pain. Despite being on hospice care for vascular dementia, the facility did not complete pain assessments as directed, update narcotic records with changes in medication prescriptions, or conduct follow-up assessments when pain interventions were ineffective. The resident's care plan included interventions for opioid medication use and pain management, but these were not effectively implemented. The Medication Administration Record/Treatment Administration Record (MAR/TAR) showed multiple instances where pain and anxiety medications were given but found to be ineffective, with no further interventions documented. Additionally, the facility failed to document pain assessments on several dates and shifts, as required by the resident's care plan. Interviews with family members and staff revealed concerns about the resident's unmanaged pain and the facility's failure to administer pain medication as ordered. The Director of Nursing acknowledged the expectation for staff to start a new Individual Narcotic Record with each prescription change and to follow up on ineffective pain interventions. The facility's policy on pain assessment and management emphasized the need for regular assessment and modification of pain management strategies, which was not adhered to in this case.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, homelike, and safe environment for its residents, staff, and the public. Observations revealed multiple deficiencies, including dust accumulation and dried food particles on table bases in dining areas, exposed insulation material at the entrance of the skilled unit, and a hole in the wall on 3-B Hall caused by a resident's electric wheelchair. Additionally, several resident room doors had jagged pieces of hard plastic sticking out, and a radiator cover was frequently falling off in a resident's room. The maintenance supervisor acknowledged these issues, noting that radiator covers were checked daily during weekdays but not on weekends, and room doors were checked monthly without detailed documentation. Further deficiencies were noted in a resident's room on Station 4, where a large amount of food debris, broken plastic fork pieces, a brown spot on the carpet, and a used Foley catheter with dark urine were found. The room had not been cleaned since the resident was transferred to the hospital days earlier. The housekeeping supervisor admitted that the room was overlooked due to a lack of coordination among the housekeeping staff, despite having three staff members assigned to the task over the weekend. The facility's Homelike Environment Policy, dated February 2021, mandates a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for wound treatments for a resident with non-pressure chronic lower leg ulcers, diabetes, renal insufficiency, stroke, and heart failure. The resident, who had intact cognitive ability, was supposed to receive daily dressing changes as per the care plan. However, observations and record reviews revealed that the dressing changes were not performed on several occasions, specifically on 1/29/25, 1/30/25, and 2/3/25. During an observation on 2/4/25, it was noted that the dressings had not been changed since 2/2/25, despite the presence of the resident's wound physician who emphasized the importance of daily dressing changes to prevent infections. Interviews with the resident and staff further highlighted the issue. The resident reported that staff informed him the dressing change was not done due to insufficient staffing. Staff B-RN, who was responsible for the dressing change on 2/3/25, admitted to not completing the task because she left her shift early and failed to ensure the task was passed on to the relieving nurse. The facility's policy for ulcer/skin breakdown, which outlines the physician's role in guiding care plans and ordering treatments, was not followed, contributing to the deficiency.
Failure to Send Insulin for Off-Campus Appointment
Penalty
Summary
The facility failed to send a resident's insulin medication for an off-campus appointment, resulting in a deficiency. Resident #2, who has multiple diagnoses including diabetes mellitus, was scheduled to attend an adult day care center as part of her discharge plan. According to the care plan, the resident required insulin administration three times a day with meals. However, during her visit to the adult day care center, the noon dose of insulin was not sent with her, as confirmed by the resident and staff interviews. Staff A, the nurse responsible for preparing the medications, admitted to forgetting to send the insulin due to a busy workload. Staff C, upon receiving a call from the adult day care center about the missing insulin, arranged for a one-time order to hold the dose. Staff B, the Director of Nursing, acknowledged that the insulin should have been sent with the resident in the morning. This oversight in medication management led to the deficiency noted in the report.
Inadequate Oxygen Supply for Resident During Outing
Penalty
Summary
The facility failed to provide adequate oxygen services for a resident, leading to a deficiency in respiratory care. The resident, who had a history of debility, cardiac respiratory condition, heart failure, renal failure, diabetes, and Chronic Obstructive Pulmonary Disease, required oxygen therapy. On a day when the resident visited an adult day care center, the facility did not supply enough oxygen, resulting in the resident's oxygen saturation levels dropping into the 70s. The resident's oxygen tank was found empty at the day care center, and emergency services had to be called to provide assistance. Interviews with facility staff revealed a lack of understanding regarding the duration a full E size oxygen canister would last at 2 liters per minute, which is approximately 5 hours according to the oxygen supply company. The staff had miscalculated the resident's return time and did not ensure the resident had sufficient oxygen for the duration of her outing. The facility's Oxygen Administration Policy, dated October 2010, did not provide adequate instructions for preparing residents for outings to ensure their oxygen needs were met.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow a physician's order for wound treatment for a resident with multiple diagnoses, including non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls. The resident, who had moderate cognitive impairment, was identified as a fall risk and had experienced a fall resulting in skin tears. The care plan directed staff to assist the resident with ambulation and remind her to use the call light for assistance. However, observations revealed that the resident's wound dressings on both forearms were not changed as per the physician's orders. The bandages were dated several days prior, indicating that the prescribed daily and every-other-day wound care was not performed. The October Treatment Administration Record showed discrepancies in the documentation of wound care. Staff members signed off on completing the wound care on specific dates, but observations and interviews revealed that the dressings had not been changed as required. An LPN admitted to not performing the dressing change and was unaware of the due date for the treatment. The Director of Nursing confirmed the failure to adhere to the physician's orders, as the bandages observed were dated earlier than the documented treatment dates. This deficiency highlights a lapse in following prescribed wound care protocols and accurate documentation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer resident call lights within 15 minutes of activation for two residents, leading to a deficiency in meeting the needs of residents. Resident #4, who has diagnoses including non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls, expressed frustration over the delayed response to her call light. Despite being able to ambulate independently with a walker, she sometimes requires assistance due to her condition. On one occasion, her call light was activated at 10:55 am and was not answered until 11:18 am, 23 minutes later, by a CNA who was returning from lunch. The CNA explained that staffing was limited at the time, with only one staff member available to answer call lights. Resident #10, who is alert and oriented with a BIMS score of 15, requires total assistance for transfers, toileting, and personal hygiene due to paraplegia and neuromuscular dysfunction. She reported waiting for an hour for staff to respond to her call light when she needed assistance to get out of bed for a meal. The Director of Nurses stated that floor nurses audit call light response times and expects staff to respond within 15 minutes, but this expectation was not met in these instances.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who was prescribed a Fentanyl patch, resulting in the resident experiencing severe pain. The resident, who had a history of malignant neoplasm of the tongue, a hip fracture, and depression, was supposed to have a Fentanyl patch applied on the evening of 8/19/24. However, due to a miscommunication and delay in prescription management, the patch was not applied until the morning of 8/21/24. During this period, the resident reported being in severe pain, with a pain score of 8 out of 10. The delay was caused by a breakdown in communication between the pharmacy, the facility's staff, and the hospice physician. On 8/19/24, the pharmacy contacted the facility regarding a denial of the Fentanyl patch order and requested to speak with the provider. However, the Assistant Director of Nursing (ADON) was not informed of this request, and a Licensed Practical Nurse (LPN) wrote an order to hold the Fentanyl patch until 8/22/24 without consulting the provider. The Physician's Assistant (PA) managing the resident's Fentanyl patch was only made aware of the issue on 8/20/24 and sent a new prescription that morning, but the patch was still not applied until the following day. The facility's pain management policy, revised in 2017, outlines the responsibilities of physicians and staff in managing pain, including timely identification and treatment. Despite this policy, the resident's pain was not managed appropriately, as evidenced by the delay in applying the Fentanyl patch and the resident's reports of severe pain. The facility's failure to adhere to its pain management policy and ensure effective communication among staff and external providers contributed to the deficiency.
Deficiencies in Cleanliness and Bed Maintenance
Penalty
Summary
The facility failed to maintain a clean, homelike environment for its residents, as evidenced by observations and resident reports. Resident #61, with intact cognition, reported that his room was only cleaned because the state was present, and it had been approximately three weeks since the floors were last cleaned. Observations revealed a black substance on the floor, cobwebs, and heavy dust in the room, despite a housekeeper's claim that rooms were cleaned daily. Resident #71 also reported dissatisfaction with the cleanliness of his room, citing dust and cobwebs, and linked his eye infection to the dust. The facility's deep clean schedule and quality control forms showed inconsistencies and lack of documentation for completed cleanings. Additionally, many unmade beds were observed throughout Station 3, with some beds having visible urine stains and strong odors. Resident #38's bed was noted to have saturated paper chux and urine-soaked sheets, yet the resident was observed in the dining room, indicating a lack of timely bed maintenance. Staff interviews revealed confusion and inconsistency regarding bed-making responsibilities, with some staff unsure why beds were not being made and others stating that beds should be made daily unless residents request otherwise. The facility's policies on cleaning and maintaining a homelike environment were not being followed, as evidenced by the lack of documentation and observed conditions. The Cleaning and Disinfecting Resident Rooms Policy lacked specific directions on the frequency of mopping and window cleaning, contributing to the deficiencies. The Homelike Environment Policy emphasized a clean and orderly environment, which was not upheld, as seen in the unmade beds and unclean rooms.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for catheter care for Resident #71, who was dependent on staff for toileting and used an indwelling urinary catheter due to a neurogenic bladder. The resident reported that his catheter had not been changed in at least four weeks, despite having informed a staff member who no longer worked at the facility. Observations confirmed the resident's catheter was draining clear yellow urine, but there was no documentation of a catheter change as per the physician's orders. The physician had ordered the catheter to be changed monthly, every 28 days, on the day shift, starting from 8/06/24, but the change had not been completed by 8/21/24. The facility's process for handling physician orders involved a double-check system, where the charge nurse noted the orders, and a second nurse was responsible for double-checking them. However, this process failed in the case of Resident #71, as the catheter change order was not executed. Staff interviews revealed a lack of clarity and accountability in implementing and overseeing physician orders, as evidenced by the failure to change the resident's catheter according to the updated physician order. The Director of Nursing expected nurses to follow physician orders, but the facility's policy lacked specific direction on who was responsible for implementing or overseeing these orders.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to conduct weekly measurements and assessments for a resident with pressure ulcers, specifically Resident #37, who had a Stage 4 pressure ulcer and an unstageable ulcer. The deficiency was identified through observations, interviews, and record reviews, revealing that the resident did not receive the required weekly assessments from the time he was seen at a wound clinic on July 10, 2024, until an assessment was conducted at the facility on August 20, 2024. This lapse in care was acknowledged by the facility's Director of Nursing, who confirmed that weekly measurements were not being performed. Resident #37 had a medical history that included heart failure, cancer, depression, and non-Alzheimer's dementia, with a documented moderately impaired cognition. The resident was dependent on staff for bed mobility, transfers, and toileting. Despite the resident's complex medical needs and the presence of significant pressure ulcers, the facility did not adhere to the professional standards of practice for pressure ulcer care, which require regular monitoring and assessment to prevent further deterioration. The Assistant Director of Nursing mentioned that the resident was followed by a wound clinic, and his wife preferred this arrangement as it allowed them to spend time outside the facility. However, this did not absolve the facility of its responsibility to perform weekly assessments as required. The facility's failure to conduct these assessments was a clear deviation from established guidelines for pressure ulcer management, which emphasize the importance of regular monitoring to optimize healing and prevent new ulcers from developing.
Resident Smoking on Smoke-Free Campus
Penalty
Summary
The facility failed to ensure that residents adhered to its smoking policy, which led to a deficiency involving a resident smoking on facility grounds. The facility is designated as a smoke-free campus, yet a resident was observed smoking on the premises. This resident, who had recently been readmitted to the facility, was seen wheeling herself to a sidewalk between the building and the parking lot, where she lit a cigarette and smoked. The resident was not accompanied by staff, and she disposed of the cigarette in a trash can outside the exit door. The resident had a care plan initiated that directed staff to educate her on the facility's tobacco and smoking policies. However, the resident stated that she was told by staff that they were too busy to assist her with smoking, although this did not happen often. The facility's Director of Clinical Operations confirmed that the facility is a non-smoking campus and clarified that residents must leave the grounds to smoke, which the resident did not do. The absence of a receptacle for cigarette disposal in the area where the resident smoked further indicated non-compliance with the facility's smoking policy. The facility's smoking policy, revised in July 2017, outlines that smoking is only permitted in designated areas outside the building, and residents must be evaluated for their ability to smoke safely. The resident in question was assessed as an independent smoker, capable of smoking safely. Despite this, the facility's policy was not enforced, as the resident smoked on facility grounds without supervision, contrary to the established guidelines. This lack of adherence to the smoking policy resulted in the observed deficiency.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident #113, who had chosen to follow a vegetarian diet. Despite the resident's clear communication of her dietary preferences, including her inability to digest meat and eggs, the facility continued to serve her meals containing these items. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), reported multiple instances where she was served meat and eggs, which she could not consume due to her dietary restrictions and personal choice. Interviews with staff members, including dietary aides and a licensed practical nurse, revealed awareness of the resident's request for a vegetarian diet. However, there was a lack of documentation in the resident's care plan and dietary notes to reflect her preferences. The dietary staff failed to update the resident's meal cards to exclude meat and eggs, leading to repeated instances of inappropriate meal service. The facility's dietary communication process was hindered by a gap in the Dietary Services Manager (DSM) position, resulting in inadequate communication and documentation of the resident's dietary needs. The facility's policy on food and nutritional services mandates that resident preferences be considered and that meals be inspected to ensure they meet the residents' needs. However, due to the transition of the Housekeeping Manager into the role of Dietary Manager and the lack of a designated person to review menus with residents, the facility did not adequately address the resident's dietary preferences. This oversight led to the resident being served meals that did not align with her vegetarian diet, highlighting a deficiency in the facility's ability to accommodate resident choices and preferences.
Failure to Provide Timely SNF ABN Forms
Penalty
Summary
The facility failed to comply with Federal Regulations regarding Medicare billing practices by not providing the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) forms 48 hours before the end of skilled services for two residents. Resident #112 received Medicare benefits for skilled services from June 10 to June 21, 2024, but was not given the required SNF ABN (CMS form 10055) to inform them of potential liability if skilled services continued. Similarly, Resident #122 received Medicare benefits for skilled services from April 3 to April 23, 2024, and also did not receive the necessary SNF ABN within the required timeframe. The deficiency was identified during a mock survey in July, which revealed that the ABNs were not being completed correctly following the retirement of the long-term social worker. The facility's policy, dated April 2021, states that the admissions coordinator or business office manager should notify the resident in writing if Medicare may not cover certain skilled services, using the SNF ABN form. This notification is crucial for informing residents of their potential financial liability if they choose to continue receiving services that may not be covered by Medicare.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 196 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Ridge Care Center | 1 mi | ★★★★★ | 3 | 0 |
| Meth-wick Health Center | 2 mi | ★★★★★ | 0 | 0 |
| The Gardens Of Cedar Rapids | 2.1 mi | ★★★★★ | 3 | 0 |
| Living Center West | 3.5 mi | ★★★★★ | 2 | 0 |
| Harmony Cedar Rapids | 4.5 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.