Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Oak Nursing And Rehabilitation Center Llc during CMS and state inspections, most recent first.
QAPI processes were not effective in addressing repeated deficiencies cited under F658, F725, and F880. CASPER reports showed F658 had been cited in multiple prior years, and F725 and F880 had been cited in 2025, yet the same deficient practices were identified again on the current survey. The QAPI plan described monitoring through CASPER reports, audits, grievances, and survey results, and the Administrator said issues were brought to the QA Committee from audits and grievance forms, with the Committee choosing topics based on need, urgency, and requirements.
Delayed response to resident call lights was observed for multiple residents with needs for toileting, transfers, dressing, and personal care. Residents with intact cognition and others with moderate impairment reported waits of 40 to 45 minutes for assistance, and one resident's call light remained on for 26 to 28 minutes before staff responded. The DON stated call lights were expected to be answered in 15 minutes, while Resident Council notes repeatedly documented that call lights were not being answered timely.
A resident with intact cognition and multiple pain-related diagnoses reported that prescribed Voltaren gel for pain and hydrocortisone cream for rash were not applied as ordered. Review of the TARs showed multiple missing entries for these scheduled topical medications over two months, indicating they were either not administered or not documented. This occurred despite the care plan interventions to monitor pain management and the facility policy requiring medications to be given as ordered and the MAR to be signed after administration, as confirmed by the DON.
Failure to complete pre-hire background and licensure checks: the facility rehired a CNA without documented DCI clearance in the employee file and hired an RN without verifying licensure before hire. The Administrator confirmed both items were expected pre-hire, and the facility’s checklist and abuse/neglect/exploitation policy required background, credential, and screening documentation.
The facility failed to notify the LTC Ombudsman of a resident’s hospital transfers and discharges. The resident had COPD, HF, chronic hypoxic respiratory failure, and altered respiratory status, with multiple hospitalizations and returns to the facility. The Administrator believed Social Services had handled the notifications, but Social Services staff said they had not been trained correctly and could not provide documentation of Ombudsman notice. The facility’s transfer/discharge policy required the Social Services Director or designee to provide the required notices.
Incomplete Dialysis Assessments and Communication: A resident with ESRD received dialysis three times weekly, but facility records showed missing dialysis communication entries and an incomplete shunt exam section. Staff reported the pre-dialysis assessment was done by the facility and the post-dialysis assessment by the dialysis center, with information expected to be returned for entry into the facility record. The DON stated the facility should complete assessments before and after dialysis, and the facility policy required ongoing assessment and monitoring before and after dialysis treatments.
Failure to implement EBP for residents with a feeding tube and an indwelling Foley catheter. Staff used gloves only during high-contact care, including tube feeding setup, flushing, bathing, and catheter-related care, despite EBP signage and supplies being present for one resident and EBP being directed in the care plan for the other. An LPN, wound nurse, CNA, IP, and DON all described inconsistent use of gown and mask during the identified care activities.
Two residents experienced repeated violations of their privacy when an Activity Assistant entered their rooms without knocking or waiting for a response, including during personal care and dressing. Both residents reported feeling uncomfortable and embarrassed, and staff interviews confirmed that these incidents were not isolated, with similar concerns raised by other residents.
The facility did not effectively implement its QAPI processes to ensure that allegations of abuse were reported as required. Despite having policies and multiple reporting channels, the failure to report abuse was identified in more than one survey, indicating ongoing issues with the facility's quality assurance activities.
A resident with severe cognitive impairment and a history of physical aggression slapped another resident, resulting in a facial injury that later developed into an abscess requiring antibiotics. Although staff documented and separated the residents, the incident was not reported to the state agency or other required authorities as mandated by facility policy. Both the administrator and DON later confirmed the event should have been reported.
Multiple residents with complex medical and cognitive needs did not receive adequate assistance with bathing, grooming, and other activities of daily living due to insufficient staffing. Documentation and interviews revealed missed or infrequent baths, lack of follow-up after refusals, and incomplete grooming care, with staff and residents reporting that high acuity and staffing shortages prevented completion of necessary care tasks.
The facility did not carry out a system of infection surveillance as required by its policy, lacking documentation and routine monitoring to identify and address infections among residents, staff, and visitors. The DON confirmed infection control activities were not completed, and there was no evidence of systematic data collection or analysis to track infection trends.
Surveyors identified significant lapses in kitchen sanitation, including dust accumulation on equipment, shelves, ceiling panels, and vents, as well as dust and hairs near food preparation and storage areas. These findings indicated that the facility did not adhere to its own cleaning schedule or professional standards for food service areas.
Four residents with varying medical conditions and cognitive abilities were not offered influenza vaccinations as required by facility policy, and there was no documentation to show the vaccine was offered during the relevant flu season. Staff confirmed the lack of documentation and acknowledged that residents should be current with immunizations.
A resident with multiple medical conditions and intact cognition was not offered the COVID-19 vaccine, as required by facility policy. Review of clinical records and staff interviews confirmed the absence of documentation showing the vaccine was offered.
Surveyors found that three residents with significant care needs were not treated with dignity and respect, including being told to use briefs instead of being assisted to the bathroom, being left in soiled clothing, experiencing missed or delayed personal care and medications, and having staff discuss personal matters inappropriately. Staff interviews confirmed these practices and revealed issues with staffing and communication.
Several residents with varying medical and cognitive conditions did not receive consistent assistance with bathing, grooming, and other ADLs as required by their care plans and facility policy. Documentation showed long gaps between baths, lack of follow-up after refusals, and missing records of care provided. Staff and resident interviews confirmed that inadequate staffing and high resident acuity contributed to missed or insufficient personal care, resulting in residents experiencing poor hygiene, unchanged clothing, and dissatisfaction with their care.
The facility did not consistently perform or document wound assessments and treatments for three residents with non-pressure wounds. One resident with a recent toe amputation and another with vascular leg wounds experienced incomplete wound documentation, missed or delayed treatments, and insufficient weekly skin observations, despite facility policies requiring regular assessment and care. The DON confirmed gaps in documentation and assessment.
The facility did not ensure that advance directive and code status information was accurately documented and easily accessible for two residents, including one with intact cognition and another with severe cognitive impairment. In both cases, the required IPOST forms were either missing from the designated binder or not properly filed, leading to delays and uncertainty regarding the residents' wishes for resuscitation. The DON confirmed that code status documentation was not up to date as required by facility policy.
A CNA was allowed to work without active certification after claiming to be certified in another state. Personnel file review and database checks confirmed the absence of certification, and it was later discovered that the individual had failed the CNA test.
A CNA did not receive a documented performance evaluation, competency assessment, or orientation training, with only a brief communication training recorded. The Administrator confirmed the absence of required evaluation and training records.
Two residents on a pureed diet did not receive the required bread or bread substitute with their meal, as the cook prepared pureed meatballs without bread and served a lunch tray missing the prescribed pureed orzo. Facility policy and menu guidelines specifying the need for a bread component in pureed diets were not followed.
A CNA did not complete the required annual in-service training, including abuse prevention and dementia care education. Personnel files showed missing orientation, competency evaluations, and documentation of necessary training, with only a brief communication session recorded. The Administrator confirmed the lack of training and documentation, citing issues with the facility's training platform.
A resident with multiple chronic conditions and intact cognition was not protected from misappropriation and exploitation when a nurse, with whom the resident had a close and unprofessional relationship, was the only person administering his Sildenafil Citrate. Significant quantities of the medication were unaccounted for, and a prescription label was later found in the nurse's personal belongings. The facility failed to document the disposition of the missing medication and did not provide adequate oversight or investigation as required by policy.
A resident with multiple sclerosis and intact cognition was involved in an unreported incident where significant quantities of prescribed Sildenafil Citrate went missing, and staff were aware of an inappropriate relationship and possible exploitation by an RN. Despite staff reports and facility policy requiring immediate investigation and reporting, the facility did not document a thorough investigation or notify authorities.
A resident with multiple sclerosis and intact cognition was involved in two reported incidents of inappropriate contact with an RN, and later, the resident's prescription medication was found in the RN's possession. The facility did not thoroughly investigate the incidents, failed to document key investigative steps, and did not ensure separation between the resident and staff during the process, contrary to facility policy.
A resident with chronic pain and multiple diagnoses did not consistently receive prescribed topical pain medication as ordered, with multiple missed doses documented over several weeks. The resident reported missed and late medications to staff and administration, and LPNs confirmed the missed or delayed administration. Facility policy required medications to be given as ordered and within a specific time frame, but this was not followed.
A resident with a history of cellulitis, heart failure, and obesity was admitted with heel wounds, but staff failed to document regular skin assessments or provide ordered treatments for the pressure ulcers. The presence and care of the heel wounds were not recorded until two weeks after admission, despite facility policy requiring weekly assessment and documentation.
A resident with severe cognitive impairment and multiple medical conditions was pushed in a wheelchair by a CNA without the use of foot pedals, causing the resident's foot to drag on the ground during transport. The DON confirmed that staff should use foot pedals, but the facility lacked a policy on their use.
Two residents with intact cognition did not receive multiple scheduled medications due to unavailability, as confirmed by MAR review and resident interviews. The DON acknowledged ongoing issues with medication availability, especially during a recent medication changeover, in violation of facility policy requiring administration of medications as ordered.
A resident reported that food served in one dining area was cold, and observation confirmed that meals delivered to that area were not kept at safe hot holding temperatures. Although food was initially prepared at appropriate temperatures, delays in plating, lack of pre-warmed plates, and time taken to distribute trays resulted in food temperatures dropping well below the facility's standard for safe and appetizing service.
The facility failed to notify providers and families in a timely manner about test results for two residents, leading to delayed communication and potential impacts on care. One resident with impaired cognition did not have chest x-ray results communicated before being sent to the hospital, while another resident's urinary tract infection results were not promptly shared with their family. The facility's policy required prompt notification, but staff did not adhere to these guidelines.
The facility failed to adequately assess and document the conditions of two residents, one with severe cognitive impairment and respiratory issues, and another with moderately impaired cognition and UTI symptoms. Staff did not consistently document vital signs or assessments, and there was a delay in communicating test results. The DON acknowledged the lack of documentation, attributing it to staff being busy, and no policy for conducting assessments was provided.
The facility failed to maintain accurate clinical records for two residents, resulting in deficiencies in communication and care. One resident's record lacked documentation of chest x-rays and follow-up, while another's lacked assessments for symptoms related to a urinalysis order. The DON acknowledged the need for better staff education, and the Administrator was unaware of the lack of regular assessments.
The facility failed to serve meals at the required temperature and ensure palatability for residents. Test trays on two consecutive days showed food temperatures below the required 135 degrees Fahrenheit, with cauliflower at 117.8 degrees and vegetables at 127 degrees. The chicken was dry despite being covered with sauce, and the Salisbury steak appeared dry and crusty. Staff acknowledged the temperature issue, and the State Ombudsman noted it as a chronic problem.
The facility failed to conduct pre-dialysis and post-dialysis assessments for a resident with renal disease, as required by their policy. Additionally, another resident's skin condition was not routinely assessed, despite the presence of a rash. The facility's policies on hemodialysis and skin assessment were not followed, as confirmed by the Clinical Nurse Consultant.
A resident with Diabetes Mellitus Type 1 experienced a critically low blood sugar level and became unresponsive. Despite having a physician's order for Glucagon, the LPN on duty, who was inexperienced, did not administer the medication immediately and instead contacted the primary care provider, delaying the intervention. The resident's condition necessitated a transfer to the emergency room, highlighting a deficiency in the facility's emergency response protocol.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed Suboxone and was given an incorrect dosage of Fluoxetine due to errors in order entry and delays in medication procurement. The resident exhibited erratic behavior and was hospitalized with acute metabolic encephalopathy and a UTI.
A facility failed to provide appropriate assessment and interventions for a resident with a PICC line. The resident was admitted without orders for PICC line management, leading to an occlusion and lack of flushing. The issue was identified through clinical record review and staff interviews, revealing a lapse in following proper procedures.
QAPI process failed to address repeated deficiencies
Penalty
Summary
The facility failed to implement effective QAPI processes to address repeated deficient practices cited under F658 Services Provided Meet Professional Standards, F725 Sufficient Nursing Staff, and F880 Infection Prevention and Control. CMS CASPER reports showed F658 had been cited in 2021, 2022, 2024, and 2025, while F725 and F880 had been cited in 2025. These same deficient practices were identified again during the facility’s most current survey conducted 4/20/26-4/23/26, with the facility reporting a census of 75 residents. The facility’s QAPI plan stated that the Governing Body reviews QAPI data, findings, trends, corrective actions, and performance improvement activities, and that the QAPI/QAA Committee is responsible for implementation, coordination, and ongoing monitoring of the QAPI program and PIPs. The plan also listed monitoring methods including quality indicator reports, CASPER reports, resident concerns/grievances, audit tools, monthly tracking and trending reports, self-reports, survey results, and DIA 2567s. In interview, the Administrator stated concerns were brought to the QA Committee from audits and grievance forms, and that the QA Committee decided which issues to work on based on what was needed, what was urgent, and what was required; the Administrator also reported providing monthly updates to the Council or as requested.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer resident call lights timely for 4 of 6 residents reviewed, including residents with needs for toileting, transfers, dressing, and personal care. Resident #26 had moderate cognitive impairment, a traumatic above-the-knee amputation of the left lower extremity, anxiety, depression, and required partial/moderate assistance with toileting hygiene; the resident reported waiting 45 minutes for staff to answer the bathroom call light while sitting on the toilet. Resident #50 had intact cognition, chronic pain syndrome, fibromyalgia, osteoporosis, muscle weakness, and required dependent to substantial assistance with toileting, dressing, and transfers; the resident reported waiting up to 40 minutes for assistance and said waits were still 20 to 25 minutes. Resident #1 had end stage renal disease, HTN, DM, intact cognition, and required partial/moderate assistance with bed mobility, transfers, and toileting hygiene; the resident reported waiting 40 minutes for staff to help and stated weekends were worse, with not enough staff on weekends. Resident #80 had heart failure, DM, respiratory failure, intact cognition, and was dependent on staff for toileting hygiene, lower body dressing, rolling, sit-to-stand, and bed-to-chair transfers, with substantial/maximal assistance needed for upper body dressing and bathing. On observation, the call light monitor showed Resident #80's room number on for 26 minutes, and the call light turned off after 28 minutes when staff entered the room. Resident #80 reported the call light had been on for some time before staff came to help. The DON stated call lights were expected to be answered in 15 minutes. Resident Council notes also documented repeated concerns that call lights were not being answered timely, including residents waiting an hour for CNA assistance. The facility policy stated call lights should directly relay to staff or a centralized location to ensure appropriate response.
Failure to Follow Physician Orders for Topical Medications and Document Treatments
Penalty
Summary
Surveyors identified a failure to ensure services met professional standards of quality when staff did not follow physician orders for topical medications for one cognitively intact resident. The resident had a BIMS score of 15/15 and diagnoses including arthritis, chronic pain syndrome, fibromyalgia, osteoporosis, and muscle weakness. Her care plan identified potential for pain related to knee pain, fibromyalgia, chronic pain syndrome, history of skin cancer of the face, and thoracic spondylosis, with interventions to anticipate pain relief needs and evaluate the effectiveness of pain interventions, including compliance with dosing schedules. During an interview, the resident reported that her Voltaren cream for pain and hydrocortisone cream for rash were not applied as ordered. Review of the Treatment Administration Records (TARs) showed missing documentation of ordered topical treatments. For March 2026, the TAR lacked documentation that the resident received Voltaren gel for 16 out of 93 scheduled applications and hydrocortisone cream for 2 out of 62 scheduled doses. For April 2026, the TAR lacked documentation that the resident received Voltaren gel for 7 out of 67 scheduled doses and hydrocortisone cream for 4 out of 45 scheduled doses. The DON stated that staff were expected to sign off treatments once completed and, if a treatment was not completed, to write a progress note and notify the physician. The facility’s Medication Administration Policy required medications to be administered as ordered by the physician and to sign the MAR after administration, which was not consistently reflected in the TAR documentation for this resident’s topical medications.
Failure to Complete Pre-Hire Background and Licensure Checks
Penalty
Summary
The facility failed to verify the licensure of 1 nurse before hire and failed to obtain Department of Criminal Investigation (DCI) clearance before 1 of 5 staff were hired. Staff H, a CNA, was rehired and the employee file did not contain a background check dated on or before the rehire date or within 30 days before hire. The DCI advised that more information was needed, and the submission status later showed the criminal history was still pending further research. Staff I’s employee file showed a SING completed before hire, but it did not include nurse licensure verification. The facility did not complete verification of Staff I’s nursing license until months later. The Administrator stated the facility expected licensure verification to be completed before hire and confirmed the facility did not have a copy of clearance for Staff H to work before the rehire date. The facility’s new hire checklist identified license/certification copy and verification, as well as SING results and a may work letter for an unclean SING report, as pre-hire requirements, and the Abuse, Neglect and Exploitation policy required background, reference, and credential checks with documentation of proof that screening occurred.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of resident discharges and transfers for one resident reviewed for hospitalizations. Resident #13’s record showed the resident entered the facility from the hospital and had a care plan for altered respiratory status, difficulty breathing, COPD, heart failure, and chronic hypoxic respiratory failure. The resident’s electronic record also listed multiple hospitalizations and returns to the facility, and the resident confirmed recent hospitalizations that contributed to breathing issues. During interviews, the Administrator stated on 4/22/26 that they believed interim Social Services staff had notified the Ombudsman appropriately. Social Services staff reported they had not been trained correctly on reporting to the Ombudsman and could not provide documentation showing notification of Resident #13’s transfers. The Administrator later stated there was a report tracking admissions and discharges and thought Social Services was reporting to the Ombudsman. The facility’s Transfer and Discharge policy stated the Social Services Director or designee would provide copies of notices for emergency transfers to the Ombudsman, and that notices could be sent when practicable, including on a monthly list if it met required contents.
Incomplete Dialysis Assessments and Communication
Penalty
Summary
The facility failed to ensure dialysis assessments were completed before and after dialysis for a resident with renal insufficiency/ESRD who received dialysis three times weekly. The resident’s MDS dated 4/5/26 documented dialysis services and a BIMS score of 15 out of 15, indicating intact cognition. The care plan initiated 4/2/26 noted the resident received dialysis three times weekly, and an intervention dated 4/6/26 directed staff to monitor vital signs pre- and post-dialysis and as needed. Review of the electronic Dialysis Communication record showed facility communication tools completed for April 1, 3, 6, 10, 14, 16, 18, and 21, but the dialysis communication tool had blank Section 2, titled Dialysis Center Communication, on 4/1/26, 4/3/26, 4/16/26, 4/18/26, and 4/21/26. On 4/21/26, Section 1 of the facility communication tool was incomplete on the shunt exam section. Staff stated the pre-dialysis assessment was completed by the facility nurse before the resident left, and the post-dialysis assessment was completed at the dialysis center, with information supposed to be returned and entered into the facility assessment documents. The DON stated an assessment should be done before dialysis and after dialysis by the facility, and the facility policy required ongoing assessment and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who had devices requiring EBP during high-contact care activities. Resident #6 had diagnoses including atrial fibrillation, acute respiratory failure, and gastrostomy tube status, and had intact cognition with a BIMS score of 14 out of 15. Although EBP supplies and signage were present on the room door, staff did not consistently use the required gown and mask during tube feeding care and related feeding tube handling. On 4/23/26, a wound nurse flushed and set up Resident #6’s tube feeding after hand hygiene and gloves, but did not use a gown and mask. Later that morning, an LPN entered the room wearing gloves only while the resident was working on swallowing exercises with speech therapy present, then left and later returned to administer medication through the feeding tube using gown, mask, and gloves. The same LPN and the wound nurse both acknowledged they had failed to wear the gown and mask during feeding tube care and flushing activities. Resident #11 had diagnoses including urinary retention and need for assistance with personal care, with intact cognition and an indwelling Foley catheter. The care plan identified the catheter and directed EBP, but the room door did not have an EBP sign or PPE holder on multiple observations. A CNA reported completing bathing for the resident and stated she only wore gloves during shower care, believing EBP was not needed for bathing or catheter-related care. Staff also stated that EBP was needed for catheter care and handling the urine bag, and the DON reported staff were expected to use EBP as directed on the signage with high-contact activities.
Failure to Ensure Resident Privacy and Dignity During Room Entry
Penalty
Summary
The facility failed to ensure that two residents received care that respected their right to privacy and dignity. One resident, who was cognitively intact and dependent on staff for personal care due to diagnoses including cancer, multiple sclerosis, and schizophrenia, was exposed when an Activity Assistant entered her room without knocking or waiting for a response while a CNA was providing peri care. The resident expressed distress and embarrassment over the incident, and both she and the CNA confirmed that the Activity Assistant had entered without proper notice. The CNA also reported that other residents had similar concerns about the same staff member not knocking before entering rooms. Another resident, with moderate cognitive impairment and diagnoses including bipolar disorder, osteoarthritis, and polyneuropathy, reported that the same Activity Assistant had repeatedly entered her room without knocking or waiting for a response, including times when she was dressing, using the restroom, or getting into bed. She stated that this made her uncomfortable and that similar concerns had been raised by other residents during resident council meetings. Facility interviews and documentation confirmed that these were not isolated incidents and that the Activity Assistant had a history of entering rooms without following privacy protocols.
Failure to Implement Effective QAPI Processes for Abuse Reporting
Penalty
Summary
The facility failed to carry out Quality Assurance activities to ensure that effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. Specifically, the CMS 2567 form identified a deficiency related to the failure to report an allegation of abuse. This issue was also identified during a subsequent complaint survey. The QAPI team met at least quarterly to discuss Performance Improvement Projects, and data was collected from various sources including Point Click Care, grievance forms, and vendor notes. Staff could report concerns through multiple channels, including anonymous compliance lines and written notes. Despite having a QAPI policy in place that outlined procedures for identifying and correcting quality deficiencies, the facility did not ensure that these processes were effectively implemented to address the failure to report abuse allegations. The deficiency persisted across multiple surveys, indicating that the mechanisms for tracking, prioritizing, and correcting such issues were not adequately followed or enforced. The report does not specify individual residents involved or their medical conditions at the time of the deficiency.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse as required by its own abuse policy and regulatory standards. On the date of the incident, a resident with severe cognitive impairment and a history of physical aggression slapped another resident in the dining room, knocking off her glasses and reportedly pulling her hair. The victim, who also had severe cognitive impairment and multiple diagnoses including seizure disorder and dementia, was later found to have a scratch and subsequently developed an abscess near her eye, which required antibiotic treatment. Staff documented the incident and separated the residents immediately, but did not report the event to the state agency or other required authorities within the mandated timeframe. Clinical record review, staff interviews, and facility policy review confirmed that the incident met the facility's definition of abuse and should have been reported. The facility's abuse policy required immediate reporting of all alleged violations involving abuse, but nursing staff failed to inform the nurse practitioner of the incident at the time of her visit and did not notify the appropriate authorities. Both the administrator and the director of nursing later acknowledged that the incident should have been reported according to policy.
Failure to Provide Sufficient Staff for Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily bathing and grooming needs of multiple residents, as evidenced by observations, clinical record reviews, policy reviews, and interviews with staff and residents. Several residents, including those with diagnoses such as heart failure, dementia, depression, and severe obesity, did not receive the required assistance with activities of daily living (ADLs) such as bathing, hair care, and oral hygiene. Documentation revealed significant gaps between scheduled and actual baths or showers, with some residents going up to 20 days without a documented bath or shower. In several cases, there was no documentation that staff re-approached residents after refusals or that alternative care was provided. Residents with varying levels of cognitive impairment and physical dependency reported or were observed to have unmet hygiene needs. For example, one resident with intact cognition stated she only received one bath per week due to short staffing, while another with severe cognitive impairment was observed with matted hair and poor personal hygiene. Documentation for multiple residents showed missed or infrequent bathing, lack of follow-up after refusals, and incomplete records of grooming assistance. Staff interviews corroborated these findings, with CNAs and the DON acknowledging that staffing shortages and high resident acuity impacted their ability to complete necessary care tasks. The facility's own policies required sufficient staffing to ensure resident safety and well-being, as well as regular assistance with ADLs. However, the evidence showed that these policies were not consistently followed. Residents and staff reported and documented missed baths, inadequate grooming, and insufficient assistance with oral care and toileting hygiene. The lack of documentation and follow-up on missed care further demonstrated the facility's failure to meet the assessed needs of its residents.
Failure to Implement Infection Surveillance System
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the lack of a functioning surveillance system to track and address infections and potential infections among residents, staff, and visitors. The Regional DON acknowledged that infection control activities had not been adequately completed and noted that a new staff member would be starting soon to address these issues. There was no documentation of a system for the prevention, identification, reporting, investigation, and control of infections and communicable diseases, nor was there evidence of an ongoing surveillance system based on national standards and the facility's assessment. Additionally, the facility did not maintain routine, ongoing, and systematic collection, analysis, interpretation, or dissemination of surveillance data to identify infections. The facility's own policy, revised in June 2024, outlined requirements for infection surveillance, including data collection on infection sites, pathogens, symptoms, resident locations, and analysis of infection trends. However, these activities were not documented or carried out, resulting in a failure to monitor adherence to infection prevention practices and to identify or address infection trends within the facility.
Failure to Maintain Adequate Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen during two separate inspections. The initial tour revealed a thick layer of dust on the back of the ice machine and dust particles hanging from the fire suppression system spigots above the stove burners. A follow-up inspection found that dust particles remained on the fire suppression system, and additional issues were identified, including a shelf near the three-compartment sink covered with dust and hairs, strings of dust hanging from the ceiling above a prep area, a thick layer of dust on the sprinkler above the prep sink, and dust covering ceiling panels and a vent above the steam table. The facility's cleaning schedule required biweekly cleaning of ceiling vents and weekly cleaning of shelves, but these standards were not met. The Dietary Manager confirmed expectations for cleanliness and noted that some ceiling panels needed replacement. No specific residents were directly involved or affected as described in the report, and the facility census at the time was 74 residents.
Failure to Offer Influenza Vaccinations as Required
Penalty
Summary
The facility failed to offer influenza vaccinations to four out of five residents reviewed for immunizations during the 2024-2025 influenza season, despite having a policy in place requiring annual influenza immunizations for residents. Clinical record reviews showed no documentation that these residents, who had various diagnoses including heart failure, bipolar disorder, diabetes, seizure disorder, dementia, and muscle weakness, were offered the influenza vaccine. The residents' cognitive statuses ranged from intact to severely impaired, as indicated by their BIMS scores. Staff interviews confirmed the absence of documentation and that residents should be up to date with their vaccinations.
Failure to Offer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to offer a Covid-19 vaccine to one resident, as required by facility policy. Clinical record review for this resident, who had diagnoses including heart failure, bipolar disorder, and depression and was assessed as cognitively intact, showed no documentation that the Covid-19 vaccine was offered. Interviews with the Director of Nursing and the Regional DON confirmed that there was no additional documentation available to show the vaccine had been offered to this resident.
Failure to Honor Resident Dignity and Respect in Care Delivery
Penalty
Summary
Surveyors identified multiple failures by facility staff to treat residents with dignity and respect during the provision of care and services. One resident with diagnoses including heart failure, seizure disorder, and anxiety, and who was cognitively intact, reported being told by CNAs to use her brief for toileting instead of being assisted to the bathroom, particularly at night. She described feeling 'nasty' and experiencing constipation as a result, and recounted an incident where she was left with feces partially expelled overnight. Observations confirmed the resident was left in the same clothing for several days, her hair was oily, and there was an odor present. Staff interviews corroborated that some CNAs refused to assist her to the bathroom and that concerns had been raised but not escalated to facility leadership. Additionally, staff were observed entering resident rooms without knocking or announcing themselves, including during times when residents were sleeping. Another resident, also cognitively intact and with significant physical care needs, reported only receiving one bath per week, delays in morning care, late medications, and missed pain cream applications. She described a specific incident where her call light was turned off without assistance, resulting in a 2.5-hour wait to be changed. She also reported inconsistent oral care and difficulty getting her clothes changed without help from her significant other. Staff interviews confirmed that missed showers and oral care were common, particularly on the second shift, and that staffing shortages contributed to these issues. A third resident, dependent on staff for most activities of daily living, reported feeling embarrassed and under duress after hearing staff discuss him and a former employee. Multiple staff members admitted to discussing the resident and rumors about a possible relationship and medication issues among themselves. The DON acknowledged receiving complaints from residents about dignity-related issues such as bathing, timeliness, and staffing, and stated expectations for staff to knock before entering rooms and to provide oral care twice daily. The facility's policy affirmed residents' rights to dignity, respect, privacy, and personal choice in care.
Failure to Provide Adequate Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing and grooming for eight out of thirteen residents reviewed for activities of daily living (ADL) assistance. Multiple residents, some with intact cognition and others with cognitive impairment, did not receive the required number of baths or showers as documented in their care plans and facility policy. Documentation revealed significant gaps between bathing dates, with some residents going up to 20 days without a bath or shower. In several cases, there was no evidence that staff re-approached residents after refusals or communicated missed baths/showers, and documentation of care provided was inconsistent or missing. Residents with various medical conditions, including heart failure, dementia, depression, obesity, and mobility impairments, were affected by these deficiencies. For example, one resident with heart failure and depression reported receiving only one bath per week due to short staffing, and documentation confirmed long intervals between baths. Another resident with severe cognitive impairment was observed with disheveled and matted hair, and records showed a lack of regular personal hygiene assistance. Several residents reported directly to surveyors that they did not receive the expected frequency of bathing, and some expressed dissatisfaction with the quality of care, including inadequate drying after bathing and lack of assistance with oral hygiene, hair care, and dressing. Staff interviews corroborated the documentation and resident reports, with CNAs and the DON acknowledging challenges in meeting residents' ADL needs due to staffing shortages and high acuity. Observations included residents with oily hair, musty odors, unchanged clothing, and unaddressed toileting needs. The facility's own records and staff statements confirmed that the required assistance with ADLs, including bathing, grooming, and hygiene, was not consistently provided, and that documentation of refusals or alternate attempts was lacking.
Failure to Complete Wound Assessments and Treatments for Residents with Non-Pressure Wounds
Penalty
Summary
The facility failed to provide appropriate wound assessments and treatments for three residents with non-pressure wounds. For one resident with a history of left foot drop, muscle weakness, and a recent toe amputation due to osteomyelitis, there was a lack of documentation regarding the assessment of a new wound on the left foot. After a verbal order for betadine treatment was received, the facility did not document the reason for the order or provide wound descriptions and measurements from the time of the order until a surgical appointment over two weeks later. Weekly skin observations during this period were incomplete, lacking details about the wound. Another resident with diagnoses including cellulitis, heart failure, and obesity was admitted with non-healing vascular wounds on both lower legs. Upon admission, wounds were noted, and care plans directed weekly documentation of wound measurements and observations. However, the treatment administration record showed several missed or undocumented wound treatments, and there were gaps in wound assessments and measurements throughout the resident's stay. Progress notes indicated delays in receiving wound care supplies, and weekly skin observation sheets lacked detailed assessments of the wounds. Facility policies required nursing staff to assess, evaluate, and document resident care, including prompt notification of physicians when changes occurred. Despite these policies, staff interviews confirmed that wound treatments and weekly skin assessments were not consistently completed as required. The Director of Nursing acknowledged the lack of additional documentation for one of the residents involved.
Failure to Ensure Accurate and Accessible Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directive wishes and code status information were accurately documented and readily accessible for two residents. For one resident with diagnoses including heart failure, bipolar disorder, and depression, and who was cognitively intact, the care plan indicated a Full Code status. However, the resident's electronic health record (EHR) face sheet did not include code status information, and the Iowa Physician Orders for Scope of Treatment (IPOST) was not present in the nurse's station binder or the EHR. The Director of Nursing (DON) confirmed the absence of this documentation. For another resident with non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities, and who had severely impaired cognition, the care plan indicated a Do Not Resuscitate (DNR) status. While staff stated that code status information was available in a binder, the IPOST for this resident was not initially found under the appropriate tab. It was located under a different tab after a delay. The DON acknowledged that code statuses should be up to date and accessible in the binder, and facility policy required CPR to be carried out in accordance with residents' advance directives or, in their absence, to assume Full Code status.
Failure to Verify CNA Certification Prior to Employment
Penalty
Summary
The facility failed to ensure that one of four Certified Nursing Aides (CNAs) was certified prior to employment, as required. Personnel file review revealed that this staff member did not have an active CNA certification, and documentation in the file indicated the facility was waiting on his CNA application. A criminal background check and a review of the Health Facility Database (HFD) confirmed there was no record of certification for this individual. Further investigation showed that the staff member had failed the CNA test and was not currently certified or employed as a CNA. The administrator confirmed that the staff member had claimed to be certified in another state, but this was not verified before he was allowed to work.
Lack of CNA Performance Evaluation and Training Documentation
Penalty
Summary
The facility failed to ensure that one of four Certified Nursing Aides (CNAs) received a performance evaluation, competency evaluation, or training based on performance reviews. Review of personnel files revealed that this CNA, hired on 12/5/23, did not have any documented performance evaluation or orientation training between the hire date and 4/8/25. The only training recorded for this CNA was a single 15-minute session on effective communication. During an interview, the Administrator confirmed that there were no available records of evaluations or training based on CNA evaluations for this staff member.
Failure to Follow Pureed Diet Menu for Residents
Penalty
Summary
The facility failed to follow the prescribed menu for two residents on a pureed diet, as observed during meal preparation and service. On the specified date, the cook pureed meatballs but did not include any bread in the puree, and a resident on a pureed diet received a lunch tray containing pureed meatballs, mashed potatoes, and pureed cake, but no bread or bread substitute. According to the facility's Week 2 Therapeutic Spread Report, residents on a pureed diet should receive 1/2 cup of pureed orzo as a bread substitute, which was not provided. Facility policy required staff to follow written menus and prepare food in a form that meets individual resident needs, which was not adhered to in this instance.
Failure to Ensure CNA Completion of Required Annual Training
Penalty
Summary
The facility failed to ensure that one of four CNAs completed the required 12 hours of annual in-service training, including mandatory education on abuse prevention and dementia care. Personnel file review revealed that this CNA did not complete orientation training, competency evaluations, or annual CNA training from the time of hire through the date of review. The orientation checklist in the file was blank, and training records showed only a single 15-minute session on communication. There was no documentation of Dependent Adult Abuse training, abuse prevention, or dementia training for this CNA. The Administrator confirmed the lack of required training and documentation, attributing the deficiency to a transition in the facility's online training platform and acknowledged that the only completed training was due to direct oversight by another staff member.
Failure to Protect Resident from Misappropriation and Exploitation by Staff
Penalty
Summary
A resident with multiple sclerosis, neurogenic bladder, anxiety, and depression, and who was cognitively intact, was not protected from misappropriation of property and exploitation. The resident had a prescription for Sildenafil Citrate, with multiple shipments documented from the pharmacy. Medication Administration Records (MAR) and progress notes failed to account for a significant number of tablets from several medication cards, with between 21 and 33 tablets unaccounted for over several months. The facility could not provide documentation regarding the disposition of these missing medications, and the medication cards were not found in the medication cart, storage room, or pharmacy bin. The resident reported a close relationship with a registered nurse, to whom he gave money as a tip for her birthday. He also indicated that this nurse was the only person who administered his Sildenafil Citrate. Staff interviews revealed observations of an unprofessional relationship between the nurse and the resident, including reports of inappropriate physical contact and private time together. Other staff reported hearing that the nurse took medications belonging to residents, including the resident's Sildenafil Citrate, and that the resident gave the nurse money for personal reasons. A police investigation found a prescription label for the resident's Sildenafil Citrate in the nurse's personal belongings. The facility's administrator confirmed that the nurse was the only staff member who administered the medication and that the missing medication was not returned to the pharmacy. The facility's policies required immediate investigation and thorough documentation of abuse, neglect, exploitation, and misappropriation, but the documentation and oversight were insufficient to prevent or account for the misappropriation of the resident's medication and money.
Failure to Report and Investigate Suspected Misappropriation and Exploitation
Penalty
Summary
The facility failed to timely report and investigate potential misappropriation and exploitation involving a resident with multiple sclerosis, neurogenic bladder, anxiety, and depression, who was cognitively intact. Pharmacy records showed that between 21 and 33 tablets of Sildenafil Citrate prescribed to the resident were unaccounted for, and the facility could not provide documentation regarding the missing medication or any audits of medication storage. Only one RN administered the medication, and there was no documentation of whether one or two tablets were given at each administration. Multiple staff members reported knowledge of an inappropriate relationship between the resident and the RN, including physical contact, exchange of money, and rumors of the RN taking resident medications for personal use. Staff interviews indicated that these concerns were reported to facility leadership, but the facility did not confirm the incidents or report them to authorities, citing the resident's denial and intact cognition as reasons for not proceeding with a report. The facility's own policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, including interviewing all involved parties and preserving evidence. Despite this, the facility did not follow its procedures, as there was no evidence of a comprehensive investigation or timely reporting to the appropriate authorities regarding the suspected misappropriation and exploitation.
Failure to Prevent Exploitation and Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to prevent potential misappropriation of property and exploitation, and did not conduct thorough investigations into two incidents involving a resident with multiple sclerosis, neurogenic bladder, anxiety, and depression, who was cognitively intact. Staff had reported that the resident and a registered nurse (RN) hugged and kissed, but the facility did not confirm the incidents after the resident denied them, and therefore did not report the alleged abuse to the state. There was no documentation of separation between the resident and the staff member during the investigation, nor were there records of the dates of staff reports, written statements, or interviews with involved parties to verify a comprehensive investigation. Further, a police investigation revealed that a prescription medication belonging to the resident was found in the former RN's possession, and the facility could not provide evidence of medication cart or storage room audits prior to this discovery. The resident confirmed a close relationship with the RN, including giving her money and sharing personal interactions. The facility's own policy required immediate and thorough investigation of abuse, neglect, or exploitation allegations, including documentation and interviews, but these procedures were not followed as required.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide services according to physician orders for a resident with chronic pain syndrome, arthritis, osteoporosis, and fibromyalgia. The resident's care plan required staff to anticipate and respond to pain, evaluate the effectiveness of pain interventions, and monitor for non-verbal signs of pain. Despite these directives, clinical record review showed that the resident's prescribed Diclofenac Sodium Gel was not administered as ordered on multiple occasions during the evening medication pass over a period of more than a month. The Medication Administration Record and Treatment Administration Record documented numerous missed doses, and the resident reported that her medications were often late and her pain cream was missed on some days. She had communicated these concerns to nursing staff, the DON, and the Administrator. Interviews with LPNs confirmed that medications had been missed or given outside the scheduled time range. One LPN also reported that the resident had expressed concerns about missed medications and other care issues, and noted that staffing levels were insufficient for the care needs of residents. Facility policy required medications to be administered by licensed nurses as ordered by the physician and within 60 minutes of scheduled times, but this standard was not met for the resident in question.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to complete regular assessments and treatments for a pressure ulcer in one resident. Upon admission from the hospital, the resident had documented wounds to both heels, but the facility's initial assessments and weekly skin observations did not record these heel wounds. The Treatment Administration Record listed an order for skin prep to the bilateral heels, but there was no documentation that this treatment was provided from admission through discharge. Additionally, the clinical record lacked documentation of the presence or care of heel wounds until two weeks after admission, when a weekly skin observation finally noted a Stage 3 pressure ulcer on the right heel and a Stage 4 pressure ulcer on the left heel, without further description or measurements. The resident had a medical history including cellulitis of the left lower limb, heart failure, and obesity, and was identified as being at risk for pressure ulcers. Despite this, the facility did not document regular skin assessments or the completion of ordered treatments for the resident's heel wounds. The facility's policy required weekly review and documentation of skin assessments and pressure injury management, but this was not followed for the resident in question.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
A deficiency occurred when staff failed to ensure safe wheelchair movement for a resident with severe cognitive impairment and multiple diagnoses, including heart failure, dementia, and anxiety. The resident was documented as dependent on staff for wheelchair mobility. During an observation, a CNA was seen pushing the resident in a wheelchair without using foot pedals, resulting in the resident's left foot dragging on the ground for approximately 50 feet. The DON later confirmed that staff are expected to use foot pedals when transporting residents in wheelchairs. Additionally, the facility did not have a policy regarding the use of wheelchair foot pedals.
Failure to Ensure Availability of Routine Medications
Penalty
Summary
The facility failed to ensure the availability of routine medications for two residents, both of whom were assessed as having intact cognition. One resident, with diagnoses including heart failure, diabetes, and anxiety, reported missing some pills. Review of the Medication Administration Record (MAR) showed that several doses of Methocarbamol were not administered, with electronic MAR notes indicating the medication was not available at the time of administration. Another resident, diagnosed with severe obesity, anxiety, and depression, also reported missing medications due to unavailability. The MAR for this resident showed that multiple prescribed medications, including Fesoterodine Fumarate, Lexapro, Metolazone, Spironolactone, Naproxen, and Hydroxyzine Pamoate, were not administered as scheduled. The Director of Nursing confirmed issues with medication availability, particularly during a recent medication changeover, and facility policy required medications to be administered as ordered.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe hot holding temperatures during a meal service. According to facility policy, staff are directed to serve food at a safe and appetizing temperature. On the day of observation, a resident reported that food served in the East dining room was cold, prompting her to prefer eating in the main dining room. During the observed meal, initial food temperatures taken by the Dietary Manager in the kitchen were within the expected range, with carrots and mashed potatoes at 163°F and meatballs at 189°F. However, the plates used for serving were not pre-warmed, and after the meals were plated and transported to the East hall, there was a delay before the trays were distributed to residents. By the time the test tray was checked after delivery and distribution, the food temperatures had dropped significantly: carrots measured at 104°F, mashed potatoes at 113°F, and meatballs at 107°F. The State Agency representative noted that the food was barely warm when tasted. The Dietary Manager later confirmed that the expected hot holding temperature should be over 140-145°F, indicating that the food served did not meet the facility's policy or safe temperature standards.
Failure to Timely Notify Providers and Families of Test Results
Penalty
Summary
The facility failed to notify residents' representatives and providers in a timely manner regarding test results related to changes in clinical conditions for two residents. For the first resident, who had severely impaired cognition and active diagnoses including Alzheimer's disease and hypertension, the facility did not document the completion of a chest x-ray or communicate the results to the resident's family or provider. The resident had complained of chest pain, and although the x-ray was ordered, the results were not communicated to the provider until after the resident was sent to the hospital. The Director of Nursing (DON) stated that the results were faxed to the provider, but there was no documentation to support this, and the nursing staff did not address the results in a timely manner. For the second resident, who had moderately impaired cognition and active diagnoses including renal insufficiency and obstructive uropathy, the facility failed to notify the resident's responsible party of a new urinary tract infection. The resident's urine sample was collected and sent to the lab, and the provider was notified of preliminary results. However, the final results were not communicated to the provider until several days later, and there was no documentation that the resident's family was informed of the condition change. The DON acknowledged that the responsible party should have been notified and that the delay in contacting the provider was excessive. The facility's policy on Notification of Changes required prompt communication with the resident, their physician, and their representative when there was a significant change in condition or a need to alter treatment. Despite this policy, the facility did not adhere to these guidelines, resulting in delayed communication and potential impacts on the residents' care. The report highlights the lack of timely notification and documentation by the facility staff, which contributed to the deficiencies identified during the survey.
Inadequate Resident Assessments and Documentation
Penalty
Summary
The facility failed to provide adequate assessments and interventions for two residents, compromising their physical and psychosocial well-being. Resident #2, with severe cognitive impairment and a history of Alzheimer's disease, anxiety disorder, and hypertension, experienced chest pain and breathing difficulties. Despite new orders for PRN oxygen, the resident was assessed only once over a 56-hour period. The resident's electronic health record lacked documentation of vital signs and oxygen saturation assessments, and there was a delay in communicating chest x-ray results to the provider. Staff interviews revealed that although changes in the resident's condition were observed, documentation was insufficient due to staff being busy. Resident #3, with moderately impaired cognition and diagnoses including renal insufficiency and obstructive uropathy, showed signs of a urinary tract infection (UTI) with blood in the urine. Despite a urinalysis and culture being ordered, there was a lack of documented assessments for pain, burning, or fever over an eight-day period while awaiting culture results. The resident's care plan required monitoring for UTI symptoms, but staff failed to document regular assessments. Interviews with staff indicated that assessments should have been conducted with any change in condition, but this was not consistently done. The Director of Nursing acknowledged the lack of documentation and assessments, attributing it to staff being busy. The facility did not provide a policy or protocol for conducting resident assessments related to changes in condition, contributing to the deficiencies observed in the care of Residents #2 and #3.
Deficiencies in Clinical Record Maintenance and Resident Assessment
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to deficiencies in communication and care. For one resident, there was an order for chest x-rays, but the clinical record lacked documentation of the x-rays being performed, the results, timely follow-up with the provider, and assessments or interventions related to an acute change in condition. The Director of Nursing (DON) confirmed that the resident was transferred to the hospital, and there was no record of assessments or communication with responsible parties during the critical period. For another resident, there was an order for a urinalysis and culture and sensitivity test, but the clinical record did not provide sufficient information for staff to respond to the resident's needs. There was no documentation of assessments for symptoms such as bladder-related pain, blood in the urine, or fever while waiting for test results. The DON acknowledged the lack of assessments and indicated that some staff needed better education. The Administrator expected regular assessments to be documented, but was unaware that this was not occurring.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide a nourishing, palatable, and well-balanced diet that meets the residents' daily nutritional and special dietary needs. During the noon meal service on two consecutive days, test trays revealed that the food was not served at the required temperature of at least 135 degrees Fahrenheit. On the first day, the cauliflower was served at 117.8 degrees Fahrenheit and tasted cold, while the chicken was dry and difficult to chew despite being covered with marinara sauce and parmesan cheese. On the second day, the vegetables were served at 127 degrees Fahrenheit after multiple attempts to raise the temperature, and the Salisbury steak appeared dry and crusty around the edges. Staff A, from the dietary department, acknowledged that hot food should be at least 140 degrees Fahrenheit. A representative from the State Ombudsman office noted that food temperatures have been a chronic problem at the facility. The facility's policy on food preparation guidelines mandates that food and drinks should be palatable, attractive, and served at a safe and appetizing temperature.
Failure to Conduct Dialysis and Skin Assessments
Penalty
Summary
The facility failed to complete necessary pre-dialysis and post-dialysis assessments for a resident undergoing dialysis treatment. The resident's Minimum Data Set (MDS) indicated diagnoses of renal disease and hyperparathyroidism of renal origin, with a dependence on renal dialysis. However, the clinical record lacked documentation of pre-dialysis assessments, post-dialysis assessments, and assessment of the shunt site. The facility's policy on Hemodialysis required staff to conduct assessments and monitor for complications before and after dialysis treatments, including checking the dialysis access site. During an interview, the Clinical Nurse Consultant confirmed that these assessments were not being completed, which was against the facility's policy and best practice expectations. Additionally, the facility did not routinely assess a resident's skin condition, as required by their policy. A resident reported having a red, itchy rash on his arm, shoulder, and buttocks, with visible red and scabbed areas. The clinical record did not contain documentation of measurements or assessments for the rash. The facility's policy on skin assessment required a full body or head-to-toe skin inspection weekly, with any issues reported to the Primary Care Provider (PCP) and treatment orders obtained. The Clinical Nurse Consultant explained that skin assessments should be completed every 7 days and reflect the current status of the resident's skin, with measurements taken every 7 days or with a change in status.
Failure to Administer Glucagon for Critically Low Blood Sugar
Penalty
Summary
The facility failed to provide adequate assessment and timely intervention for a resident with a history of Diabetes Mellitus Type 1, peripheral vascular disease, kidney failure, and heart failure. The resident required total staff assistance for hygiene, toileting, and bathing. On the date of the incident, the resident became unresponsive and was found to have a critically low blood sugar level of 40. Despite having a physician's order for Glucagon to be administered in such situations, the nurse on duty, who was inexperienced and confused, did not administer the medication immediately. Instead, she contacted the resident's primary care provider, delaying the necessary intervention. The primary care provider instructed the nurse to administer the Glucagon immediately, but the nurse's hesitation and lack of experience led to further delay. The resident's blood sugar level only slightly improved to 46 after the delayed intervention, and the resident remained unresponsive, necessitating a transfer to the emergency room. The resident returned to the facility later, alert and oriented. The incident highlighted a deficiency in the facility's emergency response to critically low blood sugar levels, as the nurse did not follow the established protocol for immediate administration of Glucagon.
Failure to Follow Physician Orders for Resident
Penalty
Summary
The facility failed to follow physician orders for a resident with severe cognitive impairment and multiple diagnoses, including opioid use disorder and depression. The resident was admitted from the hospital with orders for Suboxone and Fluoxetine. However, the resident did not receive Suboxone from the time of admission until readmission to the hospital, and the Fluoxetine dosage was incorrectly administered at 20 mg instead of the prescribed 60 mg. This error was attributed to incorrect order entry in the computerized charting system (PCC) and a delay in obtaining the Suboxone order from the psychiatric provider. The resident exhibited erratic behavior and altered mental activity, leading to a hospital transfer where she was diagnosed with acute metabolic encephalopathy and a UTI. Staff interviews revealed that the errors occurred due to miscommunication and delays in medication procurement. The DON acknowledged the mistake in entering the Fluoxetine order, and the RN reported multiple attempts to contact the pharmacy regarding the Suboxone. The LPN confirmed that the Suboxone order was eventually obtained, but the resident was hospitalized before the medication could be administered. The facility's Medication Administration policy mandates that medications be administered as ordered by the physician, but this was not followed in this case.
Failure to Provide Appropriate PICC Line Management
Penalty
Summary
The facility failed to provide appropriate assessment and interventions for a resident with a PICC line. The resident, who had intact cognitive abilities and a history of falls and pain, was admitted to the facility with a PICC line but did not have orders for its treatment and management. The admitting nurse did not reach out to the provider for orders, and subsequent nurses also failed to obtain the necessary orders. As a result, the PICC line became occluded and was not flushed, leading to a situation where the nurse practitioner had to attempt removal, which was unsuccessful due to resistance. The resident was later admitted to the hospital with pneumonia, unrelated to the PICC line, and had the PICC line removed during the hospital stay. The facility's Director of Nursing acknowledged that the admitting nurse should have obtained orders for the PICC line and that any subsequent nurse should have done the same. The facility's policy on intravenous therapy required that IV sites be checked every shift and as needed for signs of infection or inflammation, but this was not followed. The deficiency was identified through clinical record review and staff interviews, revealing a lapse in following proper procedures for managing the resident's PICC line.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing & Rehablitation - Marion | 1.1 mi | ★★★★★ | 5 | 0 |
| Linn Manor Care Center | 1.4 mi | ★★★★★ | 10 | 0 |
| Winslow House Care Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Terrace Glen Village | 2.4 mi | ★★★★★ | 5 | 0 |
| Hallmar Village | 3.6 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.