Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Living Center during CMS and state inspections, most recent first.
Surveyors found that an ice machine used to produce ice for residents had a black, blackish brown residue along its interior metal plate, indicating inadequate cleaning of this food-contact surface. The Dietary Manager confirmed the residue and stated that maintenance was responsible for cleaning the rented ice machine, while Plant Operations Personnel confirmed the black substance and reported that the rental company performed quarterly cleaning and monthly maintenance. These findings showed that the ice machine was not cleaned often enough to prevent buildup of soil or mold, in violation of FDA Food Code and SOM requirements.
A resident with cognitive communication deficit, muscle weakness, and post-stroke hemiplegia/hemiparesis was housed in a room with visibly damaged closet doors and a sink countertop, including chipped and missing paint, exposed substrate, scuff marks, and scratches. The resident reported the room did not feel homelike due to the condition of the closet and countertop. The Maintenance Director confirmed the need for repairs to the closet doors, sink counter, and nearby wall and stated that, although the closet had been painted months earlier, he did not maintain documentation for painting repairs, only for items such as outlets, lights, and mobility equipment. This resulted in a failure to ensure a safe, clean, and homelike environment.
A resident admitted for end-of-life care with heart failure and chronic kidney disease had a hospice physician’s certification of terminal illness in the record and was admitted with hospice services. However, the Admission MDS assessment inaccurately coded the hospice services item in Section O as not receiving hospice. During interview, the Administrator acknowledged that the resident was on hospice at admission and that the MDS assessment was not accurate.
Nursing staff failed to follow ISMP guidelines requiring medications to be prepared and administered immediately rather than pre-poured. An LPN was observed placing pre-poured medication cups into a medication cart drawer after reporting being behind due to assisting residents, and another unlocked cart was found unattended with three labeled medication cups in the top drawer, including stacked cups containing morphine that had already been signed out on the controlled substance log. These practices involved unsecured, pre-poured medications for multiple residents and increased the risk of medication errors, contamination, diversion, and administration to the wrong residents.
Two residents who required extensive assistance for transfers and repositioning did not receive the level of supervision and staff support specified in their care plans, resulting in falls during care. One resident with quadriplegia, cognitively intact and totally dependent for bed mobility, was being changed in bed by only one CNA instead of the required two-person assist and rolled off the bed to the floor. Another resident with impaired mobility and muscle weakness, care planned for two-person stand-pivot transfers, was transferred by a single CNA without appropriate footwear and experienced leg buckling and an assisted fall to the floor.
A resident with COPD and mild cognitive impairment had physician orders for continuous O2 at 2 L/min via nasal cannula and for O2 tubing, filter, and water to be changed every 7 days. Although the record indicated the orders were followed, surveyors observed the resident resting in bed with an O2 concentrator whose humidifier bottle and cannula storage bag were dated beyond the 7-day change interval. A CNA confirmed that O2 tubing should be changed weekly and acknowledged that the resident’s tubing had not been changed for 14 days, placing the resident at risk for respiratory infections.
A resident with a history of stroke-related hemiplegia, seizure disorder, and dementia continued to receive tamsulosin (Flomax) 0.4 mg at bedtime for kidney stones and prior stent removal, despite no current urological diagnosis. Facility records and the DON’s interview confirmed the resident’s kidney stone treatment and ureteral stent occurred before admission, and there had been no subsequent treatment or active urological condition. National Library of Medicine guidance cited by surveyors indicated tamsulosin for ureteral stones is typically used for a limited duration, yet the medication order remained in place without an appropriate, documented indication, resulting in an unnecessary drug regimen for the resident.
Surveyors found a medication cart unlocked and unattended in a resident care hallway, despite facility policy requiring medications to be stored safely, securely, and accessible only to authorized personnel. An LPN later confirmed she had left the cart unlocked and acknowledged it should have been locked, creating a situation in which medications could be accessed by individuals for whom they were not prescribed.
The facility failed to secure protected health information and to maintain accurate behavioral documentation. A medication cart was left unattended with a laptop screen active, displaying the electronic medical record system with resident information visible, and the responsible LPN admitted she had not locked the screen. In a separate issue, a resident with generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder had behavior monitoring records indicating repeated suicidal statements, as required to be monitored by the care plan, but the DON later reported the resident had not made such statements and that the same nurse had inaccurately documented these entries on multiple dates.
Staff failed to consistently follow hand hygiene and PPE requirements for a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter and PEG-tube. A CNA exited the resident’s room after incontinence care without performing hand hygiene after removing PPE, later handled the resident’s catheter and performed dressing tasks without prior hand hygiene or donning a gown as required by the EBP signage, and entered the room with another CNA for a hoyer lift transfer without either performing hand hygiene upon entry. An LPN performed hand hygiene and donned PPE before medication and nutrition administration via PEG-tube but then touched the sink and water while preparing supplies and did not change gloves or perform hand hygiene before accessing the PEG-tube. These actions did not comply with the facility’s hand hygiene policy and posted EBP instructions and created the potential for infection due to cross contamination.
The facility did not adequately address or document responses to resident concerns raised in Resident Council meetings from June to November 2024. Issues included dietary, housekeeping, call light response times, and staffing. Despite a call light audit indicating room for improvement, no follow-up actions were documented or communicated to residents. Interviews confirmed ongoing issues and lack of written documentation of follow-up actions.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four residents, as required by the State Operations Manual. Residents with various diagnoses, including cerebral palsy, TBI, cancer, and heart failure, were transferred to the hospital without the Ombudsman being informed. The facility administrator was unaware of the notification requirement.
The facility did not ensure that full-time NAs were enrolled in or had completed a State-approved training and competency evaluation program within four months of employment. Four NAs were identified as working beyond this period without certification, which could negatively impact the 54 residents in the facility. The HR Manager confirmed the facility's non-compliance.
A facility failed to adhere to infection control practices when a staff member sorted dirty laundry without wearing a gown, as required by standard precautions. This breach was confirmed by the DON, who stated that both gloves and gowns should be worn during such tasks to prevent infection and cross-contamination.
A resident's room was found to have several maintenance issues, including a detached baseboard, improperly placed toilet paper, a grab bar with chipped paint, and a corroded sink. The Maintenance Director was not informed of these issues, as the Housekeeping Supervisor had not submitted work orders. The Housekeeping Supervisor and Administrator acknowledged the problems, noting the sink required replacement.
The facility failed to ensure accurate MDS assessments for three residents. One resident's assessments incorrectly documented an active pneumonia diagnosis, another's inaccurately recorded anticoagulant use, and a third's omitted a completed PASARR level II evaluation. These discrepancies were confirmed by the DON.
A facility failed to refer a resident for a PASARR level II evaluation after diagnosing them with major depressive disorder (MDD). Despite being prescribed antidepressants and having an updated care plan for managing depression and behavioral disturbances, the pre-admission PASARR level I screening was not forwarded for further evaluation. The DON was unaware of the oversight, which could have impacted the resident's mental health care coordination.
The facility failed to administer medications according to professional standards, affecting several residents. A resident with paraplegia received Norco instead of Tramadol due to a card mix-up. Another resident with esophagitis was given rivaroxaban meant for someone else during a training session. Additionally, a resident with respiratory failure was given Anoro Ellipta despite its discontinuation, as staff were unaware of the change. These incidents reflect a failure to follow the six rights of medication administration.
The facility failed to provide care according to professional standards and residents' care plans. A resident with diabetes had high blood glucose levels without documented physician notification, and another resident requiring two-person assistance was repositioned by one CNA alone. These actions did not comply with the care plans and protocols.
A medication error rate of 6.9% was identified in an LTC facility when a resident with diabetes received insulin without proper priming of the pens, as observed by surveyors. The RN failed to prime the insulin pens before administration, which was confirmed by staff interviews, potentially affecting the resident's blood sugar levels.
Improper Cleaning and Maintenance of Ice Machine
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation when they observed that an ice machine contained visible contamination. On 4/12/26 at 2:58 PM, the interior metal plate of the ice machine was noted to have a black residue. At 3:05 PM, the Dietary Manager confirmed the presence of a blackish brown residue along the interior metal plate and reported that the ice machine was a rented unit for which maintenance staff were responsible for cleaning. Later, at 3:50 PM, Plant Operations Personnel also confirmed a black substance in the ice machine and stated that the rental company provided quarterly cleaning and monthly maintenance of the ice machines. These observations demonstrated that the ice machine, an enclosed food-contact component used to produce ice for residents, was not being cleaned at a frequency necessary to prevent accumulation of soil or mold as required by the FDA Food Code and SOM Appendix PP. No specific residents or their medical histories were mentioned in the report, but the deficiency was cited as having the potential to affect all residents who consumed ice prepared by the facility.
Failure to Maintain Homelike Room Environment and Document Repairs
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when it did not maintain a resident’s room in good repair. One resident, admitted and later re-admitted with multiple diagnoses including cognitive communication deficit, muscle weakness, and hemiplegia and hemiparesis following a stroke, was found to have significant damage to the physical environment of the room. On observation, the resident’s closet doors had large, jagged round and oblong areas with chipped, cracked, and missing paint exposing white and brown patches, along with several long black scuff marks and scratches along the mid to lower closet doors and bottom drawers. Additionally, the sink countertop had a large oblong and jagged damaged area that was missing material and exposing brown wood. When interviewed, the resident indicated the room did not feel homelike, pointing to the damaged closet doors and sink countertop, and stated a desire to have the closet doors painted and the countertop fixed. During a subsequent observation with the Maintenance Director, he confirmed that the closet doors, sink counter, and lower corner wall near the sink needed repair. He stated the closet had been painted approximately three or more months earlier but acknowledged that he did not keep documentation of painting repairs, only of repairs to outlets, lights, wheelchairs, walkers, and similar items. The lack of timely repair and absence of documentation for these environmental issues contributed to the deficiency related to maintaining a homelike environment for the resident.
Inaccurate MDS Hospice Coding for Terminally Ill Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident receiving end-of-life care. The resident was admitted with a diagnosis of heart failure and chronic kidney disease and had a hospice physician’s certification of terminal illness completed prior to admission. Despite this documentation and the resident’s admission to the facility with hospice services, the Admission MDS assessment completed on 3/5/26 inaccurately recorded in Section O, item K1 for hospice services as “no,” indicating the resident was not receiving hospice care. During an interview, the Administrator confirmed that the resident had been admitted with hospice services and that the Admission MDS assessment was not accurate. This inaccuracy in the MDS assessment was identified for 1 of 2 residents whose assessments were reviewed for potential errors, and it was determined that this failure placed the resident at risk for their needs to go unmet due to the inaccuracy.
Pre-poured and Unsecured Medications, Including Narcotics
Penalty
Summary
The facility failed to ensure medications were prepared and administered safely and in accordance with nationally recognized standards, specifically the ISMP Guidelines for Safe Medication Practices in Long Term Care, which state that medications should be prepared and administered immediately and not pre-poured for later administration. On 4/12/26 at 9:50 AM, a nurse identified as LPN #2 was observed on the 200 hall placing pre-poured medication cups into the top drawer of her medication cart. At 9:57 AM, LPN #2 stated that a CNA had called out sick, she had been assisting residents to get up all morning, and she was behind, so she pre-poured medications to pass them out faster. She confirmed she should not pre-pour medications. On 4/12/26 at 10:39 AM, a medication cart was observed on the 100 hall that was unlocked with no staff present in the area. When the top drawer of the cart was opened, three medication cups were found inside: two cups stacked together and labeled with one resident's name, and a third cup labeled for a different resident. At 10:40 AM, a nurse identified as LPN #1 stated that the top stacked cup contained morphine and confirmed that the narcotic had been signed out on the controlled substance log at 10:09 AM. LPN #1 acknowledged that she should not pre-pour medications and disposed of the medications located in the top drawer. The report notes that these practices increased the risk of medication errors, contamination, diversion, and administration of medications to the wrong residents.
Failure to Follow Care Plans for Supervision and Assistance During Transfers and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received the level of supervision and assistance required by their care plans to prevent avoidable accidents. For one resident with quadriplegia, anxiety disorder, and total dependence on staff for rolling and repositioning in bed, the MDS documented cognitive intactness and dependence for rolling, and the care plan required assistance from two staff members for turning and repositioning in bed. Despite this, on 4/1/26, the resident was being changed in bed by a single CNA when she rolled off the bed. She was found lying on the floor slightly on her right side, yelling out in pain, and was transported by emergency medical services for further evaluation. The DON later confirmed that two CNAs should have been present to assist with turning this resident at the time of the fall. Another resident, admitted with difficulty in walking, muscle weakness, and the need for assistance with personal care, had an MDS showing a need for substantial/maximal assistance for chair, bed, and toilet transfers. The resident’s care plan directed staff to use two staff members for stand-and-pivot transfers to and from the wheelchair. On 4/8/26, a CNA attempted a stand-and-pivot transfer with this resident using only one staff member, and the resident’s legs buckled, resulting in an assisted fall to the floor. At the time of the transfer, the resident was not wearing appropriate footwear. The DON confirmed that this fall could have been prevented if the care plan, which required two staff members for transfers, had been followed.
Failure to Follow Oxygen Therapy Orders and Change Oxygen Tubing as Scheduled
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for Resident #56. The resident was admitted with multiple diagnoses including mild cognitive impairment, COPD, and a need for assistance with personal care, and had physician orders for continuous oxygen at 2 L/min via nasal cannula and for the tubing, filter, and oxygen water to be changed every 7 days. Record review indicated the orders were documented as being followed as written. However, during an observation on 4/12/26, the resident was seen in bed with a nasal cannula connected to an oxygen concentrator, with the attached humidifier bottle dated 4/5/26 and the cannula storage bag dated 3/29/26. In a subsequent interview, CNA #2 stated that oxygen tubing is to be changed every 7 days and confirmed that the date on the bag reflects when the tubing was last replaced, acknowledging that the resident’s oxygen tubing had not been changed in 14 days. This failure placed the resident at risk for adverse effects, including respiratory infections. The deficiency centers on the discrepancy between the documented adherence to oxygen therapy orders and the actual condition of the resident’s oxygen equipment as observed by surveyors and confirmed by staff, specifically the failure to change the oxygen tubing according to the 7-day schedule ordered by the physician.
Unnecessary Use of Tamsulosin Without Current Urological Indication
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when a resident was maintained on tamsulosin (Flomax) without an adequate clinical indication. Record review showed the resident had multiple diagnoses including right-sided hemiplegia and hemiparesis following a stroke, a seizure disorder, and dementia, and had an order dated 4/26/21 for Flomax 0.4 mg by mouth at bedtime for stent removal and calculus of the kidney. Reference to the National Library of Medicine indicated that tamsulosin for ureteral stones is typically prescribed at 0.4 mg daily for 7 to 42 days or until stone expulsion. The DON reported that the resident had not received treatment for kidney stones or a ureteral stent since admission and that the only documented treatment for kidney stones and a ureteral stent occurred in 2020, prior to admission. The DON further stated the resident did not currently have any urological diagnoses to indicate the ongoing use of Flomax, demonstrating that the medication was being administered without a current, documented indication. This failure resulted in the resident taking a medication for which they did not have a clinical diagnosis, and the report states this placed the resident at risk for harm.
Unattended, Unlocked Medication Cart in Resident Care Hallway
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when a medication cart was observed unlocked and unattended in the 100-hall. The facility’s Medication Storage policy, revised April 2025, required that medications be stored safely, securely, and properly in accordance with manufacturer or supplier recommendations and applicable federal and state regulations, and that the medication supply be accessible only to authorized personnel. On 4/12/26 at 10:39 AM, a medication cart was found unlocked with no staff present in the area, contrary to this policy. At 10:41 AM the same day, a licensed practical nurse (LPN #1) confirmed she had left the medication cart unlocked and acknowledged that it should have been locked. The report states that this failure to secure medications had the potential to affect all residents in the facility, as unsecured medications could be accessed by individuals for whom they were not prescribed, creating a risk for harm.
Failure to Secure PHI and Maintain Accurate Behavioral Documentation
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records in accordance with its confidentiality policy and accepted professional standards. The facility’s Resident/Patient Confidentiality policy stated that HIPAA requires appropriate safeguards to protect personal health information and limits use and disclosure without authorization. Despite this, a medication cart on the 100-hall was observed with a laptop attached, displaying the electronic medical record system with resident information visible, while no staff were present at the cart. When interviewed, the LPN responsible for the cart acknowledged she had forgotten to lock the screen. The facility also failed to ensure accurate documentation of a resident’s medical record. One resident, admitted with generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder, had a care plan directing staff to monitor the resident every shift and notify the physician if the resident verbalized suicidal thoughts. Behavior monitoring records for this resident documented suicidal thoughts on multiple dates between early March and early April. When surveyors requested documentation of physician notification for these reported suicidal statements, the DON stated that the resident had not verbalized suicidal thoughts and that the behavior monitoring records had been inaccurately documented by the same nurse on each of the listed dates.
Failure to Follow Hand Hygiene and PPE Requirements for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed infection prevention and control practices, including hand hygiene and use of PPE, for a resident on Enhanced Barrier Precautions (EBP). The facility’s hand hygiene policy, revised 12/2023, required staff to perform hand hygiene before and after direct resident contact, after removing gloves and PPE, after contact with objects in the resident’s immediate vicinity, and before and after entering isolation precaution settings. Resident #1, admitted with quadriplegia, Friedreich’s ataxia, and neuromuscular bladder dysfunction, had physician orders dated 3/3/25 for EBP related to an indwelling urinary catheter and PEG-tube, with posted signage directing hand sanitizing before entering and after leaving the room and use of gown and gloves for high-contact care activities such as changing linens, providing hygiene, changing briefs, device care, and dressing tasks. On multiple observations, staff did not adhere to these requirements. On 4/14/26, CNA #1 provided incontinence care and changed the resident’s brief, then removed PPE and exited the room to obtain supplies without performing hand hygiene after removing PPE or upon exiting. Later, CNA #1 returned, performed hand hygiene, donned PPE, and completed incontinence care, but during dressing tasks, CNA #1 obtained clothing from the closet, applied socks, then donned gloves to handle the resident’s catheter without performing hand hygiene beforehand or donning a gown, despite the EBP sign listing dressing as a task requiring PPE. Subsequently, CNA #1 and CNA #3 entered the resident’s room with a hoyer lift and did not perform hand hygiene upon entry before donning gowns and, for CNA #3, gloves to transfer the resident. On 4/16/26, LPN #3 entered the resident’s room, performed hand hygiene, donned PPE, then handled a graduated cylinder and syringe at the sink, turned on the water, and filled the cylinder before mixing and administering medications and nutrition via the PEG-tube without changing gloves or performing hand hygiene between touching the sink and accessing the PEG-tube. The facility stated this practice should have included changing gloves and hand hygiene before accessing the PEG-tube. This failed practice created the potential for adverse outcomes including infection due to cross contamination.
Failure to Address Resident Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by residents during Resident Council meetings from June 2024 through November 2024. The Resident Council minutes documented various issues such as dietary concerns, housekeeping, offsite activities, call light response times, staff behavior, and laundry problems. Despite these concerns being consistently raised in meetings, the minutes did not document any actions taken to address or resolve them. A call light audit conducted in October 2024 identified the need for improvement, but no follow-up actions were documented or communicated to the residents. Interviews with residents and staff revealed ongoing issues with housekeeping, staffing, heating, and call light response times. The Social Services Designee (SSD) and the Activities Director (AD) confirmed that concerns from Resident Council meetings were supposed to be addressed in staff meetings, but there was no written documentation of follow-up actions or responses provided to the residents. The Administrator acknowledged that while concerns were discussed in team meetings, they were not consistently documented or communicated back to the residents in writing.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for four out of five residents reviewed. This deficiency was identified through a review of the State Operations Manual, Appendix PP, which mandates that facilities must notify the resident, their representative, and the Ombudsman before any transfer or discharge. The facility did not comply with this requirement, as evidenced by the lack of documentation in the medical records of Residents #19, #30, #32, and #33, who were transferred to the hospital without the Ombudsman being informed. Resident #19, who had multiple diagnoses including spastic quadriplegic cerebral palsy and aphasia, was transferred to the hospital for possible gastrointestinal bleeding without Ombudsman notification. Similarly, Resident #30, with diagnoses including TBI, anxiety, and diabetes, and Resident #32, with cancer, anemia, and heart failure, were transferred without the required notification. Resident #33, with a fracture, anemia, and congestive heart failure, also experienced a facility-initiated hospital stay without Ombudsman notification. The facility administrator admitted to being unaware of the requirement to notify the Ombudsman of such transfers.
Non-Compliance with Nurse Aide Certification Requirements
Penalty
Summary
The facility failed to ensure that full-time nurse aides (NAs) were either enrolled in a State-approved training and competency evaluation program or had completed such a program within four months of employment. This deficiency was identified for four out of eleven NAs whose personnel files were reviewed. Specifically, NA #1, hired on November 21, 2023, NA #2, hired on April 11, 2024, who completed the class but had not tested, NA #3, hired on June 5, 2024, and NA #4, hired on June 13, 2024, were all working beyond the four-month period without obtaining their nurse aide certification. The HR Manager acknowledged the facility's non-compliance with the requirement for NAs to be certified within four months of their hire date. This oversight had the potential to negatively impact the 54 residents living in the facility.
Infection Control Breach in Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during a survey. A staff member in the laundry department was seen folding clean laundry and later admitted to sorting dirty laundry without wearing a gown, which is against the standard precautions outlined in the State Operation Manual Appendix PP. The manual specifies that gowns and gloves should be worn when handling potentially contaminated laundry to prevent infection and cross-contamination. The Director of Nursing confirmed that the correct procedure involves wearing both gloves and gowns during the sorting of dirty laundry.
Deficiency in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia, malnutrition, and hypertension, was found to have a room with several issues. Observations included a six-inch section of baseboard near the bathroom that was not attached to the wall and a corner of the baseboard broken off. Additionally, a roll of toilet paper was improperly placed on the grab bar instead of the toilet paper holder. The grab bar itself had large sections of chipped and peeling paint. Furthermore, the hand washing sink was corroded with rust and chipped around the drain. The Maintenance Director was unaware of these issues, as the Housekeeping Supervisor was responsible for submitting work orders, which had not been done. The Housekeeping Supervisor acknowledged the improper placement of the toilet paper and, along with the Administrator, stated that the sink could not be cleaned and would need replacement.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident, the quarterly and significant change MDS assessments incorrectly documented an active diagnosis of pneumonia, despite the condition having resolved months earlier. This discrepancy was confirmed by the Director of Nursing (DON) during an interview. Another resident's admission MDS assessment inaccurately recorded the use of an anticoagulant, which was not supported by the physician's orders. The DON confirmed the error after consulting with the MDS Coordinator. Additionally, a third resident's admission MDS assessment failed to document a completed PASARR level II evaluation, despite the medical record indicating it had been completed. The DON acknowledged this oversight during the review.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR level II evaluation after the resident was diagnosed with a major mental illness, specifically major depressive disorder (MDD). The resident was admitted with multiple diagnoses, including MDD and dementia, and was prescribed antidepressant medication. The care plan was updated to include directions for managing the resident's depression and behavioral disturbances. However, the pre-admission PASARR level I screening identified the resident's MDD but was not forwarded to the appropriate state-designated authority for a level II evaluation. The deficiency was identified during a review of the resident's records and staff interviews. The Director of Nursing (DON) was unaware that the PASARR level I form was filled out incorrectly and that a level II evaluation should have been completed. This oversight had the potential to cause harm by not ensuring the resident's specialized mental health needs were evaluated and coordinated by the appropriate authority.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, affecting multiple residents. Resident #18, who has diagnoses including paraplegia and chronic pain, was mistakenly given Norco instead of the prescribed Tramadol due to a mix-up with medication cards. Resident #25, with a diagnosis of esophagitis, was incorrectly administered rivaroxaban intended for another resident during a training session between LPN #1 and RN #1. These errors were documented in Medication Error Reports. Additionally, Resident #27, who suffers from chronic respiratory failure, was administered Anoro Ellipta despite the physician's order for ipratropium-Albuterol and the discontinuation of Anoro Ellipta. The medication technician and LPN involved were unaware of the discontinuation, leading to the administration of the wrong medication. These incidents highlight the facility's failure to adhere to the six rights of medication administration, creating potential adverse effects for the residents involved.
Failure to Follow Care Plans and Notify Physician
Penalty
Summary
The facility failed to provide resident-centered care in accordance with professional standards of nursing practice and residents' comprehensive care plans for two residents. Resident #6, who was admitted with multiple diagnoses including metabolic encephalopathy, diabetes, and hypoglycemia, had a physician's order to notify the provider if blood glucose levels were less than 70 mg/dl or greater than 400 mg/dl. However, on two occasions, Resident #6's blood glucose levels exceeded 400 mg/dl, and there was no documentation in the medical record that the physician was notified, despite the Director of Nursing stating that the nurse had informed the nurse practitioner. Resident #19, diagnosed with spastic quadriplegia, cerebral palsy, and aphasia, required two-person assistance for repositioning in bed as per his care plan. On one occasion, CNA #1 was observed repositioning and turning Resident #19 alone while changing his bed sheet, despite the care plan's requirement for two-person assistance. CNA #1 admitted to frequently performing the task alone, and the Unit Manager confirmed that the care plan required two staff members for bed mobility, indicating a failure to adhere to the resident's care plan.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.9% error rate observed during the administration of insulin to a resident with diabetes. The resident was prescribed Insulin Glargine and Insulin Lispro, with specific instructions for administration based on blood glucose levels. On the day of observation, the resident's blood glucose was recorded at 256 mg/dl, requiring 15 units of Insulin Lispro according to the sliding scale. However, the RN administering the insulin did not prime the insulin pens before injecting the prescribed doses, which is a necessary step to ensure the full dose is delivered. The failure to prime the insulin pens was confirmed through staff interviews, where the RN admitted to not priming the pens, and the Unit Manager acknowledged that priming is required to ensure the resident receives the correct dose. This oversight in medication administration created the potential for the resident to experience fluctuations in blood sugar levels, as the full prescribed dose may not have been delivered. The deficiency was identified during a survey, highlighting a lapse in following proper medication administration protocols.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Emmett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Ridge Of Cascadia | 1.3 mi | ★★★★★ | 21 | 0 |
| Caldwell Care Of Cascadia | 18 mi | ★★★★★ | 18 | 0 |
| Canyon West Of Cascadia | 18.6 mi | ★★★★★ | 13 | 0 |
| Creekside Transitional Care And Rehabilitation | 19 mi | ★★★★★ | 0 | 0 |
| Cascadia Of Nampa | 20 mi | ★★★★★ | 16 | 1 |
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