Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Arc At Hickory Point during CMS and state inspections, most recent first.
A resident who was assessed as alert, oriented, and always continent of bowel and bladder reported feeling embarrassed and degraded after staff performed an incontinence urine bed check despite the resident’s clear statement that they were continent and did not need the bed checked. Facility staff, including a CNA and an LPN, acknowledged that care plans and policies require staff to recognize continent status and ask if assistance to the restroom is needed rather than insisting on incontinence checks for alert, continent residents. Leadership confirmed that residents have the right to dignity and to make choices about whether they are checked and changed or assisted to the bathroom, consistent with the facility’s resident rights policy and bowel/bladder program guidelines.
Unsecured Oxygen Cylinders Found in Resident Rooms: Surveyors observed two residents with portable O2 cylinders left in their rooms, including one beside a bed and another by the entry door. One resident said oxygen was not used, while the other said O2 and BiPAP were no longer used. Record review showed active physician orders for O2 and CPAP/BiPAP-related therapy, and the Maintenance Director stated portable cylinders should only be used for trips outside the building.
A resident council reported they did not know where the state survey results were located. The receptionist pointed to a dresser in the foyer, but the survey book was not accessible there and the administrator confirmed it was in her office. The administrator and RDOO also stated the survey book was missing multiple survey and complaint records from the prior year, affecting 59 residents.
The facility failed to complete weekly wound assessments and measurements and did not consistently follow wound-prevention interventions for residents with active skin breakdown. One resident had a stage 3 coccyx pressure injury with multiple wound treatment orders and inconsistent documentation, another had pressure injuries to the ankles and foot with heel-floating and heel protector interventions not reliably followed, and a third resident had multiple wounds with active treatment orders but no weekly wound assessment documentation and a soiled heel dressing noted on observation.
A facility failed to provide ordered respiratory care for multiple residents with oxygen needs. Residents with COPD, chronic respiratory failure, sleep apnea, pulmonary hypertension, and other respiratory conditions were observed without oxygen in place, with tubing disconnected or on the floor, and with oxygen equipment left undated, empty, or visibly soiled. Staff also observed a resident short of breath while the oxygen concentrator was off or not connected, and an LPN confirmed that one resident should have been wearing oxygen continuously.
A facility failed to ensure ordered meds were available for two residents. One resident did not receive ordered oxycodone on multiple occasions because it was unavailable, and the record did not show a backup pharmacy call. Another resident’s daily Trelegy was not given because it was unavailable, and the resident reported not having it for three days. An LPN stated medication availability can be a problem and was unsure why reorders get missed.
The facility failed to follow enhanced barrier precautions and Contact Precautions for two residents with wounds or an indwelling device, with no required signage posted and staff observed providing care without gloves. The facility also failed to disinfect a glucometer between resident uses for a resident receiving BID blood sugar checks; an LPN used alcohol wipes instead of the required bleach wipes after checking another resident’s blood sugar.
Staff failed to consistently respond to resident call lights in a timely manner, as evidenced by multiple grievances and Resident Council reports of extended wait times for assistance. One resident with multiple chronic conditions, including COPD, diabetes, Parkinsonism, and joint replacements, reportedly waited over 30 minutes for a call light to be answered while several call lights were visibly and audibly active and staff were observed going on break. A CNA acknowledged that call lights are not always answered promptly, while an LPN, the administrator, and a corporate nurse stated that call lights should be answered within 10–15 minutes and that staff should not leave the unit or go on break while call lights are active, in contrast to the events described.
Failure to Assess Self-Administration of Medications: A resident had Mucinex, Aspercreme, and 4% lidocaine at the bedside and stated the resident self-administered them for congestion and pain management. The EHR did not contain the required self-administration assessment or tool, and the Administrator stated the resident should not have been self-administering medications.
A resident who was cognitively intact and needed partial to moderate ADL assistance was observed with a pillowcase smeared with brown material and crumbs scattered on the bedding while lying in bed and later sitting in a wheelchair. The resident stated they eat in bed and wanted clean bedding, and said the linens had not been changed since a room move. A CNA stated bedding should be changed when soiled, and an RN stated linens should be changed daily and whenever soiled.
Failure to assess and plan for psychotropic use for insomnia: A resident was prescribed mirtazapine 7.5 mg HS for depression and insomnia after reporting inability to sleep, but the EMR lacked an assessment for the medication and did not show that nonpharmacological interventions were tried. The resident said sleep problems were lifelong and that TV or reading helped, yet the care plan did not address insomnia or document interventions, and the ADM confirmed no assessment, monitoring, care plan, or nonpharmacological measures were in place.
Inaccurate MDS wound assessments were documented for two residents. One resident was admitted with multiple wounds and had active wound treatments, but the MDS stated there were no wounds; another resident had documentation of a stage 3 pressure injury to the coccyx with ongoing wound care, but the MDS stated there was no pressure ulcer. Staff interviews and record review confirmed the wound conditions were present while the MDS entries were inaccurate.
A resident who was cognitively intact and dependent on staff for personal hygiene, including shaving, was observed with visible facial hair despite stating a preference to be clean shaven every day. The resident said staff had told the resident they could not provide the shave, and a corporate RN confirmed the facility’s policy is to offer shaving as often as the resident prefers and that CNA staff are expected to shave residents according to preference.
A resident with low back pain, migraines, and pain from a left femur fracture did not receive ordered pain meds on multiple occasions. The MAR and notes showed Oxycodone was missed or unavailable, pain ratings were as high as 9/10, and staff delayed giving PRN Norco after the resident reported pain and activated the call light.
Improper storage of medications was observed for two residents. One resident had liquid Mucinex, Aspercream, and lidocaine left on an over-the-bed table, and an LPN stated these items should have been locked in the med cart. Another resident had a medicine cup with a pill sitting in the room windowsill, and the LPN stated medications should not be stored in resident rooms.
A resident with severe cognitive impairment, multiple comorbidities, impaired mobility requiring a walker, and significant hearing and vision deficits was not properly assessed or identified as an elopement risk when admitted. The elopement evaluation was incompletely done but locked as finished, indicating no elopement risk, and the resident was not included in the elopement alert system. Overnight, the resident was last seen in bed by an LPN and was not discovered missing until a CNA on the next shift noted the empty room while doing morning vitals. The resident had exited the building unsupervised, without coat or shoes, and was later found by family and a CNA in a restaurant parking lot near major highways, with hypothermia, frostbite to toes and fingers, a forehead hematoma with laceration, abrasions to both knees, and a fractured great toe, requiring hospital treatment and IV antibiotics for a UTI.
A resident with dementia, a history of falls, and documented need for supervision with toileting and transfers experienced an unwitnessed fall while ambulating barefoot with a walker to the bathroom without assistance, resulting in multiple injuries including a forehead laceration, abrasions, and a finger injury with a foreign body. The care plan identified fall risk and interventions such as use of a gait belt and appropriate footwear, and the DON later stated a urinal should have been kept at bedside, yet observations showed the urinal repeatedly left in the bathroom and the call light out of reach. CNAs reported they had been told the resident did not need assistance walking and allowed the resident to ambulate independently, and one CNA had not checked on the resident for several hours before the fall. The DON acknowledged she did not interview staff or verify call light and footwear status during the fall investigation and confirmed the investigation could have been more thorough.
The facility failed to properly investigate and follow up on multiple residents’ grievances regarding missed showers and bed baths. Cognitively intact residents who were dependent on staff for ADLs reported not receiving scheduled showers or bed baths for extended periods, and stated that staff either claimed they had no time, would return and did not, or said they did not perform bed baths or know how to use the mechanical lift for shower transfers. Concern forms that were completed for some residents documented the complaints and listed limited corrective actions, but the sections for follow-up with the complainants were left blank, and one resident’s grievance was not documented at all. Nursing leadership later acknowledged that they shared responsibility for nursing-related grievances, were aware showers were a problem, and had not followed up with the residents, despite a written grievance policy requiring timely resolution and oversight by a grievance official.
A resident with multiple fractures and bilateral arm casts, cognitively intact but fully dependent on staff for toileting and hygiene, developed an open, red, bleeding wound in the intergluteal cleft that was not entered on the wound log or otherwise documented. The resident reported episodes of old stool being found during incontinence care and described significant pain when a CNA applied cream to the area during a shower. The CNA stated she observed the open, bleeding area, applied an unknown cream available in the room, and informed an LPN, but the ADON and DON later confirmed they were not notified and no wound assessment, documentation, or physician notification occurred, contrary to facility policy requiring daily skin observations, prompt reporting, and weekly assessment of non-pressure skin conditions.
Two residents receiving catheter and perineal care did not receive appropriate infection control practices. For one resident with a history of urinary retention and UTI, a CNA performed front perineal care, handled a trash can, and then completed perianal care without changing gloves or performing hand hygiene, and did not cleanse the catheter tubing. For another resident with multiple comorbidities including CHF, DMII, and prior UTI, a CNA used gloves from a box that had fallen to the floor and then provided catheter/perineal care, during which the resident’s penis was noted to be red, swollen, and sore. The DON confirmed that items touching the floor are considered contaminated and that staff are expected to avoid cross-contamination during perineal care.
A resident at risk for pressure ulcers developed a Stage 2 ulcer on the tailbone after staff failed to identify and report changes in skin integrity. Despite a care plan requiring regular monitoring and repositioning, documentation did not reflect any skin issues, and nursing staff were unaware of the wound until it was discovered after a fall. Hospice and wound care assessments later confirmed the presence of a pressure ulcer that had developed weeks prior.
Two residents with known fall risks suffered unwitnessed falls resulting in injuries, including swelling, skin tears, and a fractured collarbone, after the assigned CNA was repeatedly found asleep or absent from her post. The facility's policy requiring regular resident checks was not followed, and required safety measures, such as keeping beds in the low position, were not maintained.
A bathroom used by two residents was found to have a slimy, fuzzy, black substance resembling mold above the shower and on the ceiling, which had been present for some time. A housekeeper reported notifying maintenance, but the administrator could not find any record of a work order being submitted for the issue. The presence of the black material was confirmed by both the administrator and a corporate administrator.
A resident with a history of repeated falls, weakness, and partial paralysis was assessed as high risk for falls but did not have adequate fall prevention interventions in place. Staff confirmed that aside from ensuring appropriate footwear and occasionally lowering the bed, no other interventions were implemented. The resident was found on the bathroom floor and sustained multiple rib fractures, a hemothorax, and a collapsed lung, with staff and medical leadership acknowledging that proper fall protocols could have changed the outcome.
A resident with paraplegia and a history of pressure ulcers developed a new sacral pressure ulcer that was not promptly identified or treated. There was a delay in obtaining and implementing physician orders, and the care plan was not updated in a timely manner. The resident did not consistently receive pressure-relieving interventions, and staff reported delays in repositioning due to being busy. The resident experienced pain from the worsening ulcer, and observations confirmed a lack of appropriate off-loading devices.
Two residents experienced unsafe transfers when staff failed to follow required protocols, including not using a gait belt, transferring without a second staff member, and using a mechanical lift incorrectly. One resident sustained a skin tear during a transfer, while another was left in a wheelchair for an extended period, resulting in skin breakdown and pain. Staff interviews revealed that care plans were not reviewed or updated, and facility policy on safe transfers was not followed.
Three residents developed or experienced worsening pressure ulcers due to the facility's failure to perform required skin checks under immobilizers, inadequate wound assessment, and lack of timely physician notification. In one case, a wound under an immobilizer was not identified or treated promptly, while another resident's wound was not documented or communicated to the wound nurse. Additionally, a resident with a deep tissue injury did not receive appropriate wound care or physician orders in a timely manner.
A resident with a physician's order for Tramadol-Acetaminophen for moderate pain was left without pain medication after the supply ran out and staff failed to request a timely refill. The resident experienced severe pain, canceled a doctor's appointment, and was observed in discomfort, while staff confirmed the lapse in medication management and delayed action to obtain a new prescription.
The facility did not have a qualified infection preventionist consistently overseeing the infection prevention and control program, with the designated individual only present one day per week and lacking time for essential duties such as staff education. Additionally, two residents were on prophylactic antibiotics without proper assessment or care planning, and required infection surveillance and documentation were not completed.
Staff failed to follow medication administration protocols by leaving medications, including controlled substances, at the bedsides of several residents and pre-pouring unlabeled medications in a cart. Nursing staff acknowledged that medications should be administered as poured and not left unattended, but these procedures were not followed.
A resident's request to be a DNR was not properly documented or implemented, as required by facility policy. Although the resident and staff confirmed the DNR wishes and an Advance Directive form was signed, there was no physician order, POLST form, or care plan update reflecting this status in the medical record or code status binder. As a result, the resident would be treated as a full code and receive CPR.
A resident who was severely cognitively impaired and dependent on staff for transfers was moved from the toilet to a wheelchair using a sit-to-stand mechanical lift by only one CNA, despite the care plan requiring two staff for such transfers. Interviews with LPNs and another CNA confirmed that two staff are needed for these transfers, but this protocol was not followed.
A facility failed to follow its Mechanical Lift Policy, requiring two staff members for transfers, leading to a resident's femur fracture during a transfer by a CNA. The resident, who was severely cognitively impaired, experienced leg pain and was later found to have a displaced fracture, requiring hospitalization and surgery. The orthopedic surgeon suggested the injury might have occurred during the transfer.
The facility failed to complete fall risk assessments and post-fall monitoring for three residents, as required by its Fall Prevention policy. This included missing assessments upon admission, readmission, and after falls, as well as incomplete post-fall follow-up notes. Staff confirmed these deficiencies in the residents' medical records.
The facility failed to provide timely and appropriate pressure ulcer care for two residents, leading to significant deterioration in their conditions. One resident's elbow wound progressed to an infected stage 4 pressure sore due to delayed physician notification and inadequate monitoring. Another resident developed a deep tissue injury on her heel that was not promptly reported, resulting in an unstageable pressure sore. The facility did not adhere to its policies for reporting changes in condition, leading to inadequate care and worsening of the residents' conditions.
The facility failed to implement a comprehensive training program for CNAs on essential topics such as Communication, Resident Rights, Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health. Five CNAs had not completed the required training in the past year, despite actively providing care to residents. The administrator acknowledged the lack of documentation and specific training policy, potentially affecting all 55 residents.
The facility failed to ensure five CNAs completed the required twelve hours of annual education, including dementia care and abuse prevention training. This deficiency was due to a lapse in monitoring caused by a change in the HR position, potentially affecting all 55 residents.
The facility failed to notify the physician and POA about pressure sores in two residents. One resident developed a severe elbow wound, and the other a heel deep tissue injury, both without timely physician notification. The facility's policy mandates such notifications for significant condition changes.
The facility failed to review their Infection Control policies annually, affecting all 60 residents. Key policies such as 'Infection Surveillance' and 'Antibiotic Stewardship' had not been reviewed since 2017. The Infection Preventionist and Administrator acknowledged the issue, but no recent review dates were available.
The facility failed to document fluid intake and output for a resident with an indwelling urinary catheter, as required by the facility's policy and the resident's care plan. Despite the care plan's directive, the resident's medical records lacked documentation, and staff interviews confirmed this deficiency.
A facility failed to prevent cross-contamination during pressure ulcer treatment for a resident with multiple pressure ulcers. An RN applied medihoney ointment directly from the tube to the wounds without using an applicator, contaminating the ointment tube and then using it on other wounds. This action was against the facility's policy, which requires separate applicators for each wound to prevent contamination.
Failure to Honor Continent Resident’s Dignity During Incontinence Check
Penalty
Summary
The deficiency involves staff failing to honor a resident’s right to be treated with respect and dignity and to make choices about incontinence care. The resident, admitted with multiple medical diagnoses including COPD, autoimmune hepatitis, asthma, hypoxemia, type 2 diabetes, Parkinsonism, and joint replacements, was documented on the admission assessment as always continent of bowel and bladder and as alert and oriented to person, place, time, and situation, with verbally appropriate responses. Facility policies and the bowel and bladder program state that continent residents should not be placed on incontinence programs or subjected to incontinence checks, and that residents have autonomy and choice in how they receive care, as long as facility rules and regulations are followed. Despite this, staff conducted an incontinence urine bed check at approximately 4:00 a.m. after the resident had stated to staff that they were continent of urine and did not need the bed checked. The resident’s family member reported that the resident felt embarrassed, degraded, and experienced low self-esteem as a result of staff continuing the incontinence check after the resident’s statement. A CNA and the admission LPN both stated that staff should follow the care plan, recognize when a resident is continent, and ask if assistance to the restroom is needed rather than insisting on checking the bed for incontinence when an alert resident reports being dry. The administrator and corporate nurse acknowledged that residents have the right to be treated with dignity and to choose whether they are checked and changed or assisted to the restroom, consistent with the facility’s resident rights policy.
Unsecured Oxygen Cylinders Found in Resident Rooms
Penalty
Summary
The facility failed to ensure that oxygen cylinders were secured and stored properly for two residents, R71 and R1. On 3/01/2026 at 8:35 AM, surveyors observed R71 with a portable oxygen cylinder on the left side of the bed that was not secured and not in use; R71 stated that oxygen was not used. On 03/01/2026 at 9:05 AM, surveyors observed R1 with a portable oxygen cylinder by the entry door inside the room. R1 stated that oxygen and a BiPAP machine were used in the past but were no longer used. Record review showed R71 had physician orders dated 2/21/26 for 2 liters of oxygen via nasal cannula every shift for shortness of breath, and R1 had physician orders dated 1/27/26 for oxygen at 3 liters via nasal cannula and CPAP. On 3/1/2026 at 1:25 PM, the Maintenance Director stated portable oxygen cylinders should not be in the room because they are only for going out of the building for appointments.
Survey Results Not Accessible and Survey Book Incomplete
Penalty
Summary
The facility failed to ensure that state survey results were accessible to residents and that the survey book contained all surveys completed in the last year. During a resident council meeting, residents stated they were unaware of where the state survey inspection results were located. The receptionist stated the survey book was in a drawer in the foyer, but when observed, the book was not on top of or in the dresser and the administrator confirmed it was not accessible to residents because it was in her office. The administrator and regional director of operations also stated the book was missing multiple surveys and needed to be updated. The missing surveys identified by the regional director included annual surveys, complaint surveys, certification revisits, follow-up complaint surveys, licensure surveys, facility-reported incidents, and complaint investigations from the prior year. The facility's Medicaid and Medicare application signed by the administrator documented 59 residents residing in the facility.
Failure to Complete Weekly Wound Assessments and Follow Wound-Prevention Interventions
Penalty
Summary
The facility failed to complete wound assessments and measurements at least weekly for residents with active wounds and failed to implement ordered interventions to prevent wounds for three residents. The facility’s Skin Condition Assessment & Monitoring policy stated that residents identified with wounds would have weekly skin assessments by a licensed nurse, that wound assessments would be initiated and documented when pressure or non-pressure skin conditions were identified, and that wound condition would be observed daily or with dressing changes as ordered. Resident 1 was observed in bed eating breakfast and stated the wound had healed and then reopened about a month earlier. Records showed a stage 3 pressure injury to the sacrum/coccyx with multiple wound-related entries, including a wound note describing a stage 3 pressure injury to the sacrum and IAD/MASD to the peri-rectal area, a nursing progress note documenting an open area to the coccyx with new treatment orders, and later wound notes documenting a stage 3 pressure ulcer measuring 0.60 cm by 0.40 cm by 0.10 cm. The MDS did not document a pressure ulcer, while nursing staff stated the resident had a pressure ulcer to the coccyx and daily treatments were completed at bedtime. Resident 6 was observed in a wheelchair with a sign above the bed stating heels must be floated while in bed. The resident stated sores developed from lying in bed too much and that no foot protection was worn at night, using only a pillow between the legs. The care plan identified actual skin impairment with pressure injuries to the inner left and right ankles, outer left ankle, and inside of the right foot, and interventions directed staff to encourage heel protectors and heel floating while in bed. A wound care note recommended heel protectors to the lower legs, but the administrator stated staff should have been following that recommendation or documenting refusal. Resident 36 was admitted with wounds to both lower extremities and the left heel, with active treatment orders for the left heel, bilateral groin, and abdominal fold. On observation, the left heel dressing was gauze wrapped with yellow staining and appeared soiled, and the record contained no documentation of weekly wound assessments or measurements. The wound nurse confirmed the resident had multiple wounds and active treatments, stated the MDS documentation was not accurate, and said weekly documentation was only done for new open areas.
Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care as ordered for residents who had physician-ordered oxygen therapy. R58 had altered respiratory status related to pulmonary hypertension, obstructive sleep apnea, and disorders of the diaphragm, with an order for continuous oxygen at 3 liters per minute via nasal cannula. On 3/1/26, R58 was observed in bed with the concentrator set at 3 liters per minute, but the cannula and tubing were not attached to the concentrator, and R58 stated feeling short of breath. On 3/3/26, R58 again complained of shortness of breath while the concentrator was off and the tubing and cannula were coiled on top of the concentrator. R36 had an order for oxygen at 2 liters per minute while sleeping due to sleep apnea, but on 3/1/26 was observed sitting in a recliner with the cannula on the floor, the tubing and humidifier bottle undated, and the cannula covered in a crusty dry white matter. R19 had COPD, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen, with orders and care plan documentation for continuous oxygen at 2 liters per minute, yet was observed with oxygen tubing on the floor and the concentrator running in the bathroom while lying in bed, and the resident stated staff sometimes assisted with the tubing and concentrator but not often. R51 had altered respiratory status and difficulty breathing with an order and care plan for continuous oxygen at 2 liters per minute, but was repeatedly observed without oxygen while sitting in a wheelchair and at a dining table. The humidification bottle connected to R51's oxygen setup was dated 12/8 and empty, and the nasal cannula was not dated. An LPN later confirmed the order for continuous oxygen and checked the resident's pulse oximetry at 96 percent, but did not apply oxygen after reviewing the order.
Pharmacy Medications Not Available for Ordered Resident Treatments
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when ordered medications were not available from the pharmacy for two residents. For R10, physician orders dated 1/30/26 included Oxycodone Hydrochloride 30 mg one tablet by mouth every morning and at bedtime. The January 2026 MAR shows the medication was not administered, with references to progress notes on 1/30/26 and 1/31/26; however, the 1/30/26 note did not document why it was not given, and the 1/31/26 note stated the Oxycodone was not available. The record did not document an attempt to call the backup pharmacy to obtain the medication. The February 2026 MAR also shows the Oxycodone was not administered on 2/15/26 at 8:00 AM and 8:00 PM, and the progress note for that date stated it was unavailable. The Administrator stated on 3/2/26 that R10 did not receive the Oxycodone as ordered on 1/30/26, 1/31/26, or 2/15/26, and that the nurse on duty should have called the backup pharmacy. For R150, the March 2026 MAR included a current order for Trelegy Ellipta inhalation powder 100-62.5-25 mcg/act, 1 puff daily for SOB/wheezing, but the MAR documented the medication was not given on 3/2/26. The progress note stated the Trelegy was unavailable and would arrive that night. R150’s MDS documented cognitive intactness, and on 3/3/26 R150 stated the facility did not have the Trelegy for three days and that it was needed for breathing. An LPN stated there was a problem having all medications available sometimes and that it only takes one click on the computer to reorder, but she was not sure why it gets missed.
Failure to Follow Precautions and Glucometer Disinfection
Penalty
Summary
The facility failed to implement enhanced barrier precautions and Contact Precautions for two residents. Facility policy revised on 12/25 required enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities, and also stated that standard precautions, including gown and gloves, must be used for dressing, bathing/showering, hygiene, linen changes, incontinence care, medical device care, and wound care. On 3/01/2026, R71 had no enhanced barrier precautions signage on the door despite having a blister related to cellulitis and congestive heart failure. On the same day, R61 had no Contact Precautions signage and no enhanced barrier precautions signage on the door; R61 had a below-the-knee amputation that was wrapped. During observation, V4 was assisting residents with breakfast in a gown and mask but without gloves, and V4 stated she believed R4 had an eye infection, though she thought it might be from the wound. The Administrator later confirmed staff should be following enhanced barrier precautions for any open area on any residents. The facility also failed to appropriately sanitize a glucometer between resident uses for R33. R33’s MAR for March 2006 included an order initiated 2/27/26 for blood sugars twice daily, every morning and at bedtime, for diabetes. On 3/3/26, an LPN was observed cleaning a glucometer on the medication cart after checking another resident’s blood sugar and stated she was cleaning it to use on R33. The LPN stated she was using alcohol wipes but knew it should be bleach wipes, and said she had asked the housekeeping supervisor for bleach wipes for the cart that morning but was told bleach wipes were not allowed on the medication cart. The Administrator later verified the medication cart should be stocked with bleach wipes and the glucometer should be cleaned with bleach wipes.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
Surveyors identified a deficiency related to residents' rights to a dignified existence, self-determination, communication, and exercise of rights when call lights were not answered in a timely manner. Grievance forms dated December 8 and 28, 2025, and February 3 and 26, 2026, documented residents having to wait extended periods for assistance with various activities. Resident Council minutes from February 6, 2026, recorded that six residents attended and reported that staff needed to answer call lights more quickly. The facility’s Call Light policy dated January 2026 stated that resident call lights would be answered in a timely manner, that all staff should assist in answering call lights, that nursing staff should promptly respond and cancel call lights upon entering the room, and that bathroom lights should be treated as emergencies requiring immediate attention. For one resident (R76) reviewed for call light response, the medical record showed admission on February 21, 2026, with multiple diagnoses including seasonal allergic rhinitis, polyneuropathy, COPD, autoimmune hepatitis, asthma, hypoxemia, type 2 diabetes mellitus without complications, Parkinsonism, and the presence of right artificial knee and left artificial shoulder joints following joint replacement surgeries. On March 3, 2026, a CNA (V27) stated that staff should answer call lights in a timely manner but acknowledged that this does not always occur. On the same date, a family member (V30) reported that on February 25, 2026, the resident’s call light was not answered for over 30 minutes, and when the family member approached the nurse’s station, multiple staff members were going on break while multiple call lights were activated and visible above resident doors and sounding at the nurse’s station. On March 4, 2026, an admission nurse/LPN (V6) and the Administrator (V1) with the Corporate Nurse (V23) stated that staff should answer call lights within 10–15 minutes and should not leave the unit or go on break while call lights are activated, and they reported being unaware of staff failing to respond to call lights before going on break.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of one resident to self-administer medications. The facility’s Self Administration of Medication policy dated 4/2025 states that residents who request to self-administer drugs are to be assessed using the Self Administration of Medications tool at admission to determine whether the practice is safe. On 3/1/2026 and again on 3/2/2026, bottles of liquid Mucinex, a roller-ball tube of Aspercreme, and a can of 4% lidocaine were observed sitting on the resident’s over-the-bed table. On 3/2/2026, the resident stated that the resident self-administers the Mucinex for congestion and self-administers the lidocaine and Aspercreme for pain management. Review of the resident’s electronic health record did not show an assessment of the resident’s ability to self-administer medications, and the record did not contain a Self-Administration of Medications tool. The Administrator stated that the resident did not have an assessment to self-administer medications and should not be self-administering medications.
Soiled Bedding Not Changed for Resident
Penalty
Summary
The facility failed to provide clean bedding for one resident, R43, who was cognitively intact and required partial to moderate assistance with activities of daily living. On 3/03/2026, R43 was observed lying in bed with a pillowcase that had brown smearing across the top near the resident’s face and scattered brown crumbs on the upper body area of the bottom sheet; the resident stated that they eat in bed and wanted clean bedding, and also stated the bedding had not been changed since the room move on 2/21/26. Later that same day, R43 was observed sitting in a wheelchair in the room, and the same brown smearing and crumbs were still present on the bedding. A CNA stated bedding is supposed to be changed when soiled, and an RN stated bed linens are generally changed daily when the resident gets up and should certainly be changed any time they are soiled.
Failure to Assess and Plan for Psychotropic Use for Insomnia
Penalty
Summary
The facility failed to ensure a resident’s right to be free from chemical restraints by not assessing the need for a psychotropic medication, not developing a plan of care for an antidepressant used for insomnia, and not implementing non-pharmacological interventions for insomnia for one resident. The resident’s MAR showed an order for mirtazapine 7.5 mg at bedtime for depression and insomnia, and the physician progress note documented that the resident reported not being able to sleep and that the medication was prescribed for insomnia. The resident stated that sleep had been a lifelong problem related to working swing shifts and that the resident preferred to fall asleep with the television on or by reading. The resident’s EMR did not contain an assessment for the mirtazapine or documentation that nonpharmacological interventions were attempted for insomnia. The antidepressant care plan did not document the diagnosis of insomnia or interventions for insomnia. The Administrator confirmed the resident was not assessed for the use of psychotropic medications used for insomnia, was not monitored for insomnia, had no plan of care developed for insomnia, and had no nonpharmacological interventions put into place.
Inaccurate MDS Wound Assessments
Penalty
Summary
The facility failed to accurately assess wounds in the MDS for two residents. For R36, the MDS completed on 2/18/26 documented that the resident was admitted without wounds of any kind, even though the wound clinic consult dated 2/12/26 stated R36 was admitted with wounds to both lower extremities and the left heel. The MAR for March 2026 also showed treatment orders initiated on 2/12/26 for the left heel, bilateral groin, and abdominal fold. On 3/1/26, R36 was observed seated in a recliner with the left heel covered by a gauze wrap that had yellow staining and appeared soiled, and the dressing was not dated. On 3/4/26, the LPN/wound nurse verified that R36 had multiple wounds on admission and continued to have active treatments, and stated the MDS was not accurate. For R1, wound documentation showed a stage 3 pressure injury to the sacrum/coccyx and IAD/MASD to the peri-rectal area, with wound care notes, nursing progress notes, and treatment orders documenting an open area to the coccyx and ongoing wound care. The nursing progress note on 2/5/26 stated R1 had an open area to the coccyx and new wound orders were started, and later wound notes documented a stage 3 pressure ulcer on the coccyx with measurements and treatment orders. Despite this, the MDS documented that R1 did not have a pressure ulcer. On 3/2/26, an LPN stated R1 had a pressure ulcer to the coccyx and daily treatments were completed at bedtime, and another LPN stated R1 had a wound on the coccyx and that the pressure ulcer developed on 2/5/26.
Failure to Provide Requested Shaving Assistance
Penalty
Summary
The facility failed to provide shaving assistance for one resident who was unable to shave independently and preferred to be clean shaven. The resident’s MDS documented that the resident was cognitively intact and dependent on staff for personal hygiene, including shaving. On observation, the resident was resting in bed with coarse gray facial hair approximately 1/4 inch long on the face and chin. When asked, the resident stated a preference to shave every day and said the resident could not do it independently and had been told staff could not do that. A corporate RN later verified that the facility’s policy is to offer a shave as often as the resident prefers and that CNA staff are expected to shave each resident according to preference.
Pain medication not provided as ordered
Penalty
Summary
The facility failed to provide pain medication when pain was present and as ordered by the physician for one resident with low back pain, migraines, and pain related to a left femur fracture. The resident’s pain care plan included an intervention to provide pain medication as ordered, and physician orders dated 1/30/26 included Oxycodone Hydrochloride 30 mg by mouth every morning and at bedtime for pain, along with Norco 5-325 mg every six hours as needed for pain. The resident stated that when pain medication was not given, pain increased to an eight on a one-to-ten scale, while with medication the pain was a three. The MAR showed Oxycodone was not administered on 1/30/26 and 1/31/26, with pain ratings documented as nine on both days, and the progress note for 1/30/26 did not document why the medication was not given; the 1/31/26 note stated the Oxycodone was unavailable. The MAR also showed Oxycodone was not administered on 2/15/26 at 8:00 AM and 8:00 PM, with a progress note stating it was unavailable. On 3/3/26, the resident reported pain rated eight out of ten, activated the call light, and told staff pain medication had not been brought. A CNA told the resident she would report the pain to the nurse, and later stated the nurse said it was too early for pain medication. Another LPN told the resident she would notify the nurse about the pain. Staff discussed the pain medication orders, and after clarification with the physician, the resident received Norco at 11:59 AM. The administrator stated the resident did not receive Oxycodone as ordered on 1/30/26, 1/31/26, or 2/15/26, and stated the pain medication should have been given as soon as possible when pain was reported.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
Drugs and biologicals were not properly stored for two residents. For R10, on 3/1/2026 and again on 3/2/2026, a bottle of liquid Mucinex containing dextromethorphan 20 mg, guaifenesin 400 mg, and phenylephrine 10 mg, a roller-ball tube of Aspercream 4% lidocaine, and a can of 4% lidocaine were observed sitting on the over-the-bed table. R10 stated that these items were kept on the over-the-bed table and staff did not remove them from the room. An LPN stated that the Mucinex, Aspercream, and lidocaine should not have been stored on the over-the-bed table and should have been locked in the medication cart. For R51, on 3/1/2026, a medicine cup with a pill inside was observed sitting in the windowsill of the resident's room, and the LPN stated that medications should not be stored in resident rooms.
Failure to Identify and Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to identify a newly admitted resident as an elopement risk and to provide adequate supervision and interventions to prevent elopement. The resident was a 99‑year‑old with severe cognitive impairment documented on the MDS, and an undated care plan listing multiple diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, delirium, COPD, atherosclerotic heart disease, and other significant medical conditions. The care plan also documented current skin impairment, increased fall risk related to gait imbalance requiring a walker and gait belt, impaired cognitive function, impaired communication, impaired hearing requiring hearing aids, and impaired vision requiring glasses. Despite these factors, the initial elopement evaluation was not completed in full before the Social Service Director locked the assessment as completed, which then indicated the resident was not an elopement risk. The resident had a documented unwitnessed fall in the room shortly after admission, with neuro checks ordered for several days, and later a community survival skills assessment showed the resident had no safety awareness or survival skills if outside the facility alone and recommended the resident not be unsupervised outside. On the night of the elopement, the resident was last seen in bed in the room at approximately 11:00 p.m. by an LPN, who reported not hearing any door alarms during the night. The facility’s daily assignment sheet shows that two LPNs and four CNAs were assigned on the overnight shift, but the resident was not identified as missing until the following morning when a CNA arriving for the day shift noticed the resident was not in the room while doing morning vital signs and alerted the LPN. The receptionist reported that there is an elopement alert binder at the front desk identifying residents at risk of elopement and that the front entrance is monitored and locked during certain hours, but the resident had not been properly identified and listed as an elopement risk. As a result of these failures, the resident left the facility unsupervised on foot, without a coat or shoes, during below‑freezing temperatures. The resident was found approximately 0.6 miles away in a restaurant parking lot near two major highways, crouched by a wall, wearing only a T‑shirt, sweatshirt, jeans, and socks, and without a coat, hat, or shoes. Family and staff accounts, along with hospital records, document that the resident had a visible hematoma and laceration on the right forehead, abrasions to both knees, discoloration of the hands, frostbite to both great toes and additional digits, a comminuted fracture of the left great toe, hypothermia, and a urinary tract infection. The resident reported being cold, stated that the wind was very bad, and indicated having fallen several times during the night. The facility’s nurse practitioner stated the resident had poor cognition, was extremely hard of hearing, had poor vision, and no safety awareness, underscoring the resident’s vulnerability at the time of the elopement.
Removal Plan
- Reassess R1 for risk of elopement and community survival skills and update R1's Plan of Care to include current risk of elopement and associated behavioral needs; place R1 on one-to-one observation upon return.
- Review the incident and confirm door alarms/system functional status.
- Review and update the elopement binder.
- Provide Code Pink education and rounding expectations to all staff.
- Assess all residents for risk of elopement and community survival.
- Reevaluate all residents for elopement risk at admission, readmission, quarterly, annually, with significant change, and when at-risk behaviors are identified; assign responsibility; conduct audits and have results reviewed by the administrator or designee.
- In-service all staff regarding wandering/exit-seeking behavior and when to implement increased supervision for residents exhibiting these behaviors.
- In-service all staff regarding door alarms as a required safety measure; ensure alarms are never turned off, silenced, or disabled; require immediate reporting of issues and prompt response; allow the front entrance door alarm to be disabled only when the door is being monitored by staff.
- Conduct an elopement drill.
- Implement an in-servicing plan to include elopement policy, wandering/exit-seeking behavior, and door alarms upon hire and ongoing.
- In-service agency staff regarding Code Pink and rounding expectations prior to working at the facility.
- Hold an ad hoc QA meeting with the IDT regarding the Elopement Policy and Procedure.
- Have the QA committee review elopement policy and procedure as part of the Quality Assurance Process.
- Review elopement during each quarterly meeting for four meetings.
Failure to Supervise High Fall-Risk Resident and Ensure Access to Toileting Aids
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough fall investigation, implement fall interventions, and provide adequate supervision for a high fall-risk resident. The resident had diagnoses including encephalopathy, vascular dementia with behavioral disturbance, anemia, weakness, a history of falls, and a pacemaker, and was documented as moderately cognitively impaired. The MDS showed the resident required supervision with toileting, bathing, dressing, bed mobility, and transfers, and the fall care plan identified the resident as at risk for falls with interventions such as use of a gait belt for transfers and ensuring appropriate footwear. An incident fall assessment documented 1–2 prior falls in the past three months and intermittent confusion. On the date of the fall, nursing documentation showed the resident was found on the bathroom floor after an unwitnessed fall, barefoot and using a walker without assistance, with the call light not used. The resident sustained a forehead laceration, abrasions to the right knee and left foot, and was on blood thinners. Hospital records documented left ankle swelling, a foreign body and laceration of the left fifth finger, and a closed head injury with a hematoma to the right forehead, with the resident noted to have dementia and be a poor historian. Subsequent observations showed the resident repeatedly seated in his room with the urinal placed in the bathroom and not within reach, and the call light lying across the bed and not within the resident’s reach. The resident stated he did not know where his urinal was and that he would just get up and go to the bathroom if needed. CNAs reported hearing a thud and finding the resident on the floor on his right side, barefoot, with the walker on its side and blood on the floor from the finger injury. One CNA stated she had been instructed that the resident did not need assistance walking and that he walked independently with his walker to the bathroom and was not considered a fall risk. Another CNA, who was assigned to the resident on the morning of the fall, stated she had not checked on the resident for a few hours and that the resident got up independently and did not need staff assistance for toileting. The DON stated the resident should have had appropriate footwear and that the intervention for the fall was to place a urinal at the bedside and keep it within reach, but acknowledged she did not interview staff during the fall investigation, did not determine whether the call light was within reach, and did not determine the status of the resident’s footwear at the time of the fall, confirming the fall investigation could have been more thorough.
Failure to Investigate and Follow Up on Resident Grievances About Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and receive prompt resolution regarding bathing and shower services. One cognitively intact resident with multiple fractures and dependence on staff for all ADLs reported not receiving scheduled showers. A concern form documented this resident’s complaint about missed showers and indicated the complaint was only partially substantiated, with an action to monitor shower sheets and check in with the resident on shower days. However, the section for follow-up with the complainant was left blank, and the resident later stated that staff were marking shower sheets as if showers had been provided when they had not, and that no one from management had followed up with him about his grievance. Another cognitively intact resident, who required maximum assistance with toileting, bathing, and dressing, reported not receiving showers or bed baths for weeks. A concern form documented this resident’s complaint of not having had a bed bath and noted that a bath was given the following day, but again the follow-up section with the complainant was left blank. The resident stated staff told her they did not have time or would return to assist with a bath but did not come back. A friend and a family member confirmed that the resident had not been bathed for weeks and that staff repeatedly stated they would get to it but did not. A third cognitively intact resident, also requiring maximum assistance for toileting, bathing, dressing, and bed mobility, reported not receiving showers or bed baths for weeks and stated she had reported this to the DON before Christmas without any response. The facility was unable to provide any concern or grievance documentation for this resident’s report. This resident stated staff told her they did not know how to transfer her with the total body mechanical lift to the shower chair, and another staff member told her they do not provide bed baths or wash hair in bed. Facility leadership later acknowledged that nursing grievances were shared between the DON and ADON, that showers were a known problem, and that no follow-up had been done with these residents regarding their grievances, despite a written grievance policy requiring timely resolution and oversight by a grievance official.
Failure to Identify and Document Intergluteal Cleft Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, document, and report an open wound in a cognitively intact resident who was dependent on staff for all ADLs, including toileting and perineal care, due to bilateral arm fractures in hard casts. The resident’s EMR listed multiple traumatic fractures and functional dependence, and the MDS documented that the resident relied on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. Despite this, the facility wound log did not include an open wound in the resident’s intergluteal cleft. The resident reported that he could not wipe himself and described episodes where staff found old stool during incontinence care, including an instance when a CNA applied cream to an area he described as red, open, bleeding, and very painful. The resident stated that on at least two occasions staff discovered old stool when he had not used the bathroom for several hours or since the prior day. On the date of the surveyor’s interview, the ADON, who oversees the wound program, stated she had not been aware of any skin alterations other than those related to the resident’s initial trauma and later learned from the resident that there had been an unreported open area in the intergluteal cleft that had never been assessed or treated. A CNA confirmed that during a shower she observed the resident’s buttock crease to be open, bleeding, and red, and that she applied an unknown cream from the resident’s room and informed an LPN, but there was no documentation of this wound in the record or on the wound log. The DON and ADON both stated staff should have documented the open area and notified the physician and the ADON per facility policy. The facility’s written policy required CNAs to observe for skin breakdown daily and on bath days, promptly report changes to the charge nurse, and required licensed nurses to initiate and document wound assessments for non-pressure skin conditions, with notification of the resident, representative, and physician at the earliest sign of skin problems. These required assessments, documentation, and notifications did not occur for this resident’s intergluteal cleft wound.
Improper Infection Control During Catheter and Perineal Care
Penalty
Summary
The deficiency involves failures in infection control and proper catheter/perineal care for two residents during incontinence care. One resident with a history of urinary retention and prior UTIs, who was cognitively intact and dependent on staff for most ADLs including toileting, reported fear of getting another UTI and stated staff did not always clean her as often as they should. During observed catheter and perineal care, a CNA provided front perineal care, then walked to the other side of the bed to perform perianal care without changing gloves or performing hand hygiene after handling the trash can. The CNA also did not cleanse the resident’s catheter tubing during care. The CNA later acknowledged she had cross-contaminated the perianal area by not changing gloves and that she should have cleansed the catheter tubing to the junction of the drainage bag tubing. For a second cognitively intact resident with multiple medical diagnoses including CHF, DMII, and a history of UTI, a CNA prepared supplies for catheter/perineal care and had a glove box with several gloves protruding from the top. The CNA accidentally knocked the glove box to the floor, then picked it up, washed her hands, and obtained gloves from the same box to perform catheter/perineal care. The CNA used these potentially contaminated gloves while providing care. During this care, the CNA observed and verbally noted that the resident’s penis was very red, swollen, and sore, and the resident confirmed soreness. The DON later stated that staff should not cross-contaminate during perineal care, that gloves or items that touch the floor are considered contaminated and should not be used, and that existing incontinence/catheter/perineal care policies did not address these specific concerns, although the expectation was that staff would avoid cross-contamination of residents’ perineal areas.
Failure to Identify and Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and report an alteration in skin integrity for a resident at risk for pressure ulcers, resulting in the development of a Stage 2 pressure ulcer on the resident's tailbone. The resident's care plan included interventions for monitoring, turning, and repositioning at least every two hours, and required immediate nurse notification of any new skin breakdown. However, CNA documentation over a one-month period did not note any skin issues, and the Assistant Director of Nursing was unaware of the sore until it was discovered following a fall. The LPN stated that CNAs were responsible for repositioning, but expressed uncertainty about how to reposition a resident in a geriatric chair, which the resident used most of the day. Subsequent assessments by hospice and wound care staff identified a pressure ulcer on the resident's tailbone, with the wound care provider determining it was a Stage 2 ulcer that had developed three to four weeks prior, not as a result of the fall. The facility's own policy required assessment, monitoring, and documentation of skin breakdown, but these steps were not effectively carried out, leading to a failure to prevent the pressure ulcer.
Failure to Provide Adequate Supervision Resulting in Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents who were identified as being at risk for accidents. Both residents had documented histories and care plans indicating fall risk, with one resident having physical limitations, weakness, and cognitive impairment, and the other having Parkinson's disease. Despite these risks, both residents experienced unwitnessed falls resulting in injuries, including localized swelling and a displaced collarbone fracture. Observations and medical records confirmed that both residents were found with significant injuries, such as swelling and discoloration to the forehead, and in one case, a saturated incontinence garment and a bed that was not in the low position as required. Staff interviews revealed that the CNA assigned to the relevant hall was repeatedly found asleep or missing from her assigned area during the night when the falls occurred. The LPN on duty reported being unable to locate the CNA several times and did not observe her performing required rounds. The facility's policy required residents to be observed approximately every two hours to ensure safety, but this was not followed. The CNA involved was later terminated for failure to adhere to facility standards. The lack of supervision and failure to follow established protocols directly contributed to the residents' falls and subsequent injuries.
Failure to Maintain Clean and Safe Resident Bathroom
Penalty
Summary
A private bathroom with a shower shared by two residents was observed to have a slimy, fuzzy, black material resembling black mold on the grout line above the shower head and where the ceiling meets the drywall. The affected areas measured approximately 5 inches by half an inch and 12 inches by 6 inches, respectively. A housekeeper confirmed that the black substance had been present for an extended period and stated that a work order had been submitted, with maintenance being aware of the issue. However, the administrator later reviewed records from the past three months and found no evidence of a work order being submitted for this problem. Both the administrator and a corporate administrator verified the presence of the black material during their inspection.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as high risk for falls. The facility's Fall Prevention Program policy outlines the need for individualized assessment and implementation of appropriate interventions, but in this case, the resident's care plan only included ensuring appropriate footwear and did not address other necessary fall prevention measures. Multiple staff members, including CNAs and nursing staff, confirmed that no additional fall interventions were in place, aside from occasionally placing the bed in a low position. The care plan coordinator acknowledged that more interventions should have been included, and the regional nurse consultant cited an IT issue that contributed to the lack of interventions. The resident had a medical history of repeated falls, weakness, and partial paralysis on one side of the body following a stroke, and was assessed as high risk for falls. The Minimum Data Set (MDS) assessment indicated the resident required partial to moderate assistance with toileting hygiene. Despite these risk factors, the resident was found on the bathroom floor by a CNA, and subsequent medical evaluation revealed multiple left-sided rib fractures, a collection of blood in the chest cavity, and a collapsed lung. The resident's condition worsened, as documented by follow-up imaging. Interviews with staff confirmed that the resident was known to be at high risk for falls, but there was a lack of communication and implementation of fall prevention interventions. The Director of Nursing and the former Medical Director both stated that having proper fall protocols and precautions in place could have changed the outcome for the resident. The deficiency was attributed to the failure to assess and implement appropriate fall prevention measures as required by the facility's own policy.
Failure to Identify, Treat, and Prevent Worsening of Pressure Ulcer
Penalty
Summary
A resident with a history of pressure ulcers, paraplegia, urinary tract infection, and osteomyelitis was admitted to the facility with existing Stage Four pressure ulcers on the right ischium and left knee. The resident was identified as high risk for developing additional pressure ulcers and was dependent on staff for bed mobility, toileting, dressing, and required maximum assistance with bathing and personal hygiene. Despite these risk factors, the facility failed to promptly identify and treat a newly acquired sacral pressure ulcer, which was first documented as a Stage Two ulcer and rapidly progressed to Stage Four with significant necrotic tissue. There was a delay in obtaining and implementing physician orders for the sacral ulcer, as the wound was identified on 4/7/25 but treatment orders were not entered into the electronic medical record until 4/11/25. During this period, no treatment was provided for the sacral ulcer, and the care plan was not updated to reflect the new wound. The wound nurse acknowledged forgetting to obtain and implement the necessary dressing orders, and communication between floor nurses and the wound nurse regarding the new wound was lacking. Documentation confirmed that no treatment was provided for the sacral ulcer prior to the entry of orders. Observations revealed that the resident was not consistently provided with pressure-relieving interventions, such as off-loading with pillows or blankets, despite facility policy requiring dependent residents to be turned and positioned approximately every two hours. Staff interviews indicated that residents, including the affected individual, often waited longer than two hours to be repositioned due to staffing constraints. The resident experienced significant pain associated with the sacral ulcer, particularly during dressing changes, and was observed without appropriate off-loading devices in place.
Failure to Ensure Safe Transfer Practices and Adequate Supervision
Penalty
Summary
The facility failed to provide safe transfer practices for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. One resident with hemiplegia, left foot drop, and cognitive intactness was transferred by a CNA without the use of a gait belt and without a second staff member, despite care plan requirements. The CNA was also using earbuds and talking on the phone during the transfer, which led to the resident sustaining a skin tear on her left lower leg. The incident was not documented in the nurse's progress note, and the care plan was not updated to reflect the injury or provide interventions for the skin tear. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, required two-person assistance and a mechanical lift for transfers. On the day of the incident, two CNAs used the wrong sling configuration during a transfer, placing the long ends of the sling at the resident's head instead of crossing them between the legs. This improper use of equipment created a risk of the resident falling from the lift. The resident was also left sitting in a wheelchair for nearly three hours, resulting in significant skin breakdown and complaints of pain, as staff were unable to meet resident needs promptly due to low staffing levels. Facility policy mandates the use of a gait belt for all physical transfers and requires a mechanical lift for residents needing two-person assistance. Staff interviews confirmed that these policies were not followed, and that care plans were not reviewed or updated as required. The failures in following transfer protocols and providing timely care directly contributed to the residents' injuries and discomfort.
Failure to Prevent and Manage Pressure Ulcers Under Immobilizers and Inadequate Wound Assessment
Penalty
Summary
The facility failed to properly identify, assess, intervene, and treat pressure wounds for three residents, resulting in the development of facility-acquired unstageable wounds, particularly under immobilizers. According to the facility's own policy, daily skin checks and prompt reporting of skin changes are required, but these procedures were not consistently followed. For one resident, a pressure ulcer developed on the right calf under an immobilizer, and the wound nurse confirmed that the immobilizer was not removed for daily skin checks. Additionally, the same resident had an undocumented wound on the buttock that the wound nurse was unaware of, indicating a breakdown in communication and documentation. Another resident was admitted with a deep tissue injury on the right buttock, which remained unchanged in size for several weeks according to wound assessments. However, on observation, the wound was found to be larger and covered with slough, and the wound nurse applied zinc paste directly to the wound without a physician's order or notification of the wound's change in condition. The first treatment order for this wound was not obtained until several days after the wound's deterioration was observed, demonstrating a delay in appropriate intervention and physician notification. A third resident, who was dependent on staff for activities of daily living and assessed as high risk for pressure ulcers, developed a facility-acquired pressure ulcer on the right lower extremity under a leg immobilizer. Physician orders required skin checks under the immobilizer every shift, but the treatment administration record showed multiple days where these checks were not documented, despite the resident being present in the facility. The wound nurse admitted to not reviewing the treatment record for compliance with skin checks and was unaware of missed documentation, further contributing to the failure to prevent and manage pressure ulcers as required.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident identified as being at risk for pain was not provided with effective and timely pain management. The resident had a physician's order for Tramadol-Acetaminophen to be administered every 8 hours as needed for moderate pain, and the care plan included interventions to administer pain medications and evaluate their effectiveness. However, the facility failed to ensure the medication was available, resulting in the resident running out of the prescribed pain medication. Documentation showed the last dose was given on 4/15/25 at 7:00 AM, and no further doses were available after that time. As a result of the medication not being refilled in a timely manner, the resident experienced significant pain, reporting pain levels as high as 8 out of 8 and was observed grimacing and unable to move comfortably. The resident canceled a doctor's appointment due to pain and had to rely on non-prescribed interventions such as positioning for comfort. Staff interviews confirmed that the medication had run out and that agency nurses did not request a refill or new orders. The DON acknowledged that the prescription should have been refilled when four doses remained, but the facility did not attempt to refill it until after the medication was depleted.
Failure to Maintain Comprehensive Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain a comprehensive Infection Prevention and Control Program, as required by policy and regulatory guidelines. The Director of Nursing (DON) was initially identified as the Infection Preventionist but clarified that she did not hold this role and lacked the necessary infection control training and certification. Instead, a nurse from another facility, who also serves as an Administrator elsewhere, was designated as the Infection Preventionist and only present one day per week. This individual reported being unable to complete essential duties such as staff education due to limited time on-site and was unaware of residents on prophylactic antibiotics. The facility's infection surveillance and tracking practices were not fully implemented, as required by their own policy. Additionally, there were lapses in infection monitoring for residents on prophylactic antibiotics. One resident had a physician's order for Bactrim for urinary tract infection (UTI) prophylaxis, and another had an order for daily Cephalexin for prophylactic use. However, the medical record for the latter did not contain an assessment or care plan to support the use of a prophylactic antibiotic. The Regional Nurse Consultant was unable to locate documentation justifying this antibiotic use. These deficiencies in infection prevention oversight and documentation had the potential to affect all 63 residents in the facility.
Improper Storage and Administration of Medications
Penalty
Summary
Facility staff failed to properly store and administer medications according to policy and professional standards. Medications were observed left at the bedsides of four residents, with some residents stating they had not yet taken the medications, and in one case, a family member identified a specific pain medication left unattended. Additionally, pre-poured medications were found in a medication cart without any identifying labels, and the responsible nurse could not recall which medications were in the cup. The facility's Medication Administration Policy prohibits pre-pouring medications and requires that medications be administered as they are poured. Interviews with nursing staff and the Director of Nursing confirmed that medications should not be left at the bedside or in the cart and should be administered directly to residents. Medication administration records indicated that controlled substances and other prescribed medications were documented as given, despite being left unattended. These actions were observed for four residents, and staff acknowledged awareness of the correct procedures but did not follow them during the incidents.
Failure to Document and Implement Resident's Advance Directive and DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their advance directive wishes accurately documented and implemented. Upon admission, the resident expressed a desire to be a Do Not Resuscitate (DNR) and signed an Advance Directive form. Both the resident and staff confirmed these wishes. However, the resident's physician orders did not include any documentation of the Advance Directive, and the care plan was not updated to reflect the resident's DNR status. The facility's policy requires that a written physician's order be included in response to advance directives and that this information be incorporated into the care plan. Despite the resident's wishes and the facility's policy, there was no POLST (Physician Orders for Life-Sustaining Treatment) form or Advance Directive present in the resident's electronic health record or in the code status binder at the nurse's station. Staff interviews confirmed that the POLST form had been sent to the physician for signature but had not been returned or uploaded into the system. As a result, the resident would be considered a full code and would receive CPR, contrary to their stated wishes.
Failure to Follow Two-Person Mechanical Lift Transfer Protocol
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for transfers, was transferred using a sit-to-stand mechanical lift by only one Certified Nursing Assistant, despite the resident's care plan specifying that two staff members were required for such transfers. The incident was observed while the resident was being moved from the toilet to a wheelchair. Interviews with two Licensed Practical Nurses and another Certified Nursing Assistant confirmed that facility protocol and the resident's care plan required two staff members for mechanical lift transfers. The failure to follow the care plan and facility policy resulted in the resident being transferred without adequate supervision.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its Mechanical Lift Policy, which mandates the presence of two staff members during a mechanical lift transfer. This policy breach occurred when a Certified Nursing Assistant (CNA) assisted a severely cognitively impaired resident, identified as R1, in transferring from bed to wheelchair using a mechanical lift without the assistance of a second staff member. This incident led to R1 sustaining an oblique displaced fracture of the distal right femur, necessitating hospitalization and surgical intervention. The incident was documented in the resident's Nurse Progress Note, which detailed that R1 began experiencing leg pain shortly after the transfer. The Licensed Practical Nurse (LPN) on duty assessed R1 and observed that the resident's right leg appeared displaced. Despite the absence of any recent falls or trauma, the orthopedic surgeon later suggested that the fracture might have occurred during the transfer. The resident's family member expressed concerns about the lack of communication from the facility regarding the incident.
Incomplete Fall Risk and Post-Fall Assessments
Penalty
Summary
The facility failed to adhere to its Fall Prevention- Steady Steps policy, resulting in incomplete fall risk assessments and post-fall monitoring for three residents. The policy mandates that residents be evaluated for fall risk upon admission, quarterly, and after significant changes in condition, using the MAHC-10 Fall Risk Assessment Tool. Additionally, post-fall interventions require immediate and 72-hour monitoring, including neuro checks for unwitnessed falls or head injuries. However, the records for three residents showed missing or incomplete fall risk assessments and post-fall documentation. One resident experienced multiple falls, with missing fall risk assessments and incomplete post-fall follow-up notes. Another resident's records lacked the required fall risk assessments upon admission and readmission. A third resident's records were missing both the admission fall risk assessment and a quarterly evaluation, along with incomplete post-fall follow-up notes for several incidents. The facility's staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed these deficiencies in the residents' medical records.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care for two residents, leading to significant deterioration in their conditions. One resident, with a history of Alzheimer's Disease, Parkinson's Disease, and other medical conditions, developed an open wound on her left elbow that was not promptly reported to her physician. Despite being at moderate risk for skin breakdown, the resident's care plan did not include specific interventions for the pressure sore until several days after it was first noted. The wound progressed to an infected stage 4 pressure sore, requiring hospitalization, surgery, and intravenous antibiotics. The facility's nursing staff did not consistently monitor or document the condition of the wound, and there was a delay in notifying the physician and obtaining appropriate treatment orders. Another resident, who was admitted with a high risk for pressure ulcers, developed a deep tissue injury on her right heel that was not immediately reported to the physician. The facility's initial assessment did not identify any pressure areas, and the resident's care plan was not updated with appropriate interventions until several days after the injury was discovered. The delay in treatment contributed to the deterioration of the injury into an unstageable pressure sore. The facility's staff failed to notify the physician promptly, and there was a lack of consistent monitoring and documentation of the resident's condition. The facility's policies required that changes in a resident's condition, such as the onset of pressure ulcers, be reported to the attending physician and responsible party. However, in both cases, the facility did not adhere to these policies, resulting in inadequate care and worsening of the residents' conditions. The facility's failure to provide timely and appropriate pressure ulcer care led to significant harm to the residents, highlighting deficiencies in communication, documentation, and adherence to care protocols.
Removal Plan
- The facility completed skin audits of 100% of the residents.
- Administrator and the Interdisciplinary Nursing Team inserviced licensed nursing staff on Wound Protocols, Change of Condition, Skin Evaluations, Pressure Ulcer Risk Evaluations, Wound assessment and management and Skin Check Policy.
- Administrator and the Interdisciplinary Team inserviced Certified Nurse Aides on Skin Checks and following the resident careplan.
- A Quality Assurance Performance Improvement (QAPI) Ad hoc meeting was held for QAPI team to discuss concerns and plan of action.
- Senior President of Operations, who is wound care certified, provided training to current Wound Nurse/Licensed Practical Nurse (LPN).
- Weekly assessments of all skin conditions and pressure injuries were completed. Wound Physician completed weekly wound assessments/treatments.
- Clinical Documentation Specialist confirmed daily clinical meetings have occurred and will continue.
- Interim DON stated she has reviewed all residents with skin alterations and Wound Physician will review all residents with any kind of skin alteration on an ongoing basis.
- Administrator stated daily and weekly clinical meetings have been completed and will be ongoing.
- Audits of five residents per week for pressure interventions have been completed and will be ongoing. Audits of three residents per week for any skin conditions have been completed and will be ongoing. Monthly skin audits were initiated and will be ongoing.
- All new agency and/or new hire nursing staff were to be provided training.
- Annual and as needed training conducted by Wound Nurse and/or Interim DON will be ongoing.
Facility Fails to Implement Required CNA Training Program
Penalty
Summary
The facility failed to implement a comprehensive staff training program for Certified Nurse Aides (CNAs) on essential topics such as Communication, Resident Rights, Abuse, Quality Assurance Performance Improvement (QAPI), Infection Control, Compliance and Ethics, and Behavioral Health. This deficiency was identified through interviews and record reviews, revealing that five CNAs (V26, V27, V28, V29, V30) had not completed the required training in the past twelve months. The facility's Course Completion History did not document these trainings as completed for the CNAs, despite their active roles in providing direct care to residents. The facility's administrator, V1, acknowledged the absence of documentation for the required trainings and confirmed that CNAs V26, V27, and V30 had recently worked at the facility, while V28 and V29 had not worked for two months but were previously providing regular care. The administrator also admitted that there was no specific policy for the training, although it was expected that staff be trained to understand the resident care model. This lack of training documentation and policy potentially affects all 55 residents residing in the facility.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) completed the required minimum of twelve hours of education annually, which includes training in dementia care and abuse prevention. This deficiency was identified through interviews and record reviews, revealing that the CNAs had not met the educational requirements. Specifically, one CNA completed only five hours, another completed four hours, two others completed four and zero hours respectively, and the last CNA also completed zero hours of required inservices in the past twelve months. The facility's administrator acknowledged the lapse in monitoring CNA trainings, attributing it to a change in the Human Resources (HR) position. The administrator confirmed that the facility was unable to provide documentation of the required educational trainings for the CNAs. This failure has the potential to affect all 55 residents residing in the facility, as the lack of adequate training could impact the quality of care provided to them.
Failure to Notify Physician and POA of Pressure Sores
Penalty
Summary
The facility failed to notify the physician and the resident's Power of Attorney (POA) about the development and worsening of pressure sores for two residents. Resident 1, who has severe cognitive impairment and multiple medical conditions including Alzheimer's and Parkinson's Disease, developed an open wound on the left elbow. The wound was first documented on 8/13/24, but neither the physician nor the POA was informed. The POA discovered the wound on 8/24/24, noting its severe condition with visible bone and drainage. The facility administrator and medical director acknowledged that the physician should have been notified earlier to prevent the infection from worsening. Resident 4, also severely cognitively impaired, was admitted with intact skin but developed a deep tissue injury (DTI) on the right heel, identified on 8/24/24. Although the POA and on-call manager were informed, the physician was not notified until 9/10/24. The facility's policy requires notifying the physician and responsible party of any significant change in condition, including pressure ulcers. The regional director and registered nurse admitted the oversight, and the medical director emphasized the need for timely physician notification to obtain treatment orders.
Failure to Review Infection Control Policies Annually
Penalty
Summary
The facility failed to review their Infection Control policies annually, which has the potential to affect all 60 residents residing in the facility. The 'Infection Surveillance' policy was last approved on 11/1/17, with no further review or revision dates. Similarly, the 'Antibiotic Stewardship' policy was also last approved on 11/1/17 without any subsequent reviews. The 'Guidelines for Infection Surveillance Procedures for Infection Preventionist' were dated 2020, but the specific month was unspecified. The 'Pneumococcal Vaccines' policy was dated 3/2022, and the 'Covid Vaccination' policy was approved on 11/29/21, with the most recent review for resident immunizations documented on 2/15/23. Despite these dates, there was no documented proof that these policies were reviewed annually at the QA meetings. On 05/16/24, the Infection Preventionist stated that they had asked the Administrator and the Regional Clinical Director about the infection control policy reviews but received the same policies without any updated review dates. The Administrator confirmed on 05/17/24 that they were aware of the concern and had scheduled a QA meeting for the following week to conduct the reviews. However, they could not provide any more recent review dates for the policies in question. This lack of annual review documentation was identified during the survey, highlighting a significant deficiency in the facility's infection control program.
Failure to Document Fluid Intake and Output for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to document fluid intake and output for a resident with an indwelling urinary catheter, as required by the facility's policy and the resident's care plan. The resident, who was admitted with chronic kidney disease, bladder neck obstruction, and diabetes mellitus, had a history of urinary tract infections and was observed with an indwelling urinary catheter. Despite the care plan's directive to monitor and document intake and output, the resident's medical records, including the Medication Administration Record and Treatment Administration Record, lacked documentation of fluid intake and output. Additionally, the Certified Nursing Assistants Task Sheet showed that fluid output was only recorded for 6 out of 36 shifts, with no documentation of fluid intake at all. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the lack of documentation. The facility's policy on Intake and Output Measurement mandates that residents with indwelling catheters have their intake and output measured and documented every eight hours, with a 24-hour total and weekly evaluation. This policy was not followed, leading to a deficiency in the care provided to the resident, as the necessary monitoring and documentation were not performed consistently or accurately.
Failure to Prevent Cross-Contamination During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to prevent cross-contamination during pressure ulcer treatment for a resident with multiple pressure ulcers. The resident had a Stage III pressure ulcer on the sacrum, a Stage II pressure ulcer on the left heel, and a Deep Tissue Injury on the right heel. During a dressing change, the Registered Nurse (RN) applied medihoney ointment directly from the tube to the wounds without using an applicator, contaminating the ointment tube. The RN then used the same contaminated ointment tube on the resident's other wounds, thereby cross-contaminating them. This action was against the facility's policy, which requires the use of separate applicators for each wound to prevent contamination. The incident was observed and confirmed by the facility's Regional Clinical Consultant Nurse, who acknowledged that the RN should have used a separate applicator for each wound. The RN admitted to the mistake, stating that she was trying to ensure a good amount of ointment was applied to the wound beds. The facility's policy on aseptic treatments and dressing changes clearly outlines the need to prevent contamination and trauma to the wound or periwound areas, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 184 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Forsyth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab Of Rock Springs, The | 3.6 mi | ★★★★★ | 5 | 0 |
| Loft Rehab Of Decatur | 3.6 mi | ★★★★★ | 12 | 0 |
| Decatur Rehab & Health Care Ct | 5.8 mi | ★★★★★ | 0 | 0 |
| Fair Havens Senior Living | 6.9 mi | ★★★★★ | 36 | 1 |
| Imboden Creek Senior Living | 7.3 mi | ★★★★★ | 34 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Arc At Hickory Point.
100% money-back within 48 hours.
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.