Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Acres Rehabilitation And Care Center during CMS and state inspections, most recent first.
A facility failed to complete comprehensive nursing assessments and interventions for multiple residents with significant changes in condition, including falls, ER/hospital returns, altered mental status, pneumonia treated with antibiotics, nausea and vomiting, rib fractures, and skin injury. One resident had an unwitnessed fall with head/facial injury, limited neuro checks, missing nursing documentation, and later returned to the hospital with altered mental status and hypothermia before dying with sepsis listed as the cause of death. Other residents also lacked documented assessment and follow-up after acute decline, medication treatment, or injury.
A facility failed to prevent and treat pressure injuries for multiple residents with high skin-risk needs. One resident who was wheelchair dependent, incontinent, and on hospice developed a facility-acquired Stage 4 pressure sore after pressure-relief equipment was not used appropriately and repositioning/incontinence care were not provided consistently. Another resident with a Stage 4 hip wound and heel ulcers did not receive ordered protective boots and was exposed to friction and shear during incontinence care, and a third resident did not receive proper heel care or prevention for the opposite heel. Surveyors identified the issue as Immediate Jeopardy.
A resident with fractures, wounds, oxygen needs, and hospice admission had severe pain, agitation, and distress after being found tipped forward in a recliner with a new arm wound. Family reported delayed nurse response, and the chart showed gaps in pain assessment, unclear follow-up after the incident, and delayed implementation of a new morphine order because the e-script was not received correctly by the pharmacy. Grievances from other residents also described pain meds not being given timely or being unavailable, with incomplete follow-up documentation.
A resident with intact cognition and dependence for transfers was bruised during rolling and bed mobility when staff reportedly held his arms too hard, with deep purple bruises documented on the wrist/hand and elbow and photos showing finger-mark-like lines. The record also included repeated concerns about rude or intimidating staff interactions, incomplete abuse investigations, and delayed ADL and incontinence care for other residents.
Unsafe Smoking Supervision and Missing Smoking Assessments: Multiple residents with cognitive and physical impairments had outdated or missing smoking assessments, and residents who required supervision or smoking aprons were observed smoking without those protections. Staff were unable to maintain supervision in the smoking area, and one resident sustained a thermal burn when a cigarette cherry fell into a shoe.
Repeated resident complaints, grievance reports, and staff interviews showed that call lights were often answered late, residents were left wet or soiled, and assistance with toileting, showers, meals, and other ADLs was delayed. Residents reported waiting 30 minutes to 2 hours for help, being turned away after pressing the call light, and not receiving timely incontinence care. An observation also found a resident left in a hospital gown for hours without grooming, dressing, oral care, position changes, or incontinence care, while staff described difficulty meeting heavy care needs with limited aide coverage.
The facility failed to update its facility assessment to reflect recent changes in DON, MDS Coordinator, and Administrator leadership, as well as current resident care needs. The assessment understated the number of residents needing transfer and toileting assistance and did not match the roster showing many residents required assist of 1, assist of 2, EZ sit-to-stand lifts, or Hoyer lifts, with most residents incontinent. The assessment also did not reflect the number of residents on EBP observed during the survey, and the Administrator signed the review as needing no changes.
Infection control and EBP were not followed for multiple residents with MDROs, catheters, wounds, and incontinence needs. Staff were observed entering rooms without required PPE or EBP signage, changing gloves without hand hygiene, handling soiled briefs, linens, and equipment with contaminated gloves, and failing to cleanse all areas during personal care and wound care. The facility also lacked tracking records for facility-wide infection control and antibiotic stewardship, and laundry handling practices were not maintained appropriately.
Offensive urine, ammonia, body, and chemical odors were observed throughout the facility, including hallways, resident rooms, the dining area, activity rooms, and the shower room. Surveyors saw staff leave soiled briefs, trash, and linen bags on the floor or in open bags, and observed incomplete incontinence care for residents who were heavily soiled with urine and feces. A family member reported a resident was left wet and sitting in urine, and a resident reported long waits for toileting assistance. Staff interviews showed mixed awareness of the odor, with some saying they had become used to it.
Failure to document grievance outcomes and confirm whether complaints were substantiated. Multiple residents and family members reported concerns such as delayed call light response, missed incontinence care, rude or abusive staff behavior, missing belongings, and unmet care needs. The grievance forms often noted staff education or brief follow-up, but did not include a clear written determination of whether the grievance was confirmed or not confirmed, and the grievance logs repeatedly listed concerns only as resolved.
A facility-wide breakdown in leadership and resource management led to repeated grievances, delayed call light response, poor ADL assistance, pervasive urine/ammonia odors, and failures to prevent and report abuse and injuries. Surveyors found a cognitively intact resident with bruising from rough handling during care, another resident with an unexplained rib fracture that was not reported, and a resident left without timely toileting, grooming, oral care, or repositioning. The survey also cited inadequate staffing, an outdated facility assessment, and multiple SQOC and IJ-level deficiencies involving nursing assessment, pressure ulcer care, and pain management.
Failure to Monitor QAPI and Resident Care: The facility had repeated survey deficiencies and multiple SQOC tags despite ongoing QAPI/QAA oversight, consultant reviews, and grievance tracking. Surveyors cited repeat issues with resident rights, care planning, med errors, staffing, records, and infection control, and found immediate jeopardy for lack of comprehensive nursing assessment and intervention for 7 residents, lack of pressure sore interventions and care for 4 residents, and inadequate pain management for 1 resident. Leadership also did not identify problems with staffing levels, repositioning, pressure sore interventions, pain assessments, incontinence care, or urine odor.
Failure to Provide Timely ADL and Incontinence Care: Residents with significant cognitive and physical impairments were repeatedly left waiting for help with toileting, incontinence care, grooming, oral care, transfers, and showers. Grievances and observations showed call lights going unanswered, residents remaining wet or soiled for long periods, missed or delayed showers, and staff providing incomplete personal care, including incomplete cleansing after bowel and bladder incontinence and skipped oral care.
Failure to provide restorative nursing programs for residents with mobility needs. Four residents with varying cognitive and physical impairments had MDS assessments showing no restorative nursing program participation, and their care plans lacked restorative nursing programs despite documented mobility concerns, ROM needs, wheelchair use, ambulation assistance, and therapy-to-nursing maintenance plans. Staff interviews described reliance on informal communication, Kardex notes, and therapy handoffs, while CNAs reported they had not received facility training on individualized restorative therapies beyond basic CNA instruction.
Staff failed to demonstrate competency in infection control, EBP, and incontinence care, with CNAs observed entering rooms without proper PPE, skipping hand hygiene, and providing incomplete cleansing during personal care. An RN also could not accurately describe a resident’s baseline or current condition after a rash progressed to hypotension and sepsis, and another resident’s G-tube orders were inconsistently communicated and transcribed.
The facility failed to complete required transfer-related documentation for several residents, including Ombudsman notification, written bed hold notices, and records of resident disposition and belongings. Records for multiple residents showed hospital transfers or returns, but the EHR lacked the required written orientation and transfer information, and staff reported that bed hold notices could not be found. An email also indicated the facility did not have an Ombudsman policy.
Care plans were not updated to match changing resident needs for three residents. One resident’s PASRR specialized services were entered after admission rather than reflected timely, another resident’s nutrition care plan did not reflect major weight changes and conflicting weight documentation, and a third resident’s anticoagulant care plan was not revised after Xarelto was discontinued.
Food items in the kitchen were found open, unlabeled, and undated in dry storage and the cooler, including cereal, noodles, brown sugar, butter, and mozzarella cheese. Surveyors also observed old food particles on the steam table and stove top after lunch. The Dietary Director and head cook stated that open food items should be labeled and dated.
Dirty Dryer Lint Filters: Both commercial dryer lint filters were found completely filled with lint, with additional lint in the compartments and decreased airflow. Laundry staff stated maintenance cleaned the filters once daily, but no cleaning log was available, and the manufacturer’s instructions for the dryer were not available.
A resident with intact cognition and significant assistance needs for toileting and transfers was left waiting for help to use the restroom after requesting assistance during medication pass. An LPN left to find help, and later a CNA entered the room, turned off the call light, shrugged, and walked out without assisting. The resident reported waiting over 2 hours to have a bowel movement and felt abandoned due to short staffing.
A resident with intact cognition, debility, and cardiorespiratory conditions had a stated preference to shower at 11:00 AM on Tuesdays, but staff prepared him for a shower around 7:00 AM instead. The care plan did not identify his bathing-time preference, and during the shower-room observation a CNA interrupted him and spoke in an argumentative manner as he explained that staff told him it was time to wake up and shower.
A facility failed to timely report two abuse-related events to DIAL: one resident with intact cognition developed an unexplained rib fracture after worsening pain and ER evaluation, and another cognitively intact resident had bruising to the wrist and elbow after stating staff grabbed him too hard during care. The records showed internal documentation and resident statements, but no timely abuse/unknown-origin reporting to the state agency.
Incomplete Abuse and Injury Investigations: The facility did not complete thorough investigations for a resident with patterned bruising after care and turning, another allegation involving a CNA’s intimidating and harsh interaction with the resident, and a second resident with an unexplained rib fracture. The records showed the resident reports, staff observations, and limited investigation notes, but the file lacked a full abuse investigation, including a surveyor statement and complete follow-up on staff statements describing harsh or verbal abuse.
A resident with severe cognitive impairment, stroke-related deficits, dysphagia, and G-tube dependence had feeding orders that were held, extended, and later resumed in a way that was not clearly reflected in the EHR. An RD recommended holding the tube feed, and later extending the hold, but an LPN reported he could not find a clear order showing the feeding remained on hold or was discontinued. Observation found Osmolite and water flush supplies still set up in the room, and the record later showed a further RD recommendation to discontinue the G-tube feedings and flushes had not been documented as communicated to or reviewed by the provider.
Two medication management failures were identified. One resident with diabetes and intact cognition did not receive ordered mealtime insulin on two occasions because staff misread the order as a duplicate, and the DON confirmed the nurse should have verified and administered it as ordered. Another resident with a history of DVT and PE continued to have Xarelto listed on the MAR after a hospital stay for vaginal bleeding in which the anticoagulant had been discontinued; the resident repeatedly refused it, and the order remained active until later review by the physician and NP.
A resident with intact cognition and significant medical issues, including toe amputations, DVT, HF, and HTN, left the facility AMA. The chart lacked discharge documentation, discharge instructions, follow-up appts, med reconciliation, and follow-up calls. The DON said she educated the resident and called APS, but the call was not documented, and staff said social services usually handled follow-up calls.
MDS assessments failed to accurately code PASRR status for two residents in Section A. One resident had a PASRR Level II approval with Specialized Services, and another had a PASRR Level I positive screen with MH disability and ID; however, both MDSs left A1500 coded as no and A1510 blank. The MDS Coordinator acknowledged the coding errors during interview and stated the assessments should have reflected the PASRR findings.
Failure to Include Diabetes, High-Risk Medication, and Smoking Interventions in Care Plans: The facility did not develop comprehensive person-centered care plan interventions for two residents. One resident with DM and multiple insulin orders had no care plan interventions for diabetes or high-risk medication use, and another resident who smoked and had COPD had no care plan interventions for smoking status, smoking cessation, or safety strategies despite documented tobacco use and observation in the designated smoking area.
A resident with COPD and respiratory failure with hypoxia did not receive oxygen in accordance with the physician order. Staff observed the resident in a wheelchair with the portable O2 tank indicator in the red on one occasion and later with the meter set at 0 on another occasion, while the resident had tubing in place. Interviews showed a CNA did not know how to switch oxygen to the portable tank and did not notify the nurse when the tank level was low, and an RN later set the oxygen to 2 L and checked the resident’s SpO2.
Unlocked Medication Cart Observed Unsupervised: Surveyors observed a medication cart on 300 hall left unlocked and unattended while nurses, CNAs, residents, and housekeeping passed by. A CMA repeatedly prepared medications from the cart and walked into resident rooms to administer them while the cart remained unlocked, and on another observation an LPN later locked the cart. The facility’s policy required drugs and biologicals to be stored in locked compartments and for medications to remain under direct observation or locked during a med pass.
Two residents had inaccurate clinical records. One resident’s chart contained multiple weight entries that were later struck out, with conflicting MDS, progress note, and care plan documentation about weight loss versus weight gain; staff could not explain why the weights were removed. Another resident had an ARNP note documenting a routine face-to-face exam and complete assessment even though the resident was in the hospital, not in the facility, creating a record that did not match the resident’s actual location and condition.
Failure to post current daily staffing information in a public location was identified. Observation found the staffing sheet near the east entrance was hard to read, kept with multiple outdated forms, and did not show a current daily posting; staff said the schedule was in the breakroom, and the Administrator provided hall assignment sheets that did not include the total number or actual hours worked by nursing staff.
Unlocked medication and supply carts were observed left unattended in resident hallways with medications inside, including duloxetine, Baclofen, trazadone, and Eliquis. Staff were seen near the carts but did not secure them right away, and both an LVN and an RN stated the carts should be locked when left unattended. The facility policy required all drugs and biologicals to be stored in locked compartments and kept locked unless under direct observation during a med pass.
Palatability of Served Sandwiches: Dietary staff served ham and cheese sandwiches that became hard and dry during meal service. A test tray from the 100 hall showed the bun was very hard and difficult to cut, and residents reported the bread was hard, did not taste good, or was gross. The Dietary Supervisor noted the buns looked hard when removed from the oven and believed the time in the oven may have dried them out.
Unattended EHR Laptop Exposed Resident Information: An EHR laptop was left open on a resident hall with 11 residents' information visible. An RN stated laptops are not to be left open when staff are not present and said he did not know it was open. The DON stated the screen should be locked when staff walk away, and the facility's HIPAA Security Measures policy required physical safeguards to limit access to electronic information systems.
Staff failed to maintain resident dignity and respond appropriately to needs in several instances. A resident with chronic pain and a leg fracture was left on the toilet for an extended period after activating the call light, despite multiple staff reportedly walking past without responding, and later reported that an LPN was intimidating and did not provide requested PRN narcotic pain medication for severe pain, leading the resident to cry in pain. Two residents reported that staff routinely entered their rooms without knocking, which was directly observed when staff interrupted interviews without announcing themselves. Another dependent resident with CVA, malnutrition, aphasia, dementia, and severely impaired cognition was observed being fed by a CNA who appeared disengaged, did not interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before continuing to feed, contrary to expectations for dignified, respectful care.
Surveyors found that the facility failed to fully incorporate key interventions into the comprehensive care plans for two residents. One resident with a history of stroke, unsteadiness, and a recent fall from bed had been instructed by staff to keep the bed in the lowest position while asleep, but this specific fall-prevention measure was not documented in the care plan, which only referenced general mobility assistance and a clutter-free environment. Another resident with severe cognitive impairment, dementia with behavioral disturbances, anxiety, and depression had an active order for antianxiety medication and documented anxiety behaviors, yet the care plan did not list the antianxiety medication, did not describe the target anxiety behaviors for staff to monitor, and did not include non-pharmacologic interventions for anxiety management.
Staff failed to protect a resident’s heels during a mechanical lift transfer and did not provide required supervision for an at-risk smoker. One resident with impaired cognition, bilateral leg weakness, stroke history, and a moderate Braden risk was observed being transferred from bed to wheelchair in a mechanical lift by an OT and a CNA, during which his heels were dragged across the mattress and later noted to be red, contrary to staff statements and facility policy that feet should be elevated and not contact the mattress during active movement. Another resident with hemiplegia, stroke, and other comorbidities had documentation and a care plan stating he was not an independent smoker, lacked spatial and self-awareness, and required supervised smoking, yet he was able on separate early mornings to wheel himself to the enclosed courtyard, cancel or trigger the door alarm, and access the smoking area without staff present, despite a policy requiring supervision per the care plan.
Facility staff did not consistently respond to resident call lights within a reasonable time, especially during evening and night shifts. Several cognitively intact residents reported waiting 30–45 minutes for assistance with toileting and personal care, with one resident left on the toilet for an extended period and another going to bed without proper hygiene. A resident also described a prolonged delay in response while choking on mucous. Resident Council minutes documented concerns about long call light wait times, staff turning off call lights, and staff wearing earbuds during care. Although the DON and CNAs stated that call lights should be answered promptly and the written policy required all staff to respond to activated call lights, these expectations were not consistently met.
A resident with multiple chronic conditions and intact cognition received another resident’s medications after a CMA pre-poured meds for several residents, left them on the med cart, and handed responsibility to a trainee CMA who did not follow the 6 rights of medication administration or verify identity using the MAR. The trainee, unaware that a new resident shared the same room and lacking a photo in the EHR for comparison, administered a muscle relaxant, anticonvulsant, anti-anxiety, and antihypertensive intended for someone else. The resident reported being told the pills were hers despite voicing concern, then blacked out, fell from a scooter, developed hypotension and bradycardia, and required ICU admission with medication and intermittent vasopressor support.
Failure to follow physician orders occurred when a resident with depression, anxiety, toxic encephalopathy, and impaired cognition had quetiapine orders entered and administered inconsistently, with scheduled dosing not transferred correctly and PRN use documented instead. The resident had escalating behaviors, including grabbing a fire extinguisher, shredding a roommate’s pillow, increased anxiety, refusal to speak with staff and the psych provider, and later transfer to the hospital for altered mental status and unsafe behaviors.
A resident with a suprapubic catheter, impaired cognition, and multiple diagnoses including quadriplegia and abnormal bladder function was receiving perineal care when a CNA lifted the urinary drainage bag above the bladder while dressing him. Urine in the tubing, including a white mucoid substance, flowed back into the bladder. The CNA stated she knew the bag and tubing should not be higher than the resident, and the DON confirmed staff should not have raised the drainage bag above bladder level.
Failure to administer a pneumococcal vaccine after consent was obtained. A resident with cancer, sepsis, respiratory failure, and a hx of pneumonia was admitted with immunization status listed as not up-to-date and vaccine past due. The EHR showed consent for Prevnar 20, but the record lacked documentation of prior PPSV23 or other pneumococcal conjugate vaccines, and progress notes did not show the vaccine was given. The ADON/IP stated the order was entered but not marked yes and was on the MAR but not administered.
Failure to Administer Consented COVID-19 Vaccine: A resident with sepsis and non-Alzheimer’s dementia consented to receive the COVID vaccine, but the EHR showed only an older COVID booster and no documentation that the requested vaccine was ever given. The ADON/IP stated the facility had standing immunization orders, checked the IRIS registry, and offered flu and pneumonia vaccines, but had not gotten to COVID immunizations.
A resident with COPD, HF, and DM had repeated signs of decline, including lethargy, poor intake, altered MS, and possible facial droop, but staff did not timely document or escalate the change before the resident was sent out and later diagnosed with sepsis and organ failure. In a separate issue, a resident with bipolar disorder and memory impairment had 30-day psychotropic orders entered on admission, but the provider was not timely notified to clarify the stop dates even after the pharmacy flagged the orders, and the meds were stopped without tapering before being restarted.
Failure to Remove Old Fentanyl Patch Before New Application: A resident with cancer, COPD, and chronic pain had a fentanyl patch ordered every 3 days with instructions to remove the old patch before applying a new one. Records showed a new patch was applied while an old patch remained in place, and the resident later became lethargic and confused, was sent to the hospital, and had two fentanyl patches removed during EMS/ED care. The hospital course documented ICU transfer for fentanyl overdose with severe acute hepatic encephalopathy.
Surveyors found the facility failed to maintain a safe, clean, and comfortable environment, with observations of stained carpets, peeling paint, water damage, dust buildup, and soiled resident equipment. A resident's wheelchair was dirty, had a broken wheel lock, and showed signs of neglect. Facility staff and the DON confirmed these issues, and facility policy required a higher standard of cleanliness and maintenance.
Multiple residents with significant care needs, including those with morbid obesity, heart failure, stroke, and hemiplegia, experienced excessive delays in staff responding to call lights, sometimes waiting over an hour or more. Residents described staff turning off call lights and not returning, and observations confirmed that call lights were not always accessible. The DON stated the expectation was a 15-minute response, but this was not consistently met, resulting in unmet care needs and residents seeking help on their own.
Staff failed to follow infection control protocols during resident care and meal assistance, including not changing gloves or performing hand hygiene between residents, improper handling of catheter drainage equipment, and inadequate use of PPE during care for residents with MDROs. Supplies of gowns for enhanced barrier precautions were also found to be insufficiently stocked.
A resident with stroke, dementia, and hemiplegia who was fully dependent on staff for toilet hygiene did not receive complete incontinence care. During observed care, staff failed to cleanse the inner thighs, outer buttocks, and hips as required by facility policy, despite removing a wet brief and cleansing other areas. The DON confirmed that all areas should have been cleansed.
Failure to Assess and Follow Up on Significant Changes in Condition
Penalty
Summary
The facility failed to conduct comprehensive, ongoing nursing assessments and interventions for 7 of 7 residents reviewed for significant changes in condition. The cited residents included individuals with falls, hospital or ER returns, altered mental status, pneumonia treated with antibiotics, nausea and vomiting, rib fractures of unknown origin, and skin injury of unknown origin. Survey findings showed that nursing follow-up was incomplete or absent after these changes, including missing assessments, missing vital signs, missing neurological checks when indicated, and missing progress note documentation. For one resident, the record showed an unwitnessed fall out of bed with facial injury, swelling, and pain, followed by an ER visit and return with antibiotic orders for a UTI with hematuria. The facility documented only one full set of neurological checks after the fall, and the chart lacked nursing progress notes for a prolonged period despite staff interviews indicating a significant change in mental condition. The resident later returned to the hospital with altered mental status and hypothermia and was admitted to the ICU; the resident subsequently died at the hospital, with sepsis listed as the cause of death and other significant conditions including chronic osteomyelitis, diabetes, chronic subdural hematoma, atrial fibrillation, acute kidney injury, and hypertension. Other examples included a resident treated with an antibiotic for pneumonia over several days without comprehensive nursing assessment and intervention, a resident with nausea and vomiting who received antiemetic medication twice over a 6-hour period without documented assessments before cardiac arrest and CPR, and residents with rib fractures, a fall, pneumonia treatment, and a fall from a chair with a skin injury of unknown origin who also lacked adequate nursing assessment and follow-up. The facility was cited for failing to provide appropriate treatment and care according to orders, resident preferences, and goals because the nursing record did not show timely, comprehensive assessment and intervention in response to these significant changes in condition.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries for multiple residents who were at risk. Resident #73 had severe cognitive impairment, was wheelchair dependent, totally dependent for transfers and toileting, frequently incontinent of urine, and received hospice services. The resident’s record showed a pressure reducing device for the chair was part of the skin treatment plan, but the resident developed a facility-acquired Stage 4 pressure sore to the lower right posterior thigh/back of the left thigh area. The wound was documented with eschar, slough, drainage, tenderness, and later odor, and the record noted the wound lined up with the wheelchair seat. The report also states the facility failed to utilize a pressure reducing wheelchair cushion until after the wound developed, failed to maintain pressure relief once the wound was present, and failed to provide major repositioning changes and incontinence care over a 7.5-hour period based on continuous observation. Resident #83 also had significant skin integrity problems, including a facility-acquired Stage 4 pressure sore to the left hip and a chronic pressure ulcer to the left heel. The resident’s skin assessments identified the need for protective prevalon boots to the bilateral lower extremities, but the report states the facility failed to provide the ordered protective prevalon boot to the left foot and failed to ensure all skin interventions were implemented. The report further states the facility failed to prevent friction and shear when providing incontinence care for this resident who had a Stage 4 pressure sore to the left hip. Resident #94 had a pressure sore to the left heel, and the facility failed to provide proper care for that wound and failed to implement measures to prevent a pressure sore to the right heel. The report identifies these failures as part of a broader pattern involving 4 of 4 residents reviewed for pressure sore prevention and interventions, and states the deficiencies rose to the level of Immediate Jeopardy. The report also includes survey findings from a 100% skin sweep showing multiple residents with pressure injuries, moisture-associated skin damage, and other skin concerns, along with documentation that the facility’s staffing assessment reviewed hall assignments, resident acuity, incontinence care, repositioning, transfers, wound care, and equipment needs.
Delayed Pain Assessment and Medication Implementation
Penalty
Summary
The facility failed to timely and effectively manage pain for a resident with multiple fractures, wounds, oxygen use, therapy needs, and hospice admission. The resident’s record showed pain that interfered with sleep and therapy, and the hospice admission note documented crying out in pain, a PAINAD score of 8/10, anxiety, and increased agitation with movement or transfers. The resident also had pressure injuries, skin tears, bruising, a surgical wound, and a leg brace, with staff and therapy notes describing restlessness, agitation, pulling at the brace and catheter, and body language consistent with discomfort. On the day of the event, family members reported that the resident was found tipped forward in a recliner with the footrest on the floor, and they described a new arm wound, bruising, fear, labored breathing, and severe pain. The wife stated she notified staff and did not receive a nurse response for hours, while the grandson reported the resident repeatedly asked to go home and not be left alone. The nursing note documented the recliner being repositioned and the resident being settled, but the record lacked follow-up documentation overnight after the hospice nurse ordered morphine for difficult breathing and severe pain. The record also showed gaps in pain assessment and medication implementation. A pain assessment was not completed on one date, and later pain documentation showed a score of 6/10 earlier in the day but then 0 overnight without supporting reassessment details. Staff interviews reflected uncertainty about whether the resident was assessed after the recliner incident, whether the new abrasion was evaluated, and whether pain medication was given. A follow-up interview indicated the morphine order was delayed because the e-script was not received correctly by the pharmacy, the medication was not available in the emergency supply, and a stat order had to be obtained. The grievance records also showed other residents complained that pain medications were not given timely or were not available, with follow-up documentation lacking resident verification of resolution and lacking confirmation of whether the grievances were substantiated.
Physical Abuse During Resident Handling and Broader Care Failures
Penalty
Summary
The facility failed to prevent physical abuse for Resident #81 during assistance with bed mobility and transfers. Resident #81 had a BIMS score of 15, indicating intact cognition, and required extensive assistance, including a hoyer lift for transfers. The resident reported that staff held his arms too hard when rolling him, and the incident report documented bruising to the left wrist/hand and right elbow after care was provided. The bruises were described as deep purple, and photographs showed finger-mark-like lines at the wrist area and a large bruised area at the elbow region. The record also showed that Resident #81 had previously reported that nursing staff did not listen to him and that call light response times were long. The incident documentation stated the resident was alert and oriented and said he was not harmed intentionally, but he specifically linked the bruising to the way staff handled him during rolling. The facility’s skin documentation on the day after the incident recorded no bruises despite the documented bruising and photographic evidence from the prior day. The report also identified additional abuse- and neglect-related concerns involving other residents, including rude or intimidating staff interactions, incomplete investigations of resident-to-resident incidents, and repeated failures to provide timely assistance with ADLs, incontinence care, repositioning, grooming, oral care, and call light response. One resident was documented as having been left without needed care for an extended period, and another resident was found with rib fractures of unknown cause after an ER visit, with the investigation not identifying the cause of injury. These findings were documented through grievance records, clinical record review, observations, and interviews.
Unsafe Smoking Supervision and Missing Smoking Assessments
Penalty
Summary
The facility failed to ensure residents received safe smoking assessments at the required intervals and failed to provide adequate supervision and protective interventions during smoking for multiple residents. Several residents were identified as smokers with varying levels of cognitive impairment, physical limitations, and supervision needs, yet the record showed missing, outdated, or inconsistent smoking assessments and care plan interventions. Residents documented as needing supervision or protective equipment were observed smoking without a smoking apron, and staff were observed unable to maintain supervision of all residents in the designated smoking area. Resident #46 had a history of stroke, hemiplegia, diabetes, depression, and required substantial assistance with transfers and mobility. The care plan stated the resident was to be supervised while smoking because of prior burn marks on clothing and shoes, and the most recent smoking assessment documented that the resident could not extinguish smoking materials appropriately or dispose of ashes safely. Resident #51 had cancer, stroke history, hemiplegia, heart failure, COPD, and required supervision for transfers; the smoking assessment documented that the resident could not safely light a cigarette and needed a smoking apron, and IDTC notes stated the resident was legally blind. Resident #56 had stroke-related speech deficits and required substantial assistance with ambulation; the smoking assessment required supervised smoking. Resident #71 was documented as a current smoker, but the care plan did not identify current smoking status and the EHR lacked a smoking assessment until one was later requested. Resident #78 had stroke, diabetes, hemiplegia, contractures, and dependent transfers; the care plan required supervision and a smoking apron, but the smoking assessment documentation identified the resident as needing supervision for safety. Resident #80 had cancer, heart failure, peripheral vascular disease, a below-the-knee amputation, kidney failure, diabetes, non-Alzheimer’s dementia, and used a prosthesis and wheelchair. The resident sustained a thermal burn to the right heel after stating that the cigarette cherry fell into the shoe. The smoking assessment documented that the resident had a burn wound to the right foot from a cigarette cherry falling into the shoe and required supervision during smoking sessions with a smoking apron. During observation, staff assisted one resident to the smoking area and lit the cigarette, but did not provide a smoking apron, and multiple residents who required supervision were left outside smoking without staff present. The observation also showed staff inside the building while residents continued smoking outside unsupervised, and staff were unable to respond when one resident’s wheelchair became caught in the door jam.
Insufficient Staffing Caused Delays in Call Light Response and Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated reports of delayed call light response, delayed incontinence care, and delayed assistance with activities of daily living. The facility assessment identified many residents needing transfer assistance and toileting assistance, including residents requiring mechanical lifts and residents who were fully incontinent, but the assessment did not reflect the current resident needs for May 2026 or explain how staffing patterns were reviewed to address the increased care needs. Resident council minutes from two meetings documented resident concerns that call light wait times were still long and that staff should check more often on residents in common areas during evenings and nights. Monthly grievance forms documented repeated complaints from residents and family members that call lights were not answered timely, residents were left wet or soiled for extended periods, and assistance with toileting, showers, meals, and other ADLs was delayed or not provided. One resident reported not being checked and changed on the overnight shift, another reported waiting 45 minutes for help, another reported sitting in feces for 14 hours, and another reported call lights taking an hour or more to be answered. A family member reported a resident turned on the call light at 6:10 PM and no one came to help until 6:45 PM. Several grievances also described staff turning off call lights and leaving without helping, residents waiting 30 minutes to 2 hours for toileting assistance, and residents not receiving showers, snacks, or meal trays in a timely manner. Resident interviews and observations further documented the staffing-related care delays. One resident with diagnoses including heart attack, stroke, CHF, and pulmonary disease, and who depended on staff for toileting and required total assistance from two staff for bed-to-chair transfers, reported waiting over 2 hours to have a bowel movement and described staff turning off the call light and leaving without assisting. Another resident reported call lights taking forever, frequently waiting over a half hour on all shifts, and being left in a wheelchair for over an hour after being brought back to the room. A resident on the 300 hall was observed dressed in a hospital gown and, during continuous observation from 4:20 AM to 12:00 PM, staff failed to provide grooming, dressing, oral care, major position changes, or incontinence care. Staff interviews also described difficulty getting residents up in the morning because of heavy care needs, the need for a second aide to assist, and delays caused by having only one aide available on the hall.
Facility Assessment Not Updated for Leadership and Resident Care Needs
Penalty
Summary
The facility failed to revise its facility-wide assessment to reflect current resident care needs and leadership changes. The assessment dated [DATE] stated it was last reviewed in May 2026 with no changes needed, but it still listed leaders who were no longer employed by the facility. Recent leadership changes included a new DON in September 2025, a new MDS Coordinator in October 2025, and a new Administrator in January 2026. The assessment also did not accurately reflect the number of residents needing assistance with transfers and incontinence care. The assessment identified 48 residents needing transfer assistance and 53 needing toileting assistance, while a resident roster dated 5/18/26 for a census of 84 documented 64 residents needing transfer assistance, including 9 who required an EZ sit-to-stand mechanical lift and 20 who required a Hoyer full body mechanical lift. The roster also documented 79 residents with incontinence, including 6 with mixed incontinence and 73 who were fully incontinent. In addition, the assessment did not reflect the current number of residents on Enhanced Barrier Precautions. The assessment identified 11 residents on EBP and 1 acute infection, while observation on 5/11/26 found 19 room doors with EBP signs outside the rooms. The assessment also stated staffing patterns were regularly reviewed and adjusted to align with changes in resident acuity and care plans, and that staffing for other departments was adequate, but it did not reflect the current resident needs or how staffing patterns were reviewed to address the increase in care needs. The Administrator confirmed she signed the May 2026 review indicating no changes were needed and did not provide further response during the survey.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to implement infection prevention and control practices and Enhanced Barrier Precautions (EBP) for multiple residents whose care plans directed EBP use. Resident #19 had a chronic left foot ulcer with MDRO history and a care plan requiring EBP, weekly wound assessments, and physician treatment orders. During observation, the resident had a dressing on the left leg, but there was no PPE at the door and no sign indicating EBP. The resident stated staff only wore gloves during dressing changes and did not use handwashing or a gown. Resident #6 had an MDRO history and a urinary catheter, and the care plan directed EBP related to urinary output, incontinence, and ESBL history; however, observation showed no PPE at the door and no EBP sign, and staff interviewed were unaware the resident required EBP. For Resident #83, who had severe cognitive impairment, total dependence for toileting hygiene, incontinence of bowel and bladder, and multiple pressure injuries including a Stage 4 ulcer, surveyors observed repeated failures during incontinence care and wound care. Staff entered the room without PPE despite an EBP sign being present, handled soiled briefs and wipes with contaminated gloves, changed gloves without washing hands, and did not cleanse all areas contaminated by urine or feces. Soiled trash bags and linens were placed on the floor in the hallway and in an empty room used for garbage and soiled linen bags. During shower transfer and wound treatment, staff again failed to perform hand hygiene after glove removal and handled equipment and resident care items without cleaning between tasks. Resident #52, who was totally dependent for toileting hygiene and always incontinent of bowel and bladder, was observed during personal care with a strong ammonia odor in the room. Staff changed gloves without washing hands, placed clean supplies on the bed without a barrier, and did not cleanse all areas contaminated by the soiled brief before replacing it. Resident #85, who had severe cognitive impairment, an indwelling catheter, and bowel incontinence, was observed receiving perineal care in which staff wiped only limited areas, placed a soiled brief on the bed with clean wipes, and continued care with contaminated gloves before washing hands. After removing gloves, a CNA touched the resident’s soda bottle and provided a drink without hand hygiene. Resident #73, who had moderate cognitive impairment, bowel and bladder incontinence, a Stage 4 pressure injury, MASD, and hospice services, was observed with a strong ammonia smell in the room and a heavily soiled brief; staff failed to change soiled gloves or sanitize hands before placing a new brief and did not cleanse all skin areas contacted by the brief. The report also states the facility lacked tracking records for the entire facility and antibiotic stewardship program from January 2026 to June 2026, and that soiled laundry and clean laundry were not handled with appropriate infection control measures.
Offensive Odors Throughout Facility
Penalty
Summary
The facility failed to maintain an environment free of offensive odors, with strong urine, ammonia, body, and chemical smells observed throughout multiple hallways, the dining room, activity areas, and resident rooms during the survey period. Surveyors documented pungent urine/ammonia odors in the breezeway, on the 100, 200, and 300 hallways, outside and inside multiple resident rooms, and in the shower room. The odors were described as strong enough to irritate surveyors’ eyes, throat, and sinuses, and in some areas the smell continued down the hall and into the dining room area. The observations also showed repeated handling of soiled briefs, trash, and linens in ways that contributed to the odors. Surveyors saw staff performing incomplete incontinence care for residents who were heavily soiled with urine and feces, then leaving trash bags and soiled linen bags on the floor in hallways or in vacant rooms. In several instances, open trash bags containing soiled incontinence briefs were left exposed to the air, and a strong urine smell remained in rooms after care was provided. A shower room door was observed wide open with running water and a razor on the shower floor, and a pallet of supplies, a Hoyer lift, carts, and other items were placed in a hallway, reducing available space. Resident and family interviews supported the observations. A family member reported that staff did not change a resident’s incontinence brief often enough, leaving the resident frequently wet and sitting in urine. A resident reported waiting long periods after incontinence episodes for help to the bathroom. Staff interviews reflected that some staff noticed the odor throughout the building, while others said they had not noticed it or had become used to it. The DON and Administrator acknowledged concerns about urine odor, carpet cleaning, and staff placing soiled linen and trash bags on the floor.
Failure to Document Grievance Outcomes
Penalty
Summary
The facility failed to effectively resolve resident grievances and failed to document written outcomes showing whether grievances were confirmed or not confirmed. Review of grievance logs from January through the beginning of May 2026 showed 75 grievances filed by 36 different residents, representatives, or staff. The monthly grievance logs repeatedly listed grievances as resolved, but the disposition section did not indicate whether the concerns were confirmed or not confirmed, and many forms lacked a written decision date or any documented outcome beyond a brief notation of resolution. Multiple grievance forms showed complaints about call light response times, incontinence care, rude or abusive staff behavior, missing belongings, delayed showers, and concerns about pain medication, hygiene, and treatment during care. Examples included residents reporting long waits for call lights, being left in soiled briefs or bowel movement for extended periods, staff speaking rudely or using profanity, and family members reporting missing clothing, untreated needs, or poor care. In several cases, the forms documented staff education, huddles, or brief conversations with staff, but did not include a documented investigation summary, a clear determination of whether the allegation was confirmed, or follow-up with the resident or representative to verify the concern was resolved. The grievance records also showed allegations involving possible abuse or neglect, including rude language, threats, improper handling during care, and resident-to-resident conflict. Some forms documented statements from staff or residents that conflicted with each other, but the facility did not document a final written outcome stating whether the grievance was confirmed or not confirmed. Several forms also lacked documentation of representative notification, further monitoring, or any additional interview after the initial response. The grievance logs for January, February, and March 2026 similarly showed the disposition column left blank or marked only as resolved, without indicating confirmed or not confirmed.
Systemic failures in leadership, staffing, abuse prevention, and resident care
Penalty
Summary
The facility failed to provide effective leadership and administration of resources to ensure a safe, clean environment, free from abuse and neglect, with quality care services provided by sufficient and competent staff. Survey findings described widespread systemic concerns affecting all residents in the building, including repeated grievances about delayed call light response, lack of assistance with toileting and incontinence care, poor hygiene care, and staff not providing timely help with transfers and other personal care needs. The facility’s grievance logs from January through early May 2026 documented 75 grievances from 36 different residents, representatives, or staff. The logs showed that nearly all entries were marked resolved, but none identified whether the grievances were confirmed or not confirmed, and the individual grievance forms contained no information on confirmation status. Surveyors also noted prior repeat deficiencies and higher scope and severity citations from the earlier survey ending 1/8/26, along with multiple current citations involving resident rights, grievances, abuse/neglect, care planning, staffing, infection control, and facility administration. Resident interviews and observations showed ongoing concerns with care delivery and environment. One cognitively intact resident stated call lights took forever to be answered, staff said they were short staffed, and staff came in and left quickly. The same resident reported staff grabbed him harshly during care and left bruises on his wrist and elbow. Another cognitively intact resident had a rib fracture of unknown origin documented after an ER visit, and the facility did not report the injury to the Regional Director of Operations or DIAL. Surveyors also observed pervasive urine/ammonia odors throughout multiple halls and common areas on several dates, with staff and leadership acknowledging the odor concerns and attributing them to carpet, soiled linen, and trash handling practices. The survey further documented failures in assistance with ADLs and incontinence care, including a resident who required extensive assistance and was observed for hours without major position changes, incontinence care, grooming, or oral care until late morning. The facility assessment did not reflect current resident needs, including the increased number of residents needing transfer assistance, toileting assistance, and mechanical lifts, and it did not account for leadership changes or staffing implications. The current survey also cited immediate jeopardy-level deficiencies for nursing assessment and intervention, pressure ulcer care, and pain management, along with deficiencies for sufficient and competent nursing staff, facility administration, and QAPI.
Failure to Monitor QAPI and Resident Care
Penalty
Summary
The facility failed to effectively monitor and improve the quality of care residents received under its QAPI/QAA process. The report states that, despite a written QAPI plan describing a data-driven, facility-wide program with monthly QAA committee review, the facility continued to have repeat deficiencies and multiple substandard quality of care tags. Survey outcomes showed 12 deficiencies on the prior recertification survey and 33 deficient practices on the current survey, including 6 substandard quality of care tags, with 3 rising to immediate jeopardy. The facility had been operating under a Directed Plan of Correction with monthly consultant reviews and biweekly calls. Those reviews documented trends in falls, wounds, medication errors, and smoking-related concerns, and the facility reported various monitoring activities such as audits, huddles, rounds, and tracking of incidents. However, the current survey found that leadership did not identify current issues with staffing levels, failure to provide cares such as repositioning, failure to keep pressure sore interventions in place, failure to perform pain assessments, inadequate incontinence care, and failure to maintain an environment free of urine odor. The monthly grievance logs from January through early May 2026 showed 75 grievances filed by 26 different residents, representatives, or staff. The Administrator stated that grievances were routed to different department leaders depending on the issue and that she would sometimes follow up with families and discuss concerns in huddles. The survey also identified repeat deficiencies in areas including resident rights, care planning, significant medication errors, resident records, sufficient nursing staff, and infection prevention and control, along with new immediate jeopardy findings for lack of comprehensive nursing assessment and intervention for 7 residents, lack of pressure sore interventions and care for 4 residents, and inadequate pain management for 1 resident.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide timely and complete assistance with activities of daily living for residents who needed help with toileting, incontinence care, grooming, oral care, transfers, and showers. Grievance documents and interviews described repeated complaints that residents were left wet or soiled for extended periods, call lights were not answered promptly, showers were missed or delayed, and residents did not receive needed help with toileting or personal care. Several grievances involved residents reporting that staff did not check and change them overnight, did not provide requested showers, did not answer call lights, or left them waiting for assistance with toileting and hygiene needs. Resident #81 had intact cognition and care plans directing staff to assist with oral hygiene, bathing, dressing, toileting checks every 2 to 3 hours, and transfers with a Hoyer lift and 2-person assistance. The resident reported call lights took a long time to answer, that staff often said they were short-staffed, that he had waited up to 2 hours for help, and that he frequently waited over a half-hour on all shifts. He also stated he was left in his wheelchair for over an hour after being brought back to his room and, during an interview, was wet with urine and had a bowel movement while still waiting for incontinence care. Resident #73 had moderate cognitive impairment and required extensive assistance for transfers, toileting, personal hygiene, dressing, and oral care, with constant bowel and bladder incontinence. During a continuous observation, staff did not provide major position changes, incontinence care, grooming, or oral care for several hours, and the resident remained in bed in a semi-Fowler's position while staff cared for other residents. When care was finally provided, staff assisted with incontinence care, dressing, and transfer but skipped oral care, and the room had a strong ammonia odor with the brief heavily soiled with urine and feces. Resident #83, who had severe cognitive impairment, constant bowel and bladder incontinence, and pressure ulcers including a Stage 3 left hip wound and an unhealed Stage 4 pressure ulcer, was observed with a heavily soiled brief and fecal contamination while staff performed incomplete cleansing. Similar observations were documented for Resident #52, Resident #85, and Resident #86, each of whom had significant cognitive and physical impairments and required staff assistance for toileting hygiene and incontinence care, yet were observed wet, soiled, or receiving incomplete personal care.
Failure to Provide Restorative Nursing Programs for Residents With Mobility Needs
Penalty
Summary
The facility failed to provide a restorative program for residents with mobility concerns for 4 of 4 residents reviewed. The deficiency was identified through observations, interviews, and record review, and the facility reported a census of 81. Records showed that each of the four residents had mobility-related needs documented in their MDS assessments and care plans, yet their care plans lacked restorative nursing programs, and the MDS assessments documented 0 of the past 7 days of restorative nursing program participation for each resident. Resident #3 had diagnoses including heart failure, hypertension, diabetes mellitus, anxiety, and depression, and the MDS documented an impairment of the lower extremity. Her care plan lacked a restorative nursing program. She stated that she did not think a restorative program existed at the facility, that she did not work with anyone, and that the facility only offered Tuesday group exercises. She also stated that she wanted to get up and walk and talk to therapy about her walker. Staff interviews reflected that therapy did not have a restorative program in place, that therapy used a therapy-to-nursing CNA handoff maintenance plan, and that the facility relied on communication books, huddles, and Kardex information rather than a formal restorative nursing program. Resident #71’s MDS documented intact cognition, diagnoses including UTI, multiple right rib fractures, COPD, cirrhosis, anxiety, and depression, and mobility needs requiring partial to moderate assistance or supervision with wheelchair use. The care plan included assistance with ADLs, ambulation with a FWW and wheelchair follow, and encouragement to report decline, but it lacked a restorative nursing program. Resident #83’s MDS documented severely impaired cognition, Down Syndrome, aftercare following hip replacement, wound infection, adult failure to thrive, pressure ulcers, and substantial to maximal assistance for ambulation, with walker and wheelchair use. His care plan directed staff to encourage him to do as much as possible and use a wheelchair, but it also lacked a restorative nursing program. A confidential interview stated that staff had to respect refusals, that he needed more encouragement, and that he had declined from walking and standing to needing more assistance. Resident #85’s MDS documented severely impaired cognition, neurogenic bladder with catheter, aphasia, stroke, hemiparesis, dysphagia, pressure ulcer, and right-hand contracture, with dependence for ambulation using a wheelchair. Her care plan directed PT, OT, and ST, ROM with morning and evening care, and repositioning or ambulation every 2 hours as tolerated, but it lacked a restorative nursing program. CNA interviews stated that staffing shortages and lack of training affected completion of ROM and exercises, and that CNAs had not received facility training on each resident’s restorative therapies beyond basic CNA school instruction. The DON stated that CNAs were educated by therapy during onboarding and that residents needing ROM or adaptive equipment were noted on the Kardex.
Failure to Demonstrate Nursing Competency in Infection Control, Incontinence Care, and Resident Assessment
Penalty
Summary
Nursing staff failed to demonstrate the competencies and skills needed to provide care that met residents’ needs, including infection prevention practices, incontinence care, and use of Enhanced Barrier Precautions (EBP). During observed care for multiple residents, CNAs were seen entering rooms without appropriate PPE, failing to perform hand hygiene between contaminated tasks, and providing incomplete cleansing during incontinence care. Staff handled soiled briefs, wipes, linens, and equipment with contaminated gloves, changed gloves without washing hands, and in several instances did not cleanse all areas exposed to urine or feces before placing clean briefs or continuing care. For one resident with severe cognitive impairment, Down syndrome, pressure ulcers, a wound infection, and dependence for transfers and personal care, staff observed a heavily soiled brief and fecal contamination during incontinence care. Staff failed to cleanse all contaminated areas, used contaminated gloves repeatedly, and removed the brief with audible friction and shear against the resident’s skin. Staff also failed to consistently use PPE despite an EBP sign on the door, and one CNA stated she had not received specific facility training on EBP since hire. Similar failures were observed with other residents, including incomplete cleansing, handling of soiled items without proper hand hygiene, and continued contact with resident care items after glove removal. Licensed nursing staff also failed to demonstrate the knowledge and competencies needed to assess, monitor, and communicate residents’ conditions. One resident developed a rash that progressed to bilateral leg involvement, hypotension, lethargy, decreased intake, and eventual transfer to the ER, where the facility reported the resident had become hypotensive and was admitted for IV antibiotics and later diagnosed with sepsis related to cellulitis. Interviews reflected that staff could not clearly describe the resident’s baseline or current condition, and one nurse stated she did not know much about the resident. Another resident’s G-tube feeding orders and dietitian recommendations were inconsistently communicated and transcribed, with staff uncertainty about whether the feeding was on hold, resumed, or discontinued, and the record did not show timely clarification of the changing orders.
Missing Transfer Notifications and Bed Hold Documentation
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers and discharges for 5 of 5 residents reviewed for discharge processes. The record review showed that the facility did not notify the Long-Term Care Ombudsman of hospital transfers, did not obtain or retain written bed hold notices, and did not document the disposition of resident belongings and discharge status for the affected residents. The facility reported a census of 81 residents. For Resident #1, the clinical census showed hospital unpaid leave entries in February 2026, but the Notice of Transfer Form to the Long Term Care Ombudsman lacked documentation of the hospitalizations, and the clinical record lacked documentation of a bed hold notification for those hospitalizations. Staff stated the prior social worker would have reported the discharge to the Ombudsman, but the census information had been entered late into the EHR, resulting in an incorrect discharge date on the report. An email from the Regional Director of Operations indicated the facility did not have an Ombudsman policy. For Resident #2, the EHR showed multiple transfers to a short-term general hospital, but only one transfer and discharge form was recorded, and the record lacked written orientation and transfer information for two of the transfers as well as written bed hold notices. The progress notes referenced a follow-up after the hospital transfer and noted the resident remained in the critical care unit, but the record lacked documentation of the resident’s disposition, including whether the resident passed away, and lacked documentation regarding belongings and medications. Similar omissions were identified for Resident #7, Resident #52, and Resident #93, whose records lacked written bed hold notices and, for Resident #7, written orientation and transfer notification. Resident #93’s progress notes documented transport to the hospital and return to the facility, but the record still lacked a bed hold notice.
Care plans not revised to reflect resident status changes
Penalty
Summary
The facility failed to revise comprehensive care plans in a timely manner for residents whose needs had changed, and the care plans did not accurately reflect current resident status for 3 of 3 residents reviewed. The report cites that the comprehensive care plan was to be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals, but the facility did not update care plans when resident conditions changed. For one resident, the PASRR Level II outcome showed approval with specialized services and the MDS coded conditions related to ID/DD and serious mental illness. The care plan created in March documented PASRR specialized services, psychiatric medication management, individual therapy, supportive counseling, activities, and retrieval of archived psychiatric/behavioral health records, but these interventions were entered after the resident’s initial admission date and did not timely reflect the specialized services required upon admission. The care plan lacked timely revision to include the PASRR specialized services needed at the time of initial admission. For another resident, the record showed multiple weight entries with conflicting values, including weights that were later struck out as technical error, other, re-weighed, or incorrect documentation. The resident’s weights ranged from 154.2 lbs. on admission to 182.6 lbs. later in the record, and progress notes documented weight gain, questionable weights, and later weight loss concerns. Despite these changes, the care plan remained focused on altered nutrition/hydration status with a goal weight of 148 lbs. plus or minus 4%, and it did not include documentation reflecting the resident’s weight gain or the later recorded weight of 182.6 lbs. For the third resident, the MDS identified anticoagulant use related to a history of DVT and PE, and the care plan addressed anticoagulant therapy and monitoring. However, a progress note documented that vaginal bleeding had resolved after inpatient treatment and that anticoagulation had been discontinued from the last hospitalization, while the medication still appeared active on the MAR at that time. The order recap later showed Xarelto 20 mg daily had been discontinued, but the care plan was not revised to reflect that the anticoagulant medication had been stopped.
Food Items Not Labeled or Dated and Kitchen Surfaces Not Cleaned
Penalty
Summary
Food items in the kitchen were not labeled, dated, or stored in a sanitary manner during the initial observation. In dry storage, surveyors observed an open, unlabeled, and undated bag of Cheerios that was not taped shut, Cortonia noodles and Cortonia bowtie noodles that were not labeled or dated, a brown sugar container that was not labeled or dated, and an open, uncovered butter container sitting on the counter with the butter knife in it. In the cooler, surveyors observed an open, unlabeled, and undated large bag of mozzarella cheese. The kitchen also had food preparation surfaces that were not clean after lunch. The steam table had old food particles on it and had not been cleaned or sanitized after lunch, and the top of the stove had food particles on it. The Dietary Director stated that all food items should be labeled and dated if not in their original container and said the observed items should have been marked. The head cook later stated that all open food items should be labeled and dated. The facility's Sanitation Inspection policy dated March 2026 directed that all food service areas be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects.
Dirty Dryer Lint Filters
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition when both commercial dryer lint filters were found completely filled with lint, with lint also present in the dryer compartments and decreased airflow noted. During observation in the laundry room, two washers were actively washing loads and two dryers were present, with one dryer actively drying a blanket. The other dryer was opened and its lint filter was completely filled, with a moderate amount of lint on the bottom of the compartment; the second dryer’s filter and compartment contained a larger amount of lint. Staff stated the dryer filters were cleaned once daily by maintenance staff, but no daily cleaning log was available, and the Maintenance Director stated he would have a log form made immediately. The manufacturer’s instructions for the commercial dryer were not available.
Failure to Respect Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to respect a resident’s dignity throughout care and failed to speak to the resident with dignity and respect. Resident #25 had diagnoses including heart attack, stroke, CHF, and pulmonary disease, and the MDS showed a BIMS score of 14, indicating intact cognition. The MDS also showed the resident was dependent on staff for toileting and required total assistance of two staff for bed-to-chair transfers. On 4/13/26, Resident #25 requested assistance to use the restroom during medication pass, and the LPN left to find additional staff. Later that morning, the resident’s call light was on and a CNA was observed exiting the room. The resident reported that the CNA came in, turned off the call light, shrugged her shoulders, and walked out without assisting him. The resident stated he waited over 2 hours to have a bowel movement and felt abandoned due to short staffing. The resident’s son also expressed concern about the quality of care, and staff documentation recorded the resident’s complaint that he had requested help to the toilet and was left waiting after staff turned off his call light and left the room.
Resident bathing preference not honored
Penalty
Summary
The facility failed to honor Resident #81’s choice of bathing time and did not include that preference in the care plan. The resident’s MDS assessments documented that choosing between bathing options was very important to him, and the quarterly assessment showed intact cognition with a BIMS score of 15. The resident also had diagnoses including debility and cardiorespiratory conditions, and his functional status indicated he was dependent on a helper for mobility and showering. The care plan addressed adjustment to the facility, self-led activities, and assistance with ADLs related to weakness and decreased mobility, but it did not identify any preference for bathing time or the level of assistance to be provided for showers. During interview, Resident #81 stated that Tuesdays were his shower days and that he preferred to shower at 11:00 AM. On observation, staff were preparing him for a shower at about 7:03 AM, and CNA Staff EE spoke to him in an argumentative manner and interrupted him when he explained his preference. The resident stated staff told him it was time to wake up and take his shower, and later said he would not be told what to do and when to do it. He also stated he believed Staff EE provided the shower at 7:00 AM because she told him the State expected the shower to be done at that time.
Failure to Timely Report Abuse and Injury Allegations
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to DIAL in a timely manner for two residents. One resident, who was cognitively intact with diagnoses including UTI, COPD, cirrhosis of the liver, anxiety, depression, and prior right rib fractures, developed worsening right-sided pain and was sent to the ER. Imaging showed an age-indeterminate but presumably acute nondisplaced right posterior 11th rib fracture that was new compared with prior imaging. The facility completed an internal investigation and a physician signed a non-major injury form, but the facility later acknowledged that the rib fracture of unknown origin had not been reported to the Regional Director of Operations or DIAL. The second resident, who was cognitively intact and required extensive assistance with ADLs and Hoyer lift transfers, had bruising to the left wrist and right elbow/forearm after care and rolling. The resident stated the staff grabbed him too hard when moving him and that they held on too hard. The incident report documented deep purple bruises, and photographs showed finger-mark-like lines at the wrist and a large bruise at the elbow/forearm. The resident later repeated that staff were too rough when they grabbed his arms to move him, and he described staff grabbing his arms harshly and leaving bruises. The facility’s documentation did not show that this event was treated as an allegation of abuse or that an abuse investigation file was submitted to the State Survey Agency. The Administrator stated the bruising was not treated as abuse because it was not considered unknown origin since the resident knew the bruise was there, and the only documentation was a grievance form noting staff education. As of the survey date, no abuse investigation file had been received related to the bruises on the resident’s wrist and elbow, and the facility failed to report the allegation of abuse to the State Survey Agency.
Incomplete Abuse and Injury Investigations
Penalty
Summary
The facility failed to conduct thorough investigations of allegations of abuse and injuries of unknown origin for two residents. For one resident with intact cognition, the record showed bruising to the left wrist and right elbow after care and rolling, with the resident stating staff grabbed him too hard when turning him. The incident report documented deep purple bruises, the resident’s statement that staff held on too hard, and photographs showing patterned bruising consistent with finger marks. However, the grievance documentation did not show that an abuse investigation was initiated, and the facility administrator later stated the bruising was not treated as an allegation of abuse because the resident knew the bruise was there. The same resident later reported that staff grabbed his arms harshly when helping move him and that some staff were too rough when turning him. During survey observation in the shower room, a CNA spoke to the resident in a manner that the surveyor perceived as intimidating, and the resident and CNA were overheard in a back-and-forth exchange. The surveyor reported an allegation of potential intimidation and verbal abuse, but the facility’s investigation file was limited. It included a few staff and resident statements, but it did not include a written statement from the surveyor who made the initial report, and the final investigation summary omitted statements that described the CNA speaking harshly to the resident. The administrator also stated the investigation was good enough based on the resident’s denial of feeling threatened, despite the surveyor’s report and staff comments that the CNA was rude and disrespectful to residents. For the second resident, the record showed an acute episode of right-sided abdominal and rib pain that led to an emergency room visit and a diagnosis of a right 11th rib fracture. The resident was cognitively intact and denied falling or recent injury. The facility investigation form documented the fracture and pain, but the report excerpt provided did not show a completed explanation for the injury’s cause or a full abuse/injury-of-unknown-origin investigation. The facility policy defined abuse and listed physical marks such as bruises and physical injury of unknown source as possible indicators, but the policy review noted it lacked a definition for injuries of unknown origin as defined in the State Operations Manual.
G-tube Feeding Order Not Followed and Order Communication Was Unclear
Penalty
Summary
The facility failed to ensure staff followed a G-tube feeding order for a resident with severe cognitive impairment, stroke-related deficits, aphasia, hemiplegia, dysphagia, and dependence on tube feeding. The resident’s MDS documented a BIMS score of 4 and extensive physical dependence, but it did not document the G-tube for feeding and nutrition. The care plan identified the resident as at risk for altered nutrition and hydration status related to cognitive status, post-stroke condition, feeding tube, foley catheter, and being bed or chair bound, and another care plan focus stated the resident required tube feeding because of dysphagia secondary to stroke. The resident’s nutrition record showed that the RD recommended holding G-tube feedings for six nights and asked the provider to approve the hold. The ARNP later documented that the resident remained G-tube dependent and was stable on night feeds via the G-tube, with continued discussion about reducing dependence pending swallow study results. The MAR/TAR reflected a feeding order for Osmolite 1.2 from 9:00 PM to 3:00 AM, with a hold beginning on 5/12/26 and a discontinuation date of 5/15/26. Nursing documentation showed the feeding was held on 5/12/26, 5/13/26, and 5/14/26, and then the order was extended through 5/21/26. The MAR/TAR for the extended order showed the feeding was administered on 5/15/26 and 5/16/26, held on 5/17/26 through 5/19/26, and administered again on 5/20/26 and 5/21/26. The resident also had an order for 60 mL water flushes every hour via the G-tube during the feeding period, and those flushes were documented as completed as ordered. Staff U stated that he connected and administered the feeding on 5/15/26 as shown on the MAR, but on 5/16/26 he did not administer the feeding as indicated because he learned during shift report that the feeding required a hold and he could not find an order in the EHR stating that the feeding remained on hold or was discontinued. On 5/21/26, observation of the resident’s room found a bottle of Osmolite with 400 mL remaining and a feeding bag with 500 mL of water hanging on a pole with tubing inserted through the feeding pump, with no date of use on either item. A feeding syringe and graduate were also present on the bedside table labeled 5/20 PM. Later review of the EHR showed that the 5/22/26 RD recommendation to discontinue the G-tube feedings and water flushes had not been documented as communicated to, reviewed by, approved by, or declined by the physician, and the facility identified concerns with the communication, transcription, and follow-up process related to the dietitian’s recommendations and the G-tube feeding order.
Medication Administration and Order Reconciliation Failures
Penalty
Summary
The facility failed to administer insulin as ordered for one resident with intact cognition and diagnoses including diabetes mellitus, hypertension, anxiety, and depression. The physician orders required Insulin Lispro after meals based on meal consumption, with additional correction doses based on blood glucose levels. Review of the May MAR showed the scheduled insulin was not administered on two dates because staff documented it as a duplicate order. An LPN stated she must have misread the order and acknowledged she did not give the insulin on those days, and the DON verified there were two different insulin sliding scale orders and expected the nurse to verify and administer the insulin according to the order. The facility also failed to discontinue an anticoagulant for another resident with a history of DVT and PE. The resident’s hospitalization summary documented admission for acute blood loss anemia secondary to vaginal bleeding, that Xarelto was held on admission, and that the bleeding resolved. The summary further stated there was no specific reason for chronic anticoagulation given the resident’s vaginal bleeding and multiple prior GI bleeding episodes, and it recorded that the anticoagulation was discontinued. Despite this, the February, March, and April MARs continued to show Xarelto 20 mg daily with supper as an active medication. The resident repeatedly refused the medication because she believed it had been discontinued during the hospitalization, and staff documented that the medication remained active on the MAR. A nurse later contacted the physician, who reviewed the discharge summary and confirmed the discontinuation, and an NP note also documented that the anticoagulation had been discontinued during the last hospitalization but remained active on the MAR. The care plan was not revised to reflect the discontinuation, and the MDS still identified anticoagulant use within the recent assessment period.
Incomplete discharge planning and documentation for AMA departure
Penalty
Summary
The facility failed to complete discharge planning and documentation for a resident who chose to leave against medical advice. The resident had a BIMS score of 13, indicating intact cognition, and diagnoses that included a right great toe surgical amputation, DVT, heart failure, and hypertension. He had been admitted from the hospital after a right great toe amputation and gangrene of the left great toe, and an encounter note later stated he still did not wish to go home at that time, although he met the qualifications for home health care. The resident left the facility against medical advice and signed the AMA form, and the physician was notified. The clinical record did not contain discharge documentation, discharge instructions, follow-up appointments, medication reconciliation, or follow-up phone calls. The AMA form documented that the resident left at his own insistence against the advice of the facility and attending physician, and that he was informed of the risks and potential complications of leaving. The DON stated she educated the resident on treatments and the amputation of his left toe, that he wanted to go home to be with his significant other, and that she called APS but did not document it. Staff stated social services usually performed follow-up phone calls, but the former social worker no longer worked at the facility.
MDS PASRR Coding Errors
Penalty
Summary
The facility failed to document the presence of PASRR Level II conditions in Section A of the MDS for 2 of 4 residents reviewed for accurate MDS assessments. For Resident #1, the MDS assessment recorded an admission date and coded A1500 as 0, indicating no ID/DD-related condition, and left A1510 blank. However, the PASRR Level II outcome notice dated 1/18/26 showed the resident was approved with Specialized Services and instructed the facility to mark Yes for A1500 and check the applicable PASRR conditions in A1510. The resident’s later MDS after readmission did code PASRR correctly, and the care plan later documented PASRR Specialized Services as a newly created entry. For Resident #16, the MDS assessment recorded an admission date and also coded A1500 as 0 with A1510 left blank. The PASRR Level I Screen Outcome dated 10/25/25 identified the resident as Level I Positive with suspected or confirmed PASRR conditions of Mental Health Disability and Intellectual Disability, and it instructed the facility to mark Yes for A1500 and check the applicable conditions in A1510. During interview, the MDS Coordinator stated she used the hospital face sheet and PASRR documents to complete Section A, acknowledged Resident #1 should have been coded for PASRR Level II, and stated Resident #16’s Section A should have been marked yes and that she would need to amend that MDS.
Failure to Include Diabetes, High-Risk Medication, and Smoking Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, including care plan interventions for high-risk medications and smoking status. One resident had a BIMS score of 14 and diagnoses of diabetes mellitus, anxiety, depression, and bipolar disorder. That resident’s MAR listed multiple insulin orders, including insulin lispro injections and Lantus Solostar, as well as a Freestyle Libre glucose monitoring device, but the comprehensive care plan initiated on 1/22/26 did not include interventions for diabetes mellitus or a high-risk medication. The second resident had a BIMS score of 15 and diagnoses of metabolic encephalopathy, liver cirrhosis, COPD, anxiety, and depression. The resident was observed sitting outside smoking in the designated smoking area, and the admission progress note documented tobacco use. The comprehensive care plan initiated on 8/21/25 did not include interventions for smoking status, smoking cessation, or safety strategies. The facility’s smoking policy required staff to assess tobacco use, complete a safe smoking assessment, and document safe smoking measures on the care plan, and the comprehensive care plans policy required measurable objectives and timeframes to meet identified needs.
Oxygen Not Administered Per Order
Penalty
Summary
The facility failed to administer oxygen in accordance with physician orders for a resident with COPD and respiratory failure with hypoxia. The resident’s care plan directed staff to monitor SpO2 levels, observe for respiratory changes, note mental changes, and monitor oxygen settings via nasal cannula as ordered. The physician order required SpO2 and oxygen liters to be checked every shift, the doctor to be called if the blood oxygen level dropped below 90%, and continuous oxygen at 2 to 4 liters. On observation, the resident was found in a wheelchair with oxygen tubing in her nose, but the portable oxygen tank indicator was in the red and the tank had an inadequate to no supply of oxygen. The oxygen concentrator was set at 4 liters and located behind the resident, with tubing on the floor under the bed, no label date on the tubing, and no black infection control bag connected to the concentrator. Staff interviews showed the CNA did not know how to switch oxygen to the portable tank and did not notify the nurse when the tank level was near red. On another observation, the resident was again found with oxygen tubing in place, but the portable tank meter was set at 0, indicating no oxygen supply, until an RN arrived and set the meter to 2 liters and checked the resident’s SpO2.
Unlocked Medication Cart Observed Unsupervised
Penalty
Summary
The facility failed to ensure the medication cart was locked when the Certified Medication Aide (CMA) responsible for the cart was not in sight. On 5/18/26 from 10:54 AM to 11:12 AM, surveyors observed a medication cart on 300 hall unlocked and unsupervised while nurses, CNAs, and residents passed by. During continued observation from 11:13 AM to 11:31 AM, Staff I, CMA, approached the cart six times, prepared medications, left the cart unlocked, and walked into residents’ rooms to administer the prepared medications. On 5/21/26 from 11:10 AM to 11:28 AM, surveyors again observed a medication cart on 300 hall unlocked and unsupervised while residents, housekeeping, and CNAs passed by. At 11:28 AM, Staff J, LPN, approached the cart and locked it. During an interview on 5/27/26 at 4:00 PM, the Facility Administrator and DON were notified of the unlocked medication cart observations. The Medication Storage Policy revised March 2026 stated that all drugs and biologicals are to be stored in locked compartments, and that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart.
Inaccurate resident records and conflicting clinical documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident, the clinical record contained multiple weight entries that were later struck out months after they were recorded, and the remaining documentation across the MDS, progress notes, care plan, and weight record did not consistently reflect whether the resident had experienced weight loss or weight gain. The resident’s weights varied across the record, including an admission weight of 154.2 lbs. and later weights up to 182.6 lbs., while several earlier weights were removed from the chart with notations such as technical error, re-weighed, or incorrect documentation. Staff interviews showed the MDS/Care Plan Coordinator and DON did not know why the weights were struck out and stated the dietician was responsible for the weight entries. The record for the same resident also contained conflicting nutrition documentation. Some notes described questionable weights, a history of significant weight increases, and a weight gain since admission, while other entries referenced no weight loss or a goal weight range that did not include any documented weight gain. The MDS assessments alternately coded the resident for weight gain and weight loss, and the survey findings noted that without the struck-out weights, the resident actually had a weight gain rather than a weight loss since admission. For the second resident, the nurse practitioner documented a routine face-to-face visit and complete assessment even though the resident was in the hospital and not in the facility. The note described the resident as sitting in her room, in no acute distress, wearing oxygen, with clear lungs and stable vital signs, and included a full exam and total time spent for the encounter. This documentation conflicted with the resident’s actual location, as the resident had been transferred to the hospital after oxygen saturation dropped into the high 70% range and later returned from the hospital after treatment for an upper respiratory infection.
Failure to Post Current Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing report in a public location for residents and visitors to see on a daily basis. With a census of 81 residents, observation on 5/23/26 at 7:07 PM found the staffing report posted by the east entrance before the dining/activity room, but the print was very small and hard to read from greater than 12 inches away and from an approximate height of 5 feet. The posting was kept in a page protector sleeve with several forms inside, and the top page was dated 5/20/26 while the other forms behind it were dated prior to 5/14/26. No posting since 5/20/26 was found anywhere else in the facility. Staff interviews showed the current staffing schedule was kept in the staff breakroom, not in a public location. An LPN stated the schedule was in the breakroom, and an RN stated he knew nothing about the daily staff posting. When the Administrator was asked for staffing assignments for Saturday through Monday because the daily posting was not current, she provided hall assignment sheets that did not include the total number and actual hours worked by nursing staff, and no public posting was done after the request. On 6/1/26, the daily staff posting near the east entrance still showed 5/28/26 as the most recent posting, with older sheets behind it dating back to 1/13/26. The Administrator stated she did not know why the posting was not current and said the scheduler was responsible for posting it, but could not explain who would post it on weekends.
Unlocked Medication Carts Left Unattended
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to properly secure medications from unauthorized access. Based on observations, staff interviews, and policy review, 2 of 2 medication carts observed were left unlocked in resident hallways in front of the nurse's documentation room. On 01/06/26 at 4:56 AM, an unlocked medication cart containing duloxetine and Baclofen was observed in the hall, and Staff I, LVN, was sitting in the documentation room while the cart drawer remained open for one full minute before she approached it. She stated the carts should not be left unlocked but added she was about to access the cart. On 1/07/26 at 3:05 am, an unlocked medication cart and supply cart were found in the resident hallway with no staff members or residents visible in the unit hallway. The cart contained duloxetine, trazadone, Eliquis, and Baclofen. After three minutes, Staff J, RN, approached the cart and stated the medication and supply carts should be locked when left unattended. The facility's Medication Storage policy revised 01/2025 stated that all drugs and biologicals must be stored in locked compartments, only authorized personnel may have access to the keys, and medications during a medication pass must be under direct observation or locked in the medication storage area/cart. On 1/08/26 at 2:26 PM, the DON stated staff should lock the medication carts when stepping away from the computer.
Palatability of Served Sandwiches
Penalty
Summary
The facility failed to prepare and serve food that was palatable for one of four hallways observed during the lunch meal service. On 1/7/26, dietary staff removed a large pan of ham and cheese sandwiches from the oven and reported the sandwich temperature at 130 degrees Fahrenheit. Staff then placed another pan of buns with ham and cheese into the oven, wheeled the warming cart to the dining room, and served residents in the dining room while the second pan remained in the oven for 40-45 minutes. After the dining room residents were served, staff removed the second pan from the oven and reported the sandwich temperature at 147 degrees Fahrenheit. Room trays for the 100 hall were plated later, and a test tray obtained from the 100 hall cart showed the ham and cheese sandwich was hard to cut, with a very hard and dry bun around the edges and only the middle section edible. Resident interviews from the 100 hall indicated three of four interviewable residents said the bun was hard and difficult to eat, one resident said the food was not good, and another said the sandwich was gross and she could only eat half of it. The Dietary Supervisor stated the bread came frozen from the vendor and that the buns looked kind of hard when removed from the oven, and she thought the length of time in the oven may have caused the buns to dry out. The facility policy stated food shall be prepared by methods that conserve nutritive value, flavor and appearance, and food palatable and attractive.
Unattended EHR Laptop Exposed Resident Information
Penalty
Summary
The facility failed to properly protect resident information from unauthorized access when an EHR laptop was left accessible on a resident hall with 11 residents' information visible. On 1/06/26 at 5:05 AM, surveyors observed the laptop displaying EHR information for residents 301, 304, 305, 306 A, 307, and 308 while it was unattended. At 5:09 AM, Staff H, an RN, stated that laptops are not to be left open when staff are not present and said he did not know it was open. On 1/08/26 at 2:26 PM, the DON stated the laptop screen should be locked when staff walk away. A facility policy titled HIPAA Security Measures, revised 02/2025, stated that physical safeguards will be implemented to limit physical access to electronic information systems while ensuring properly authorized access is allowed.
Failure to Maintain Resident Dignity, Timely Call Light Response, and Appropriate Pain Management
Penalty
Summary
Facility staff failed to maintain resident dignity and timely response to needs in multiple situations. One cognitively intact resident with osteoarthritis, chronic pain, and a history of a fall with fracture required assistance of one staff for toileting and transfers and was non‑weight bearing to the left lower leg while receiving therapy for a leg fracture. This resident reported that a CNA assisted her onto the toilet and left the room; after activating the call light within about five minutes, no staff responded for approximately 45 minutes, despite her roommate observing several staff walking past the room without answering the call light. The resident stated that the CNA who eventually responded was not assigned to her hall and that being left on the toilet for that length of time made her feel like no one cared about her. The same resident also reported that when she requested PRN pain medication for left leg pain rated at 7, staff told her she could not receive PRNs at that time because they could not locate the assigned LPN. When the LPN did respond, the resident stated the nurse was mean and intimidating, insisted she would receive Tylenol instead of the PRN narcotic ordered for higher levels of pain, and that this behavior caused the resident to avoid requesting narcotics when that nurse was on duty. The resident reported sitting and crying for two hours due to pain and experiencing breakthrough pain related to therapy, and stated she had informed the DON that she endured a lot of pain because the LPN did not administer the requested PRN medication. Additional dignity concerns were identified with other residents. One resident reported that staff frequently entered his room without knocking, and this was observed when a staff member entered during an interview to check his ice without knocking. Another resident reported that staff had been entering his room without knocking for a long time and that he was fed up; this was observed when three staff entered his room without knocking and interrupted an interview. During a lunch observation, a dependent resident with CVA, malnutrition, aphasia, dementia, severely impaired cognition, and total dependence on staff for eating was fed by a CNA who sat with her elbow on the table, head resting on her hand, did not look at or interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before resuming feeding without apparent hand hygiene. These actions and inactions occurred despite facility policies on promoting/maintaining resident dignity and call light response, and staff and DON statements that expectations included timely call light response, knocking and announcing before entering, and providing appropriate pain control and dignified, engaged feeding assistance.
Failure to Include Fall-Prevention and Antianxiety Interventions in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility did not develop and implement complete, individualized care plans for two residents following changes in condition and treatment. For one resident with a history of stroke, unsteadiness on feet, and muscle weakness, records showed the resident fell from bed while sleeping and was hospitalized. Progress notes documented that new fall prevention interventions would be determined upon the resident’s return and that the care plan was reviewed and updated. The revised care plan referenced the fall and directed staff to assist with mobility and maintain a clutter-free environment, but it did not include the specific intervention that staff had instructed the resident to follow: keeping the bed in the lowest position when asleep. During interviews, the resident confirmed staff had given this instruction, and an LPN and CNA both stated that such a bed-positioning intervention should appear in the care plan, but it was not present. For another resident with severely impaired cognition, non-Alzheimer’s dementia with behavioral disturbances, anxiety, and depression, the MDS and electronic health record documented an order for antianxiety medication and described the behaviors the resident exhibited when anxious. A progress note also described the resident’s anxiety behaviors and indicated they had not been recently observed. However, the resident’s care plan, although it listed an anxiety disorder, did not include the ordered antianxiety medication, did not specify the resident’s anxiety behaviors for staff to monitor, and did not outline any non-pharmacological interventions for staff to attempt. In interviews, an LPN and CNA indicated that the antianxiety medication, target behaviors, and related interventions should be included in the care plan, and the DON stated that care plans should be updated to accurately reflect care based on physician orders, consistent with the facility’s comprehensive care plan policy.
Failure to Protect Resident During Mechanical Lift Transfer and to Supervise At-Risk Smoker
Penalty
Summary
Surveyors identified that staff failed to protect a resident’s heels during a mechanical lift transfer. One resident with moderately impaired cognition, bilateral leg nerve damage causing muscle weakness, a history of stroke, and a documented moderate risk for pressure ulcer development required extensive assistance with ADLs and mobility. His care plan directed staff to follow facility protocols for prevention of skin breakdown. During observation of a bed-to-wheelchair transfer using a mechanical lift, an OT and a CNA repositioned the resident in the sling while his heels dragged across the mattress. After transfer, the OT exposed the resident’s heels and noted redness on the right heel. Multiple CNAs later stated that residents’ feet and bodies should not contact the mattress while being actively moved with a mechanical lift, and the DON stated staff should have lowered the bed or elevated the heels to prevent shearing or rubbing. The facility’s Safe Resident Handling/Transfers policy required safe handling and transfers to prevent or minimize injury and provide a safe, comfortable experience. Surveyors also found that staff failed to provide required supervision for an at-risk smoker who accessed the courtyard alone. Another resident with intact cognition but significant physical impairments, including hemiplegia, stroke, acute respiratory failure, hypertension, and diabetes, required extensive assistance with mobility and ADLs. A progress note and a Safe Smoking Assessment documented that he was not an independent smoker, lacked spatial and self-awareness, and required supervision for smoking. His care plan directed staff to supervise smoking, ensure cigarettes were fully extinguished, and assist him to and from the designated smoking area as needed. On one early morning, the resident wheeled himself through an exit door into the enclosed smoking courtyard by canceling the door alarm and activating the automatic door opener, with no staff present and no audible alarm heard. On another early morning, he opened the courtyard door and triggered the alarm, to which the DON immediately responded and reminded him he needed staff present to smoke. The facility’s Resident Smoking policy required that supervision be provided as indicated on each resident’s care plan.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves facility staff not consistently answering resident call lights within a reasonable amount of time, particularly during evening and night shifts. Multiple residents with intact cognition, as indicated by Brief Interview for Mental Status (BIMS) scores of 15, reported extended waits after activating their call lights for assistance with toileting and personal care. One resident stated that after being assisted to the toilet by a CNA, she activated her call light within five minutes but did not receive help back to bed for approximately 45 minutes. Another resident reported turning on the call light for toileting assistance and waiting about 30–45 minutes without a response, ultimately going to bed without being properly cleaned. A third resident reported experiencing prolonged call light response times for a long period during evenings and overnights, including an incident where he choked on mucous and waited about 15 minutes for staff to respond, during which he feared he was choking to the point of death before clearing it himself. Resident Council minutes from a recent month documented concerns that staff were turning off call lights, wearing earbuds during care, and that there were long wait times for call lights to be answered. The facility census was reported as 81 residents. The DON and CNAs interviewed stated that staff were expected to respond to call lights within an appropriate time and as quickly as possible, and the facility’s call light policy directed all staff who see or hear an activated call light to respond and notify appropriate personnel of the resident’s need.
Significant Medication Error Leading to ICU Admission After Wrong-Resident Administration
Penalty
Summary
A resident with intact cognition and multiple diagnoses including chronic kidney disease, peripheral vascular disease, hypertension, and diabetes was involved in a significant medication error shortly after admission. The resident reported that she was given medications that belonged to her roommate and stated she told the staff member the medications were not hers, but the staff member insisted they were. She took the medications, believing the physician might have changed her regimen upon admission, and subsequently blacked out and fell from her scooter. The clinical record included a progress note documenting that the resident fell as a result of a medication error and that her blood pressure was low, prompting contact with the nurse practitioner and transfer to the hospital. Hospital records showed the resident was admitted to the ICU for accidental ingestion of a muscle relaxant, an anticonvulsant, an anti-anxiety medication, and a blood pressure medication, and was followed for persistent bradycardia and hypotension requiring medications, oxygen, and intermittent vasopressor support. Facility staff interviews revealed that a CMA who was training another CMA removed medications for three residents, placed them in cups on top of the medication cart, and handed the keys to the trainee before going on break. The trainee then administered the medications, believing she was giving them to the intended resident, but was unaware there was a new resident in the same room and did not use the six rights of medication administration. The trainee acknowledged that the new resident did not yet have a photo in the EHR and admitted she did not follow the required resident identification and medication verification process. The facility’s policy required use of the resident photo in the MAR and adherence to the six rights of medication administration, which were not followed in this incident.
Failure to Follow Quetiapine Orders for a Resident With Behavioral Changes
Penalty
Summary
The facility failed to follow physician orders for a resident with anxiety disorder, depression, toxic encephalopathy, and moderately impaired cognition. The resident’s care plan identified a history of suicide attempt, episodes of behaviors, refusal of medications and cares, and attention-seeking behaviors. The care plan directed staff to administer medications as ordered, complete a medication review for behavior management, obtain a psychiatric consult, and observe and document behaviors. The resident’s admission medication orders included quetiapine 25 mg by mouth every night and 25 mg twice a day as needed, but the medication administration record showed multiple changes to quetiapine orders that were documented as PRN rather than scheduled. The MAR showed quetiapine PRN doses were given on several dates in November and only once in December, while a medication review later noted that the resident’s quetiapine 25 mg scheduled dose was not transferred to the orders on admission. A psychiatric assessment also documented psychosis and listed Seroquel 25 mg daily and Seroquel 50 mg at bedtime PRN. The resident had documented behavioral incidents during the stay, including grabbing a fire extinguisher, spraying it outside, and later shredding a roommate’s pillow with scissors. Progress notes described increased anxiety, a blank stare, shaking, refusal to speak with staff, and refusal to talk to the psychiatric provider. The resident was later sent to the hospital for altered mental status and unsafe behaviors, and the transfer form noted she had been rocking, stating she was scared, isolating herself, and recently refusing medications.
Catheter drainage bag raised above bladder during care
Penalty
Summary
Provide and implement an infection prevention and control program was not met when staff failed to follow catheter care practices during perineal care for a resident with a suprapubic catheter. Resident #16 had a BIMS score of 09 out of 15, diagnoses including quadriplegia, stroke, multidrug-resistant organism infection, abnormal bladder function, and obstructive uropathy, and required extensive assistance with ADLs and mobility. The care plan identified the resident as high risk for UTI due to suprapubic catheter use and directed staff to provide catheter care per protocol. During perineal care, two CNAs assisted the resident while he was lying in bed, and at the end of the procedure one CNA lifted the urinary drainage bag above the resident's bladder while putting on his shorts. The urine in the drainage tubing, which contained a white, mucoid substance, flowed back into the resident's bladder. The CNA later stated she had received IC training and knew the drainage bag and tubing should not be higher than the resident, and the DON stated staff should not have raised the drainage bag over the level of the resident's bladder. The facility policy directed staff to keep the drainage bag below the level of the bladder to discourage backflow of urine.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to provide the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations. Resident #12 was admitted on 9/25/25, was over age [AGE], and had diagnoses including cancer, sepsis, and respiratory failure. The MDS dated 10/2/25 identified the resident’s pneumococcal immunization as not up-to-date and indicated the vaccine was not received because it was not offered. The Iowa Registry Immunization System record scanned into the EHR showed the resident had not received a pneumococcal vaccine and listed the vaccine as past due. A Pneumococcal Vaccine Consent Form signed by the resident’s representative on 9/26/25 showed consent to receive the vaccine, and the EHR clinical immunization list showed Prevnar 20 as pending immunization. The immunization record lacked documentation showing whether the resident had ever received Pneumovax (PPSV23) or any pneumococcal conjugate vaccine, including Prevnar 20, Prevnar 21, or Vaxneuvance, per CDC guidelines. Progress notes from 9/25/25 through 12/22/25 documented a history of pneumonia but did not show that a pneumococcal vaccine was administered. Staff F, the ADON and Infection Preventionist, stated the facility offered flu and pneumonia vaccines, checked IRIS on admission, obtained consent or declination, and used standing orders, but also stated the resident had consented and requested the pneumonia vaccine and it was not given because the order was entered but not marked yes and was on the MAR but not administered.
Failure to Administer Consented COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to 1 of 5 sampled residents reviewed for immunizations, Resident #20. The resident’s MDS assessment identified an admission date of 4/28/25 and diagnoses of sepsis and non-Alzheimer’s dementia. A COVID-19 Vaccine Consent Form dated 4/28/25 showed the resident gave consent to receive the COVID vaccine, but the EHR Clinical Immunizations tab showed only a COVID-19 booster last administered on 8/26/22. Review of the clinical record on 1/7/25 found no documentation showing whether Resident #20 had ever received the requested COVID vaccine. During interview, the ADON/Infection Preventionist stated she had worked at the facility since 6/2025 and in the Infection Preventionist role since 10/2025. She reported that she referenced CDC guidelines for COVID vaccine recommendations, checked the IRIS registry for resident immunization history, and that the facility had standing orders for immunizations. She stated the facility offered flu and pneumonia vaccines but had not gotten to COVID immunizations. She also reported that residents were offered immunizations on admission, consent or refusal was obtained, and the vaccine was obtained from the pharmacy. Later, she stated she was not employed when Resident #20 admitted, saw that the resident had consented and requested the COVID vaccine, but the vaccine was not given.
Failure to Respond to Change in Condition and Clarify Psychotropic Orders
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who experienced a change in condition and was later hospitalized with sepsis, acute renal failure, acute hypoxic respiratory failure, and acute metabolic encephalopathy. The resident had diagnoses including COPD, heart failure, and diabetes, and the care plan directed staff to monitor and report symptoms such as fatigue, communication changes, and signs of discomfort or distress. Staff interviews and the record showed multiple observations of lethargy, altered mental status, reduced verbal response, difficulty swallowing, poor intake, and breathing concerns over the course of the day, but the progress notes did not document a change in status before the resident was sent to the hospital for altered mental status. The record and interviews showed that staff members observed the resident was not acting normally, including staring off, not talking much, appearing lethargic, having difficulty remaining upright, and eating and drinking very little. A CNA reported concerns to an LPN, and another nurse later noted the resident had a slight left-sided facial droop and was not talking right. The on-call provider’s note documented altered mental status, lethargy, possible facial droop, and that the resident had been symptomatic for about one day before transfer. The facility policy required prompt notification of the physician and resident representative for significant changes in condition, including deterioration in health or life-threatening conditions. The facility also failed to notify the provider to evaluate and review a 30-day psychotropic medication order for a new admission before the order expired. The resident had diagnoses including bipolar disorder, anxiety disorder, and memory impairment, and the care plan identified risk related to psychotropic drug use. Hospital discharge instructions included trazodone, quetiapine, and divalproex for 30 days, and the admission medication review specifically asked for clarification on whether the 30-day supply should be continued. The pharmacy medication regimen review also requested follow-up with the prescriber regarding the 30-day stop dates because the medications appeared to be maintenance medications, but the clarification was not documented, and the medications were stopped without tapering before being restarted later.
Failure to Remove Old Fentanyl Patch Before Applying New Patch
Penalty
Summary
The facility failed to follow the physician’s order to remove an old fentanyl patch before applying a new patch for a resident with cancer, polyneuropathy due to toxic agents, COPD, and unspecified abdominal pain. The care plan directed staff to administer fentanyl as ordered, and the physician’s order summary specified that a 25 mcg fentanyl patch was to be applied every 3 days, with the old patch removed before the new one was applied and sites rotated. The EMAR showed a 25 mcg patch applied on the left arm and, three days later, another patch applied on the right arm. Clinical records and interviews showed that after the second patch was applied, the resident became confused, lethargic, and unable to answer questions. Staff A, ARNP assessed the resident and noted lethargy and confusion, with a history of urosepsis and hydronephrosis, and sent the resident to the hospital. The EMS report documented that a fentanyl patch was removed en route to the hospital, and the ED physician noted that a second fentanyl patch was removed in the ED. The hospital discharge summary stated that on 9/7 the patient was transferred to the ICU for fentanyl overdose with severe acute hepatic encephalopathy and increased ammonia levels. Interviews indicated the nurse who applied the patch stated she removed the old patch before applying the new one, but she could not identify who witnessed the disposal or where it was documented. Staff A stated she did not look to see how many fentanyl patches were on the resident, though she heard there were two. The Administrator stated the nurse should have removed the prior patch before applying the new one and acknowledged that the ED notes showed two patches were present during transport. The facility policy on medication administration required medications to be given as ordered, and the controlled substance policy addressed disposal of removed patches but did not direct removal of old patches before applying a new patch.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance of a safe, clean, and comfortable environment. In one resident room, the carpet was excessively stained with dark and pink spills, and the bathroom shower was used for storage of trash bags filled with empty cans, while personal hygiene items were stored on the floor. The dining room had peeling paint, exposed drywall, and hanging plaster from water leaks, with one damaged area directly above a dining table. Additional findings included a large vent with dust buildup, stained ceiling tiles, windows with residue and tape marks, corroded sink cabinetry, and an actively leaking water line saturating the floor. The nurses' station and main facility areas had heavily stained carpets, and a skylight area had ceiling tiles with brown and black discoloration and powder-like particles falling onto the floor. The entertainment area vent was covered in a fuzzy, black substance, and the main carpeted areas were soiled with various stains. A resident who used a wheelchair was found to have a visibly soiled wheelchair with debris buildup and multiple cigarette burns on the cushion. The wheelchair's left wheel lock was nonfunctional, and the resident reported it had not worked properly for a long time. The DON confirmed that staff were expected to clean wheelchairs at least weekly and as needed, and that carpets had been shampooed multiple times without success in removing stains. Facility policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, but these standards were not met as evidenced by the observations.
Failure to Provide Timely Response to Call Lights Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights for all residents reviewed, as evidenced by multiple resident interviews, observations, and record reviews. Several residents, all with significant care needs such as morbid obesity, heart failure, stroke, hemiplegia, and cognitive impairments, reported excessive delays in staff responding to their call lights, with some waiting over an hour and, in one case, over two hours. Residents consistently described situations where staff would turn off call lights, promise to return, and then not come back for extended periods, leaving residents without necessary assistance for toileting, transfers, and other essential care needs. Observations confirmed that call lights were not always accessible to residents, with instances where the call light was out of reach, preventing residents from requesting help. One resident was observed with the call light cord draped over the bed footboard and the button out of reach, and another resident confirmed they could not access the call light when needed. The facility's policy required call lights to be within reach and secured as needed, but this was not consistently followed. The Director of Nursing acknowledged that the policy did not specify a required response time but stated her expectation was for call lights to be answered within 15 minutes. Residents reported negative experiences due to these delays, including being left wet for extended periods, which contributed to ongoing skin issues, and having to leave their rooms to seek assistance themselves. The facility census at the time was 79 residents, and the deficiency was identified through a combination of resident interviews, staff interviews, observations, and policy review.
Widespread Infection Control Lapses During Resident Care and Dining
Penalty
Summary
Staff failed to maintain infection control practices for all residents reviewed, as evidenced by multiple observed lapses. During meal assistance, a CNA wore the same pair of gloves while touching multiple residents and their food items, without performing hand hygiene between contacts. In another instance, staff emptied a resident's catheter bag by placing the graduated container directly on the carpeted floor without a barrier and allowed the catheter drain spout to touch the inside of the container, contrary to facility policy. For another resident, although a barrier was used, the catheter spout repeatedly touched the inside of the graduated container during emptying, and the container was left uncovered on the back of the toilet after use. Additionally, a package of perineal wipes used for one resident was placed on another resident's bedside table after care was completed. Further deficiencies included a staff member providing ostomy care to a resident with a multidrug-resistant organism diagnosis without wearing a protective gown, as required by enhanced barrier precautions. It was discovered that PPE supply bins outside resident rooms were inadequately stocked, with only one out of several bins containing gowns. The DON confirmed expectations for proper hand hygiene, use of barriers, and PPE, which were not met during these observed care activities.
Incomplete Incontinence Care Provided
Penalty
Summary
Staff failed to provide complete incontinence care for a resident with a history of stroke, non-Alzheimer's dementia, and hemiplegia, who was dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. During observed care, staff removed a visibly wet brief and cleansed the area above the penis, the penis, and the scrotum, but did not cleanse the inner thighs. When the resident was turned, staff cleansed between the buttocks and inner buttocks but did not cleanse the outer buttocks and hips. Facility policy required cleansing of the buttocks and anus, and the Director of Nursing confirmed the expectation to cleanse all areas of the buttocks and hips during incontinence care.
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 394 citations issued within 25 miles in the last 12 months — including the 3 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 West Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iowa Jewish Senior Life Center | 2.1 mi | ★★★★★ | 20 | 0 |
| Karen Acres Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
| Walnut Ridge | 2.8 mi | ★★★★★ | 0 | 0 |
| Calvin Community | 2.9 mi | ★★★★★ | 12 | 0 |
| Wesley On Grand | 3.1 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.