Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Center Home Hispanic Elderly during CMS and state inspections, most recent first.
The facility failed to provide sufficient licensed nursing staff to meet resident needs, as evidenced by an LPN on one floor being responsible for 37 residents and reporting consistent delays in completing BP checks, blood sugar monitoring, medication administration, and assessments. The staffing coordinator acknowledged that only one nurse was working on a floor when two were typically planned, and staffing sheets on multiple days showed only one nurse per floor despite a census exceeding 115 residents. The DON stated the facility was not short-staffed and that one nurse per floor was considered adequate, denying awareness of late medications. However, a resident’s MAR audit showed several 08:00 medications, including cyclobenzaprine, metformin for DM2, and budesonide-formoterol for chronic respiratory failure with hypoxia, were administered around noon, despite the resident’s care plan requiring diabetes medications as ordered and monitoring for effectiveness. The facility assessment documented an average census of about 116 and an expected average of six licensed nurses on day and evening shifts and three on nights, with staffing to be based on acuity, which did not consistently match the actual staffing documented.
Surveyors found that kitchen staff failed to label and date a bag of diced turkey ham in a freezer and did not follow posted manufacturer instructions for manual utensil sanitizing in a three-compartment sink. A cook preparing a puree meal washed and rinsed utensils without filling the rinse compartment, rinsed items under running tap water instead of immersing them, did not maintain the required sanitizer contact time, and reused utensils without allowing them to air dry. The head cook, dietary supervisor, and administrator all acknowledged that food items should be labeled and dated upon entry and that all three sink compartments should be filled to the indicated levels, with utensils fully submerged in sanitizer for the specified time and then air-dried before reuse. At the time of the survey, most residents were receiving food prepared in this kitchen.
The facility failed to follow its Waste Management policy by not properly maintaining its dumpster area. Surveyors observed one dumpster without a lid in place, two dumpsters overfilled so their lids could not close, and multiple latex gloves on the ground. Staff, including the head cook, dietary supervisor, and maintenance director, acknowledged that dumpsters were full, not covered, and that the area should be kept clean with lids closed and trash inside the dumpsters, consistent with facility policy requiring trash containers to be emptied when full, liners tied and placed in dumpsters, and lids kept closed.
Surveyors identified that the facility failed to maintain current infection control policies and an active water management plan, and did not follow its own housekeeping and linen procedures. Multiple infection control, linen, and antibiotic stewardship policies were several years out of date and not reviewed annually, and the water management plan had expired, with water temperature logs not readily available when requested. In the laundry and clean linen areas, a wall‑mounted fan and a portable fan were visibly dusty while operating near wet and clean linens, contrary to facility policies requiring clean equipment, daily housekeeping, and protection of clean linen from contamination.
Surveyors found that the facility did not follow its own immunization policies for both residents and staff. Several residents lacked any documented COVID-19 vaccination, and one had no immunization documentation at all, despite policy requiring assessment and documentation of immunization history and offering flu, pneumococcal, and COVID-19 vaccines upon admission. The Infection Control Preventionist acknowledged that these residents had not yet been included in the vaccination process. Human Resources reported that the facility does not offer COVID-19 vaccines to staff who are unvaccinated but want vaccination, and review of staff records showed multiple CNAs, an RN, an LPN, and other staff were not included in COVID-19 vaccination screening, with an LPN providing direct care not offered a COVID-19 booster dose.
Surveyors found that two rooms on a floor housing many residents with dementia were left unlocked, despite one being a trash room and the other a clean utility room posted for employees only. The trash room contained full sharps containers, trash, and dirty linen, while the clean utility room contained multiple packs of disposable razors, mouthwash, personal care items, adult briefs, gloves, gowns, urinals, oxygen tanks, and an IV pole. An RN, the Maintenance Director, and the Administrator all acknowledged that residents should not have access to sharps, razors, trash, or discarded medications, and the facility’s sharps policy required storage in areas not considered a risk to residents.
The facility failed to ensure timely medication administration and proper controlled substance accountability. On multiple occasions, an LPN and an RN on an upper floor did not complete morning med passes within the one-hour before/after window, and the eMAR showed numerous late doses in red, with one nurse acknowledging she had not documented administered meds. Audit reports confirmed multiple residents received medications late. Separately, review of the controlled substance shift-change records for a first-floor med cart showed missing nurse signatures on several first, second, and third shifts, despite policy requiring two licensed nurses to perform and document narcotic counts at each shift change, affecting residents on that unit.
Surveyors observed multiple medication administration errors resulting in a medication error rate above 5%. During a med pass, nurses gave incorrect doses of vitamin D preparations, substituted one vitamin D product for another, and failed to administer ordered medications including a cough medication, a topical antifungal cream, a topical calamine-zinc lotion, and an antidepressant prescribed for MDD/GAD, with staff citing medication unavailability and pending pharmacy reorders. In another case, a stool softener was administered at double the ordered dose. These actions and omissions conflicted with the facility’s policy requiring adherence to the five rights of medication administration.
Surveyors found that open house stock and resident-specific medications on two 3rd floor medication carts were not managed according to facility policy. Open bottles of Diphenhydramine with past manufacturer expiration dates were stored in the carts, an open Sodium Chloride bottle lacked a visible expiration date, and open Acetaminophen and Melatonin bottles had no open dates. Two open liquid Megestrol Acetate bottles for a resident also lacked open dates. An LPN confirmed that expired medications should be discarded, that medications without known expiration dates would not be safe to administer, and that all opened house stock and liquid medications must be dated when opened, consistent with the facility’s Medication Administration Policy.
The facility did not follow its immunization policy and CMS/CDC guidance for offering and documenting influenza and pneumococcal vaccines for four residents. Record review showed that one resident had no vaccination documentation at all, and three residents had only Mantoux TB skin tests recorded, with no influenza or pneumococcal immunizations noted. The Infection Control Preventionist confirmed there was no documentation that these vaccines were offered, despite facility policy requiring assessment and documentation of immunization history within 72 hours of admission and that flu, pneumococcal, and COVID-19 vaccines be offered upon admission as part of infection prevention.
A resident with severe cognitive impairment, dementia, and behavioral disturbances, identified as a wanderer and elopement risk, was not adequately monitored and did not have care plan interventions implemented. The resident was observed sitting for an extended period on another resident’s bed, while a CNA and an LPN acknowledged that the resident frequently wanders into other residents’ rooms and needs constant redirection, and that the room is located out of direct view of the nurses’ station. Required elopement precautions, including a photo at the nurses’ station and reception and inclusion on the reception elopement-risk list, were not in place, and the resident was not wearing a wander guard, despite staff stating these measures were expected per the care plan and facility policies on resident rights and supervision and safety.
The facility failed to initiate new PASRR Level I screenings and Level II referrals for two residents who developed new serious mental illness diagnoses during their stays. One resident, originally screened as not having SMI/ID/RC, later received diagnoses of delusional disorder, generalized anxiety disorder, and major depressive disorder, exhibited paranoid delusions, was started on quetiapine, and had MDS indicators of psychosis and delusions, yet was not re-referred for PASRR. Another resident, with severe cognitive impairment, was newly diagnosed with delusional disorder and dementia with psychotic disturbance, was treated with quetiapine for dementia with psychosis and paranoid delusions, and showed behavioral disturbances, but no new PASRR screening or Level II referral was completed. The Social Services Director acknowledged responsibility for monitoring new psychiatric diagnoses and stated that both residents should have been re-screened under facility policy but were missed due to oversight.
A resident with bipolar disorder, alcohol abuse, and on antipsychotic therapy was admitted with a PASRR Level I screen that triggered a required Level II evaluation, which granted only short-term approval without specialized services and specified an end date and timeframe for submitting a new Level I screen if continued stay was needed. The Social Service Director acknowledged that the short-term approval expired and that he failed to request a new PASRR screening because it did not trigger in his computer system, despite facility policy requiring compliance with PASRR regulations and review of PASRR documents to assess resident needs.
A resident reported having been prescribed eyeglasses on two separate visits to an eye doctor and stated that facility nurses lost the prescriptions both times, leaving the resident without needed corrective lenses. The social services assistant confirmed the resident’s reports that a prescription had been given to an escort and said social services never received it, and her review of the facility’s electronic bulletin board did not show the eye appointment, despite facility documentation indicating that an eye doctor visit had been scheduled. An eye clinic receptionist verified that the resident was seen, prescribed eyeglasses for reading and distance, and that the escort was informed of the prescription and need to contact insurance, while an LPN’s progress note documented the resident’s return from the eye center “without any order,” demonstrating the facility’s failure to follow physician orders and assist the resident in obtaining corrective lenses.
A resident with COPD and acute/chronic respiratory failure, ordered oxygen at 2–4 L/min via NC and requiring partial/moderate assist with mobility, was found with oxygen concentrator tubing uncovered and lying on the floor next to the bed. The DON reported that facility policy requires oxygen tubing to be changed weekly, kept in bags when not in use, and not placed on the floor, and written oxygen equipment guidelines specify that oxygen must be administered under maintained infection control conditions with tubing/masks covered when not in use. The observed condition of the tubing did not comply with these infection control requirements.
A resident with moderate cognitive impairment and a sacral pressure ulcer did not receive daily wound care as ordered, with missed treatments documented on multiple dates. Staff interviews and record review confirmed that wound care was not performed or documented according to facility policy, resulting in a deficiency related to wound care management.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents.
A resident with a history of falls, cognitive impairment, and lack of coordination sustained serious facial injuries requiring sutures after falling during a shower when left briefly unattended by CNAs. Additional lapses in supervision were observed, including a CNA inattentive to resident calls for help and two high fall risk residents left unsupervised in an activity room, all contrary to facility policy.
A facility-wide deficiency occurred when mechanical equipment, specifically the hot water mixing valve and boiler, failed, resulting in the loss of hot water for all residents. Multiple sinks and showers were found with water temperatures below regulatory standards or with no water supply. The Maintenance Director and Corporate Project Manager identified equipment failure and difficulties in obtaining the correct replacement parts, while the Administrator instructed staff to provide alternative hygiene care. The facility lacked a preventative maintenance program for plumbing, and temperature logs confirmed prolonged inadequate hot water.
A facility failed to provide adequate supervision for three high-risk residents, resulting in multiple unwitnessed falls and injuries. Despite being identified as high risk, the residents were not closely monitored, leading to falls during times when staff were on break or not present. The facility's lack of sufficient staff coverage and failure to implement necessary safety measures contributed to the incidents.
The facility failed to ensure call lights were within reach for nine residents, as observed during a survey. Residents were found in various positions, such as in bed or in a wheelchair, with call lights placed out of reach. Staff members acknowledged that call lights should be within reach, especially for those at risk for falls. The facility's policy on call light placement and fall prevention was not adhered to, as evidenced by the observations.
A former CNA at an LTC facility took inappropriate photos of a resident with severe cognitive impairment and shared them with a group of CNAs via text. The resident was found in a vulnerable state, and the CNA claimed she was unaware of the prohibition against sharing such images due to a lack of training and language barriers. The incident was reported, and the CNA was terminated for HIPAA and resident rights violations.
A facility failed to conduct a thorough investigation into an alleged verbal abuse incident involving a resident. The investigation, led by the Former Administrator, lacked essential details and did not involve social services or interviews with additional staff and residents who interacted with the accused CNA. The facility's policy requires comprehensive interviews to determine any prior incidents, which was not adhered to, resulting in a deficiency.
A facility failed to follow a care plan and address a dietician's recommendations for a resident with complex medical conditions, including severe cognitive impairment and chronic kidney disease. Despite repeated requests for follow-up labs to monitor hydration status, the nursing department did not act on these recommendations. The lack of communication and follow-up resulted in inadequate care for the resident.
The facility failed to provide adequate restorative care for residents due to staffing shortages, resulting in unmet needs for range of motion exercises. A resident with hemiplegia was not receiving necessary therapy, and another with mobility issues reported inconsistent care. Restorative aides were frequently reassigned, leaving CNAs to perform exercises, which were not consistently documented.
A facility failed to provide adequate nursing staff, resulting in care deficiencies for residents. On one floor, only three CNAs were available for 40 residents, leading to missed restorative care and improper monitoring of personal refrigerator temperatures. Several residents experienced issues such as unlabeled g-tube feeding bags, unchanged incontinence briefs, and medication administration errors. The facility did not utilize agency staff despite having a contract, and restorative staff were frequently pulled from their duties to cover shortages.
The facility failed to maintain food safety and hygiene standards, affecting 111 residents receiving oral nutrition. Staff did not perform hand hygiene upon entering the kitchen, and temperature logs for food storage were incomplete. A gallon of milk lacked an open date, and a dietary aide's hair was not fully covered. The kitchen drain was clogged, causing water backflow, and the ceiling paint was disintegrating. Sanitation logs were incomplete, indicating lapses in maintaining a safe environment.
The facility failed to properly dispose of garbage, resulting in an overflowing dumpster with an open lid. The Dietary Supervisor observed the issue, noting that the trash bags were from the Dietary department, while the Maintenance department was responsible for the dumpster. The Maintenance Director confirmed the importance of keeping the lid closed to prevent pest migration. Facility policies require the dumpster lid to be closed and all trash bags to be inside to prevent infection spread.
The facility failed to implement proper infection control measures, including inadequate isolation signage for a resident with ESBL and lapses in hand hygiene during dining services. A chaplain entered the resident's room without PPE due to improperly secured signs, and a CNA did not sanitize hands between tasks. These deficiencies could impact all residents, including those with severe cognitive impairments and various health conditions.
The facility failed to follow its policy on self-administration of medication, affecting three residents. Medications were found at residents' bedsides without proper labeling or documentation, and there were no physician orders or care plans for self-administration. The Director of Nursing acknowledged the importance of assessments, which were not conducted as required.
The facility failed to administer and document medications on time for several residents, with medications being dispensed hours after their scheduled times. An LPN acknowledged inefficiency, and the EMAR system highlighted these delays. The DON was present but did not assist, and a nurse reported a resident's consistent refusal of medications without timely documentation.
The facility failed to ensure a safe environment for residents, as observed by surveyors. A resident's room contained a cup with an unidentified gold liquid, suspected to be soap, posing a risk if ingested. Another resident had razors on their nightstand, with staff unaware of proper disposal policies. The DON confirmed that residents should be supervised while shaving, and razors should be discarded in a sharps container. These oversights could affect all residents on the unit.
The facility failed to securely store controlled medications and properly label insulin and eye medications. Controlled drugs for two residents were found in an unlocked refrigerator, and insulin and eye medications for four residents lacked open and expiration dates. An expired insulin pen was also found on a medication cart. The facility lacked a policy for controlled substance storage, contributing to these issues.
The facility failed to properly monitor and maintain residents' personal refrigerators, leading to unsafe storage conditions. Several refrigerators lacked daily temperature logs, had temperatures outside the safe range, and showed ice build-up. Staff were unclear about their responsibilities and the required temperature range, affecting residents with chronic conditions like COPD and asthma.
A facility failed to provide a homelike environment by not replacing missing window coverings for a resident, affecting their comfort and privacy. The resident, who has moderate cognitive impairment and other health conditions, was exposed to direct sunlight due to missing vertical blinds on one window. The Maintenance Director acknowledged the issue but had not replaced the blinds despite conducting regular rounds. Facility policies emphasize maintaining a safe and comfortable environment, which was compromised in this instance.
The facility failed to provide necessary ADL assistance to three residents with self-care deficits. One resident with dementia and hemiplegia was observed with poor personal hygiene, while another with dementia had a soiled brief and an untouched meal tray out of reach. A third resident was left in bed in a nightgown, with no clear indication of recent care. These observations indicate a lack of adequate personal care and feeding assistance for residents requiring support.
The facility failed to ensure proper pressure ulcer care and equipment management for three residents. A resident's low air loss mattress was found unplugged, risking exacerbation of an unstageable wound. Another resident lacked PRN wound care orders, and their dressing was improperly maintained. A third resident's wound care orders were not transcribed, leading to inadequate management of stage 2 wounds on both buttocks.
A facility failed to follow its gastrostomy feeding policy by not labeling a g-tube feeding bag with the required information, such as the resident's name, type of feeding, date, and time. A nurse admitted to hanging the bag without labeling it, contrary to the facility's policy.
The facility failed to properly label, date, and contain oxygen equipment for two residents, leading to potential infection control issues. A resident with COPD and another with cardiac arrhythmia were observed with oxygen tubing touching the floor and not stored in bags, contrary to facility policy. Staff acknowledged the importance of proper storage to prevent contamination.
A facility failed to obtain a physician's order for a resident requiring dialysis, despite the resident being admitted with diagnoses necessitating such care. The resident, who was cognitively intact, received dialysis without documented orders, which the DON acknowledged as a missed responsibility of the admitting nurse. This oversight could lead to the resident missing necessary dialysis treatments.
The facility failed to provide prescribed medications for two residents due to not following the medication ordering policy. An LPN confirmed the absence of Cetirizine for one resident and the unavailability of Fenofibrate and Trulicity for another, as the pharmacy had not sent them. The facility's policy requires medications to be ordered 72 hours before the last dose, which was not adhered to.
A facility failed to maintain a medication error rate below 5%, resulting in a 46.15% error rate. An LPN administered medications late and some were unavailable, affecting two residents. The errors included late administration and unavailability of prescribed medications, contrary to the facility's medication administration policy.
Two residents experienced significant medication administration errors due to delays and unavailability of prescribed medications. One resident with convulsions and Parkinson's disease received their medications 1.75 hours late, while another resident with diabetes and hypertension had their medications administered 2.75 hours late, with one medication unavailable. The facility's policy requires timely administration, which was not followed.
A resident experienced severe pain due to the facility's failure to manage pain medication effectively. The resident's Norco prescription was not reordered in a timely manner, leading to a 24-hour period without the medication. The medication convenience box was not stocked, and the nurse was unable to access it, resulting in the resident receiving only Tylenol for pain relief. The pharmacy confirmed the delay in restocking, which contributed to the deficiency.
The facility failed to provide adequate pressure ulcer care for three residents, resulting in facility-acquired pressure ulcers. Insufficient Wound Care Nurses led to delayed incontinence care and missed treatments. Staff were unaware of the correct Low Air Loss Mattress (LALM) settings, leading to incorrect settings for the residents. One resident developed a stage 4 ulcer with tailbone exposure, while two others had stage 3 ulcers. The facility's LALM policy lacked specific settings, contributing to the issue.
A facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Multiple CNAs and a nurse called off or arrived late, leaving only two CNAs to care for 38 residents on one floor. This led to residents being found with soiled briefs, untrimmed nails, and unmet basic needs. The facility did not utilize agency staff despite having an emergency staffing policy.
The facility failed to provide restorative care to maintain or improve the range of motion for three residents due to inadequate staffing and failure to follow policy procedures. On the second floor, only two CNAs were available for 38 residents, and one was pulled from restorative duties to perform general CNA tasks. This resulted in missed Active and Passive Range of Motion exercises for the residents on specified dates, as documented in their care plans and nursing rehab documentation.
The facility failed to provide adequate ADL care for two dependent residents. One resident, with moderate cognitive impairment, was found with unkempt facial hair, long fingernails, and a soiled incontinence brief. Another resident, with severe cognitive impairment, was found extremely thirsty and with a soiled brief, despite the facility's policy for regular checks. The care plans requiring assistance with ADLs were not followed.
A resident with Multiple Sclerosis missed a Neurology appointment due to being hungry, and the facility failed to reschedule it. The resident's daughter raised concerns about the missed appointments, which were communicated to the DON, but no action was taken. The facility lacked a policy for scheduling or rescheduling appointments, leading to unresolved care concerns.
A facility failed to follow its catheter care protocols for a resident with neuromuscular dysfunction of the bladder. The resident's care plan required monitoring for UTI signs, but necessary catheter treatments were not transcribed onto the TAR or MAR. Observations showed the resident's catheter tubing had a purulent substance, and urine was cloudy, yet these issues were not reported to a physician. Staff interviews revealed confusion about catheter care procedures, and the facility's policy guidelines were not adhered to.
Insufficient Licensed Nursing Staff Leading to Delayed Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to meet residents’ needs as outlined in the facility assessment and staffing plan. An LPN assigned to the entire third floor reported being responsible for 37 residents and stated she felt overwhelmed, was consistently late with medication administration, and could not complete blood pressure checks, blood sugar monitoring, medication administration, and resident assessments effectively within the required two-hour window. She identified a specific resident for whom medications were given late. The staffing coordinator stated she tries to staff two nurses per floor but acknowledged that on the day of review there was only one nurse working on the third floor because another nurse could not be obtained. Facility nursing daily staffing sheets on multiple dates showed only one nurse assigned to the second and third floors, and on some dates only one nurse per floor for all three floors, despite a census ranging from 115 to 122 residents. The DON stated the facility is “never short-staffed,” asserting that one nurse per floor is considered adequate and that two nurses per floor are provided only to offer additional support and “TLC.” The DON also stated she was not aware of residents receiving medications late and that she conducts medication review audits, including checking administration times more than once a month, and denied that nurses had raised staffing concerns. However, medication administration audit reports for the identified resident showed multiple medications, including cyclobenzaprine for muscle spasm, metformin for type 2 diabetes mellitus with unspecified complications, and budesonide-formoterol for chronic respiratory failure with hypoxia, were scheduled for 8:00 AM but were not administered until around noon. The resident’s care plan included diabetes management with medications as ordered and monitoring for side effects and effectiveness. The facility assessment tool documented an average 2025 census of 116 residents, a current census of 118, and an average staffing plan of six licensed nurses on days, six on evenings, and three on nights, with assignments to be based on resident needs, preferences, and acuity, including higher-acuity residents on the second floor and greater behavioral symptom management needs on the third floor. Actual staffing patterns documented did not consistently align with this plan.
Improper Food Labeling and Three-Compartment Sink Use in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food service practices related to labeling and dating of food items and manual sanitizing of utensils. During a kitchen tour, one bag of diced turkey ham was observed in a freezer without any label or date. The head cook later stated that items should be labeled to know when they need to be discarded and that residents should not be served expired foods because they could get sick. The dietary supervisor and the administrator both confirmed that food items in the kitchen should be labeled and dated upon entry so it is known when to discard them, consistent with the facility’s 2017 policy on labeling and dating foods, which requires refrigerated food prepared in the healthcare community to be labeled with a discard or use-by date. Surveyors also observed improper use of the three-compartment sink during preparation of a puree meal. A cook washed utensils, a blender container, blade, top, and spatula in the three-compartment sink with the middle rinse compartment not filled with water, rinsing items under running tap water instead of immersing them. The cook did not allow utensils to remain submerged in the sanitizer for the manufacturer-specified time and did not allow them to air dry before reuse. The posted procedures above the sink required filling the wash and rinse sinks with hot water, immersing utensils in the rinse sink, immersing them in the sanitizer sink for a full minute, then inverting and air-drying without wiping. The head cook and dietary supervisor both described that all three compartments should be filled to the indicated fill lines, utensils should be submerged rather than rinsed under the tap, sanitizer contact time should be approximately 50–60 seconds, and items should be completely air-dried before reuse. At the time of the survey, the facility census was 118, with five residents NPO, and 113 residents consuming food from the kitchen.
Improper Maintenance and Overflow of Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse and to maintain the dumpster area in accordance with its Waste Management policy. On 1/20/26 at 10:30 AM, surveyors observed the dumpster area and noted one dumpster without a lid in place, two dumpsters overfilled with trash bags so that the lids could not close properly, and multiple latex gloves scattered on the ground. On 1/22/26 at 12:23 PM, the Head Cook acknowledged that the dumpsters were full and not covered and stated that dumpsters should be covered and that there should not be trash on the ground around them. Later that day at 12:23 PM, the Dietary Supervisor stated that the kitchen disposes of trash into the dumpsters and that the lids should be closed even if the trash is overflowing, and that the area should not have trash on the ground. At 3:57 PM, the Maintenance Director stated that dumpsters should not be overflowing, that lids must be closed at all times, and that the area around the dumpsters should be clean. The facility’s Waste Management policy dated 5/25 requires that trash containers be emptied when full, plastic liners tied and placed in outside dumpsters with lids kept closed, and that Maintenance and Housekeeping ensure the dumpster area is kept clean with all trash bags inside the dumpsters and lids closed. No specific residents or their medical conditions are mentioned in the report, but the deficiency is described as having the potential to affect all residents residing in the facility.
Outdated Infection Control Policies and Unsanitary Laundry Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an up‑to‑date infection prevention and control program and to follow its own policies for laundry and environmental sanitation. Surveyors found that multiple infection control policies, including the General Infection Control Policy, Coronavirus (Covid-19) Policy, Antibiotic Stewardship Policy, Linen Storage and Transport Policy, Linen and Laundry Policy, and Linen Handling Policy, had not been reviewed annually and were several years out of date. The Infection Control Preventionist stated that policies and procedures were only reviewed when changes were sent by the nursing director, consultant, or corporate, and acknowledged understanding that infection control policies and procedures need at least annual review. The facility’s Water Management Plan was also found to be expired, with a stated expiration date more than three years prior to the survey, and the Maintenance Director could not initially produce current water temperature logs for required daily checks, explaining that the Assistant Maintenance Director, who was out of the country, had taken the logs home. In the laundry area, surveyors observed environmental conditions inconsistent with the facility’s own housekeeping and linen policies intended to prevent spread of microorganisms. A large wall‑mounted fan in the washing machine area was visibly covered with dust and debris, and the Housekeeping Director stated she did not know how to turn it off and acknowledged it needed cleaning. She also stated that clothes and linens washed in that area were still wet and needed to be dried, which could attract dust from the dirty fan. In the clean linen area, a table used for folding clean linens was full of linens while a portable fan, described as orange and black, was running and directed at the clean linens; the Housekeeping Director confirmed that these linens were clean and acknowledged that the fan was dirty. Existing housekeeping and linen policies required housekeeping equipment to be kept clean and in good repair, daily cleaning by users, and storage of clean linen in a manner that prevents contamination, as well as regular environmental cleaning to minimize microorganisms, but these practices were not followed.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
Surveyors identified that the facility did not follow its immunization policies for residents regarding COVID-19 and other vaccines. Record review for four residents showed missing documentation of COVID-19 vaccination and, in one case, no documentation of any vaccinations at all. Three residents had only Mantoux TB skin tests recorded with no COVID-19 vaccination entries, and one resident had no immunization documentation. The Infection Control Preventionist confirmed there was no documentation that COVID-19 or other vaccines were offered to these residents and stated that these residents were still in the process of being included for flu, pneumococcal, and COVID-19 vaccinations, even though the facility’s policy requires that immunization history be assessed and documented within 72 hours of admission and that flu, pneumococcal, and COVID-19 vaccines be offered upon admission. Surveyors also found that the facility failed to include all staff in COVID-19 vaccination screening and did not follow its own policy to offer recommended immunizations to employees without documented immunity. Human Resources presented a COVID-19 staff vaccination status document and stated that the facility does not offer COVID-19 vaccines to staff who are unvaccinated but wish to receive them. Comparison of the staff vaccination status list with the list of all active employees showed that fourteen staff members, including CNAs, an RN, an LPN, an escort, a laundry aide, and a dietary worker, were not included in the COVID-19 vaccination screening. Eleven of these staff provided direct resident care, and one LPN who provided direct care had not been offered a COVID-19 booster dose, contrary to the facility’s employee immunization policy.
Unlocked Trash and Clean Utility Rooms With Sharps and Razors Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to keep hazardous areas and materials inaccessible to residents on the third floor. During a tour, an unlocked room with no signage was accessed and found to contain two red bins holding a total of three full sharps containers, two grey bins with filled trash bags, a tall blue laundry container, and two sinks filled with small bins, boxes, and metal bed rails. Another room, labeled as a Clean Utility Room and posted with multiple signs restricting entry to employees and instructing that the door remain closed, was also found unlocked. Inside this room were four packs of ten blue stick razors, bottles of mouthwash, deodorant, shave cream, toothbrushes, toothpaste, hairbrushes, adult briefs, gloves, gowns, urinals, two oxygen tanks, and an IV pole. A registered nurse stated that the first room was the trash room, that residents should not be able to enter it, and that housekeeping used it and staff brought full sharps containers there when carts were full. The nurse confirmed that residents should not have access to sharps containers because they contain needles and discarded medications, and that residents should not have access to razors because they have blades and could cause cuts and bleeding. The nurse also stated that most residents on the third floor have dementia. The Maintenance Director and the Administrator both acknowledged that residents should not have access to sharps, razors, trash, and other items in these rooms. At the time of the survey, the third-floor census was 37 residents, with seven residents dependent for mobility. The facility’s Needle Sharps - Handling and Disposal policy stated that used sharps must be placed in puncture-resistant biohazard containers and, if stored in an isolated room, must be kept in an area that will not be considered a risk for residents.
Untimely Medication Administration and Incomplete Controlled Substance Counts
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and facility policy, specifically related to timely medication administration and proper controlled substance accountability. On one morning, an LPN on the third floor reported starting her shift at 6:00 a.m. but not beginning medication administration until approximately 8:00 a.m., and by 9:47 a.m. she had not completed her medication pass for 37 residents. When the eMAR was opened at 10:14 a.m., multiple residents’ medication records were displayed in red, which the nurse explained indicated late medication administration beyond the one-hour before/after scheduled time window. On another day, an RN assigned to the east wing of the third floor stated she had completed her morning medication pass, but when she opened the eMAR at 10:49 a.m., multiple residents’ records were also red; she stated she had administered the medications but had not documented them, resulting in the appearance of late medications. Facility medication administration audit reports for two consecutive days documented that multiple residents on the third floor received their medications late. The facility also failed to ensure controlled substances were counted and documented at the beginning and end of each shift as required by its policy. An RN responsible for the first-floor west medication cart stated she performed a narcotic count at the start of her shift but forgot to sign the shift change accountability record. Review of the Shift Change Accountability Record for Controlled Substances for the first-floor west cart for January showed that for nine shifts, nurses had not counted and documented controlled substances, with missing signatures on multiple first, second, and third shifts throughout the month. The facility’s controlled substance policy dated 02/2017 required that at each shift change, a physical inventory of selected medications be conducted by two licensed nurses and documented on an audit record, which was not consistently done. Census information showed 37 residents on the third floor and 17 residents on the first-floor wing served by the involved carts, indicating the scope of residents potentially affected by these failures.
Failure to Maintain Acceptable Medication Error Rate During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors calculating a 27.27% error rate during a medication pass observation. For one resident, the eMAR ordered Cholecalciferol 25 mcg (1000 units) 2 capsules by mouth once daily at 9:00 a.m., but the RN administered only 1 capsule. Another resident’s eMAR ordered Ergocalciferol 50 mcg (2000 units) 1 tablet by mouth once daily at 9:00 a.m., yet the RN instead administered Cholecalciferol 25 mcg (1000 units) 1 tablet. The same resident also had an order for Mucus Relief ER (Guaifenesin) 600 mg by mouth every 12 hours for cough, scheduled for 8:00 a.m., which was not administered during the observed medication pass; the RN stated the medication was not available and that it had been reordered two days earlier. Additional errors were observed with other residents. One resident had an order for Clotrimazole 1% cream to be applied topically to both plantar surfaces once daily at 9:00 a.m., but this medication was not administered during the observed pass. Another resident’s eMAR ordered Docusate Sodium 50 mg by mouth twice daily at 8:00 a.m., but the RN administered Docusate Sodium 100 mg instead. A further resident had an order for Calamine-Zinc Oxide lotion to be applied topically twice daily at 8:00 a.m., which was not administered, and an order for Cholecalciferol 25 mcg (1000 units) 2 tablets once daily at 9:00 a.m., but only 1 tablet was given. The same resident also had an order for Venlafaxine ER 150 mg by mouth in the morning for MDD/GAD at 9:00 a.m., which was not administered because, according to the RN, the medication was not available and needed to be reordered. The facility’s own medication administration policy requires medications to be administered in accordance with the physician’s order, including the right resident, right medication, right dosage, right route, and right time.
Improper Labeling and Storage of House Stock and Liquid Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices on the 3rd floor medication carts, affecting house stock and resident-specific medications. During observation of the East medication cart, one open house stock bottle of Diphenhydramine HCL 25 mg was found in the cart with a manufacturer expiration date of 07/2025, indicating it should have already been discarded. On the West medication cart, another open house stock bottle of Diphenhydramine HCL 25 mg with the same 07/2025 expiration date was observed, along with an open house stock bottle of Sodium Chloride 1 GM that had no visible expiration date. Additional open house stock bottles of Acetaminophen 325 mg and Melatonin 3 mg were present without any open dates labeled. Further review of the West cart revealed two open liquid medication bottles of Megestrol Acetate 40 mg/mL labeled for a specific resident (R9), both lacking open dates. The LPN accompanying the surveyor stated that Diphenhydramine should not be stored in the medication carts and should have been discarded once expired, and acknowledged that it is not safe to administer expired medications or medications without a known expiration date. The LPN also confirmed that all opened house stock and liquid medications are required to be labeled with an open date. Facility census documentation showed 37 residents residing on the 3rd floor, and the facility’s Medication Administration Policy dated 09/2025 states that multi-use vials and house stock liquids must be dated when opened and that expired medication may not be administered to residents.
Failure to Offer and Document Required Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to follow its immunization program policy and procedure for offering and documenting influenza and pneumococcal vaccinations for four of five sampled residents reviewed for immunizations, out of a total sample of 24. Record review showed that one resident had no documentation of any vaccinations, and three residents had documentation only of Mantoux skin tests for TB, with no records of influenza or pneumococcal vaccines. The facility’s Immunization Program Policy and Procedure dated 03/2025 requires that residents and responsible parties be informed of the vaccination prevention programs prior to or at the time of admission, and that the resident’s immunization history be assessed and documented in the medical record within 72 hours of admission. During an interview on 01/21/2026 at 11:29 AM, the Infection Control Preventionist (V3) stated there was no documentation that influenza or pneumococcal vaccinations were offered to these four residents. V3 also stated that any vaccinations received by residents are documented in the immunization report and that she was still in the process of including these four residents for flu, pneumococcal, and COVID-19 vaccinations, even though flu, pneumococcal, and COVID-19 vaccinations should be offered upon admission as part of infection prevention. Regulatory and guidance documents cited in the report, including CMS vaccine regulations and CDC interim guidance, state that facilities must offer influenza and pneumococcal vaccines to all residents, provide education on benefits and side effects, and document vaccination, refusal, contraindications, or unavailability, which was not done for these four residents.
Failure to Monitor Wanderer and Implement Elopement Precautions
Penalty
Summary
The deficiency involves the facility’s failure to monitor and implement care plan interventions for a cognitively impaired resident with known wandering and elopement risk. The resident, who has dementia with behavioral disturbance, delusional disorder, depression, and anxiety, had an MDS BIMS score of 1/15 indicating severe cognitive impairment. On 01/20/2026 at 11:00 AM, the resident was observed sitting on another resident’s bed and remained there for forty minutes, and was unable to answer questions. A CNA confirmed that the room and bed did not belong to this resident and stated that staff are supposed to monitor the resident to prevent entry into other residents’ rooms but are usually too busy to do so. An LPN stated the resident wanders into other residents’ rooms and needs constant redirection, and that the resident’s room is located around the corner and far from the nursing station, where nurses cannot see the room from the station. Review of the resident’s care plan dated 04/23/2025 showed that a picture of the resident was to be placed discreetly at the nursing station and front reception to notify staff that the resident is an elopement risk, but no picture was found at the nursing station. The LPN stated that care plans are for nursing staff to follow and that the picture was intended to notify staff that the resident is a wanderer and elopement risk. On examination, the resident was not wearing a wander guard, despite the LPN stating the resident should have one due to wandering and elopement risk. The receptionist reported that names of elopement-risk residents are kept in a binder at reception to alert staff if such residents try to leave, but the binder did not contain this resident’s information. The DON confirmed the resident wanders into other residents’ rooms, that staff should monitor the resident to keep her safe, and that the resident is at risk for resident-to-resident abuse because of wandering. Facility policies on Resident Rights and Supervision and Safety state that residents have the right to an environment that preserves dignity and that supervision is a core component of resident safety, including for wanderers and confused residents.
Failure to Initiate PASRR Re-Screenings After New Serious Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to initiate new PASRR (Pre-admission Screening and Resident Review) Level I screenings and referrals for Level II evaluations when residents developed new serious mental illness diagnoses during their stays. For one resident (R40), the original PASRR Level I completed in May 2024 indicated no serious mental illness, intellectual disability, or related condition and no Level II was required. However, subsequent records showed new psychiatric diagnoses, including delusional disorder and generalized anxiety disorder with onset dates in March 2025 and major depressive disorder with an onset date in April 2025. Psychiatry notes documented that the resident frequently presented with paranoid delusions and was started on quetiapine to manage delusional thinking. The MDS dated December 2025 identified potential indicators of psychosis and delusions, and the care plan documented the need for psychotropic medication to manage anxiety and delusions. Despite these changes, the Social Services Director acknowledged that the resident should have been referred for another PASRR screening due to the new diagnoses but was not, attributing this to oversight. For another resident (R92), a PASRR screening had been completed in January 2025, but later in the stay the resident was diagnosed with delusional disorder and unspecified dementia, moderate, with psychotic disturbance. The resident had severe cognitive impairment as evidenced by a BIMS score of 7/15 and was receiving quetiapine for dementia with psychosis and paranoid delusions, as well as melatonin for insomnia. Nursing documentation described episodes of the resident becoming upset, yelling, and cursing at staff. The Social Services Director stated it was his responsibility to review medical records for new mental health diagnoses, complete a new PASRR Level I, and trigger a Level II evaluation by an outside screener when indicated. He admitted he missed the new diagnoses of dementia with delusional disorder and dementia with psychotic disturbance for this resident and did not complete a PASRR Level II, acknowledging that this failure could lead to the resident not receiving specialized care. Facility policy stated that a new PASRR Level I should be considered when there is a suspected psychiatric condition or a new psychiatric diagnosis added by a physician, but this was not followed for these two residents.
Failure to Renew PASRR Authorization for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to obtain required PASRR evaluations for a resident with serious mental illness. The resident, an adult with diagnoses of bipolar disorder and alcohol abuse/dependency, was admitted on a specified date and was taking Lurasidone 60 mg, an antipsychotic medication. Upon admission, a PASRR Level I screen identified the resident as having a mental health diagnosis and substance-related diagnosis and indicated that a PASRR Level II evaluation was required. The subsequent PASRR Level II determination granted only a short-term approval for the resident’s stay without specialized services, with a clearly defined end date for that short-term approval. The PASRR Level II notice specified that the resident’s short-term approval would end on a particular date and that, if the resident needed to remain beyond that date, facility staff were required to submit a new PASRR Level I screen no later than 10 days before the short-term approval expired. The Social Service Director acknowledged in interview that the resident’s short-term approval had expired and that he had missed requesting a new PASRR screening because it did not trigger in his computer system. He further stated that a new screening should have been done because the prior approval had expired and that PASRR screening is important to determine the right setting or placement for the resident. The facility’s PASRR policy, dated 12/2023, states that the facility will comply with Federal, State, and screening agency requirements and will review PASRR documents to help assess resident needs and functioning, but this was not followed for this resident.
Failure to Obtain and Process Prescription for Corrective Lenses
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in maintaining vision by not following through on an eye doctor’s prescription for corrective lenses. The resident reported that he had visited an eye doctor twice and had been prescribed eyeglasses, and that on both occasions he gave the prescription to facility nurses, who then lost it. As a result, the resident remained without the eyeglasses that had been prescribed for him. An eye care clinic receptionist confirmed that the resident had been seen at the clinic and was given a prescription for eyeglasses for both reading and distance vision, and that the escort accompanying the resident was informed of the prescription and the need to contact the resident’s insurance regarding payment for the eyeglasses. The Social Services Assistant stated that the resident had informed her on two separate occasions that he received a prescription for corrective lenses and had given it to the escort, who allegedly passed it to social services; however, social services never received the prescription. The Social Services Assistant attempted to identify the nurse or escort involved and to locate the appointment information on the facility’s electronic bulletin board, which lists residents’ outside medical appointments, but she could not find any record of the eye doctor appointment within the prior several months. In contrast, facility documentation from the clinical communications bulletin board showed that an eye doctor appointment had been made for the resident, and a progress note by an LPN documented the resident’s return from the eye center “without any order,” despite the external documentation showing that a prescription for corrective lenses had been written that day. Ombudsman guidance on residents’ rights states that the facility must make reasonable arrangements to meet residents’ needs and choices, which was not done in this case regarding access to prescribed eyeglasses.
Failure to Maintain Infection Control for Stored Oxygen Tubing
Penalty
Summary
Surveyors identified that the facility failed to implement infection control measures for oxygen tubing for one resident when respiratory care was needed. On 1/20/2026 at 12:43 PM, the resident’s oxygen concentrator tubing was observed uncovered and lying on the floor next to the bed. The DON later stated that the facility has an oxygen equipment policy requiring oxygen tubing to be changed weekly and kept in bags when not in use, and confirmed that tubing should not be on the floor due to infection control concerns and the possibility that residents could place the tubing back in their nose. The resident involved is an individual with chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypercapnia, with active physician orders for oxygen at 2–4 L/min via nasal cannula. The resident’s assessment indicates a need for partial/moderate assistance with transfers and bed mobility, requiring one-person assistance. Facility documentation titled “Oxygen Equipment” states that oxygen is to be administered in conditions in which infection control is maintained and that oxygen tubing/nebulizer masks will be covered when not in use. Despite these policies and the resident’s condition and assistance needs, the oxygen tubing was not stored in accordance with infection control requirements.
Failure to Provide and Document Ordered Wound Care for Resident with Sacral Ulcer
Penalty
Summary
The facility failed to follow its policy to ensure appropriate wound care treatment for a resident with a sacral pressure ulcer. The resident, who is moderately cognitively impaired and has a history of wounds, developed a sacral wound while in the facility and was later diagnosed with MRSA of the sacral bone after a hospital visit. The wound care nurse confirmed that the resident requires daily wound care with Santyl ointment as ordered, and that wound care is to be documented on the Treatment Administration Record (TAR). However, review of the TAR revealed that wound care was not documented or performed on several specific dates. Interviews with staff, including the wound nurse, DON, and infection preventionist, confirmed that the resident did not receive wound care on the identified dates, and that lack of documentation on the TAR indicates the treatment was not done. The facility's policy requires wounds to be assessed and measured at least every seven days and for treatments to be recorded. The failure to provide and document daily wound care as ordered constitutes a deficiency in following the facility's wound care policy.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents from occurring in the specified area. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Failure to Provide Adequate Supervision and Monitoring Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, resulting in a significant incident where a resident with a high risk for falls sustained serious injuries during a shower. The resident, who had a history of falls, cognitive impairment, lack of coordination, and required maximal assistance with bathing, was being showered by a CNA who left the resident momentarily to retrieve towels. During this time, another CNA was present but was occupied putting on gloves and not in direct contact with the resident. The resident became agitated, attempted to ambulate, and fell, sustaining complex facial lacerations that required 12 sutures. The incident was witnessed by staff who reported that the resident should not have been left unattended, even briefly, given his known fall risk and behavioral tendencies. Additional observations during the survey revealed lapses in supervision and monitoring in other areas of the facility. On the second floor, a CNA was found using her phone in an empty resident room while a resident was calling for assistance, indicating inattentiveness to resident needs. On the third floor, two residents assessed as high risk for falls were observed sitting unsupervised in the activity room, contrary to facility policy that requires continuous monitoring in such settings. The CNA responsible for monitoring these residents was not present at the time but later stated she was assigned to supervise the area during that period. Facility policies reviewed by the surveyor specify that residents requiring staff assistance should not be left alone during bathing or showering and that supervision is a core component of resident safety. Despite these policies, staff actions did not align with established protocols, as evidenced by the incident in the shower room and the lack of supervision in other areas. The failure to maintain adequate supervision and monitoring directly affected multiple residents identified as high risk for falls, resulting in preventable harm.
Failure to Maintain Hot Water Supply Due to Mechanical Equipment Breakdown
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, resulting in the lack of hot water accessible to residents throughout the building. During a facility tour, multiple resident-accessible sinks and showers on all floors were found to have water temperatures significantly below the required range, with some fixtures having no water supply at all. The issue was traced to a malfunctioning hot water mixing valve, which was leaking and caused flooding in the boiler room. The leaking water extinguished the boiler's pilot light, further preventing the restoration of hot water. The Maintenance Director was aware of the issue but did not inform the surveyor during the initial tour. Facility records indicated that the hot water mixing valve had failed due to corrosion and age, and the correct replacement part was not immediately available. The Corporate Project Manager confirmed ongoing difficulties in sourcing the correct mixing valve and restarting the boiler. The Administrator was notified of the hot water outage and instructed staff to provide bed baths and use wipes for ADL care instead of showers. The facility did not have a preventative maintenance program for the plumbing system, and hot water logs confirmed that water temperatures remained below regulatory requirements for several days.
Inadequate Supervision Leads to Multiple Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate measures to prevent falls for three residents identified as high risk for falls. Resident 1, who was admitted with multiple health issues including alcoholic cirrhosis and dementia, experienced three unwitnessed falls in February, resulting in lacerations that required medical attention. Despite being identified as high risk for falls, Resident 1 was not under strict supervision, and staff failed to monitor the resident adequately, leading to falls that occurred without staff presence. Resident 2, admitted with chronic kidney disease and dementia, also experienced two unwitnessed falls in March, both resulting in injuries that required hospital visits. The facility's investigation revealed that the falls occurred during times when staff were on break, and there was insufficient staff to monitor residents adequately. The lack of supervision and failure to ensure staff coverage during breaks contributed to the incidents. Resident 3, with a history of hydrocephalus and cerebral infarction, had two falls, one in February and another in March, both resulting in injuries. The facility's investigation indicated that the falls occurred due to inadequate supervision and failure to assist the resident with repositioning. The physician confirmed that all three residents would benefit from close supervision to prevent falls, highlighting the facility's failure to implement necessary safety measures and supervision for high-risk residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for nine residents, as observed during a survey. Residents were found in various positions, such as in bed or in a wheelchair, with call lights placed out of reach. For instance, one resident was eating in their room with the call light not within reach, while another was in bed with the call light under the bed. A resident in a wheelchair was unable to reach the call light placed on the opposite side of the bed. Staff members, including a CNA and an RN, acknowledged that call lights should be within reach of residents, especially those at risk for falls. The facility's policy on call light placement and fall prevention was not adhered to, as evidenced by the observations. The policy states that call lights should always be accessible to residents, and the fall prevention program emphasizes the importance of keeping call lights within reach for residents at risk of falls. Despite these guidelines, multiple residents, including those identified as fall risks, were found without accessible call lights. This deficiency was noted by surveyors and confirmed by staff members, who admitted that they were aware of the requirement to keep call lights within reach.
Inappropriate Photos of Resident Shared by CNA
Penalty
Summary
The facility failed to protect a resident from mental abuse when a former CNA took inappropriate photos of the resident and shared them with a group of CNAs via text message. The resident, who had severely impaired cognition due to multiple medical conditions including cerebral infarction and hemiplegia, was photographed in a vulnerable state with her diaper open and soiled. The incident was reported on 12/30/2024, and the CNA responsible was terminated the following day for violations of HIPAA and resident rights. The former CNA claimed that she took the photos to highlight the neglect the resident was experiencing, as she found the resident in a distressing condition with no staff present to assist. The CNA stated she was unaware that sharing the photos was prohibited, citing a lack of abuse training and language barriers as contributing factors. The incident was reported to the Director of Nursing and Human Resources, and the resident's family was informed. The facility's policy strictly prohibits photographing or recording residents for non-medical purposes, and the sharing of such images is considered an allegation of abuse.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy by not conducting a thorough investigation into an alleged incident of verbal abuse involving a resident, identified as R4. The Human Resource Director, V11, reported that a CNA, V5, was accused of using profanity towards R4. However, the Former Administrator, V7, who was responsible for the investigation, did not involve social services or interview additional staff and residents who might have had relevant information. V7's investigation was incomplete, lacking essential details such as dates, times, and comprehensive statements from other staff and residents who regularly interacted with V5. The Director of Clinical Services, V17, noted that V7's investigation was missing critical information and instructed V7 to obtain a detailed account of the incident, which was not done. The facility's Abuse Prevention Program policy requires interviews with residents and staff who regularly interact with the accused to determine if there have been any prior incidents of abuse or neglect. This policy was not followed, as the investigation did not include statements from all relevant parties, leading to a deficiency in the facility's handling of the abuse allegation.
Failure to Follow Dietician's Recommendations for Resident's Hydration Status
Penalty
Summary
The facility failed to follow the care plan for a resident, identified as R2, to maintain adequate nutritional and hydration status. The facility also did not implement professional standards of practice by failing to address a Registered Dietician's recommendations for follow-up lab tests. R2, who is severely cognitively impaired and has multiple complex medical conditions, including severe sepsis, diabetes, chronic kidney disease, and pressure ulcers, was at risk due to this oversight. The dietician, V8, had repeatedly requested follow-up labs to monitor R2's hydration status, but these requests were not acted upon by the nursing department. The dietician, V8, noted that R2's lab results showed elevated sodium and blood urea nitrogen levels, indicating potential dehydration and other health concerns. Despite V8's multiple recommendations for follow-up labs, communicated via email to the nursing department, including the Director of Nursing (V2) and Assistant Director of Nursing (V10), no action was taken. V8 stated that she was informed by V10 that the doctor would be consulted, but there was no follow-up. The Nurse Practitioner, V19, emphasized the importance of following up on healthcare professionals' recommendations, noting that he was not informed of the dietician's requests. The Director of Nursing, V2, admitted to being unaware of the status of the lab requests and relied on V10, who was on vacation, to handle the follow-up. R2's attending physician, V21, stated that he was not informed of the dietician's recommendations but would have agreed to them if he had been. The lack of communication and follow-up on the dietician's recommendations resulted in a failure to provide appropriate care for R2, who was already in a vulnerable state due to his complex medical conditions.
Inadequate Restorative Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide appropriate restorative care to maintain or improve the range of motion and mobility for four residents, which could potentially affect 104 residents. The surveyor observed that the facility did not have sufficient staff available to provide the necessary restorative care, as restorative aides were frequently pulled to work on the floor due to staffing shortages. This resulted in the failure to deliver the prescribed restorative interventions, such as active and passive range of motion exercises, as documented in the residents' care plans and Kardex reports. One resident, who had hemiplegia and hemiparesis following a cerebral infarction, expressed the need for therapy as they were unable to move their right upper extremity. The resident's care plan included active range of motion exercises for the left extremities but omitted passive range of motion for the right extremities, which was not documented in the facility's records. Another resident, diagnosed with lack of coordination and gait abnormalities, reported receiving inconsistent physical therapy and expressed dissatisfaction with the lack of restorative care to prevent decline in daily living activities. Documentation for this resident showed gaps in the provision of active range of motion exercises. The facility's restorative nurse confirmed that both restorative aides were often reassigned to other duties, leaving the CNAs to perform range of motion exercises, though it was unclear if these were consistently carried out. The facility's restorative nursing policy requires individualized programs based on assessments, with documentation of interventions, but these were not consistently followed, leading to the deficiencies noted by the surveyor.
Staffing Shortages Lead to Care Deficiencies
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by the observations and interviews conducted by the surveyor. On the 2nd floor, there were only three CNAs available for 40 residents, which was deemed insufficient by the staff themselves. The restorative aide was pulled from her duties to work the floor, leaving no one to provide restorative care. This staffing shortage led to inadequate care for residents, including missed restorative care and improper monitoring of personal refrigerator temperatures. Several residents experienced deficiencies in care due to the staffing issues. For instance, R11 had an unlabeled g-tube feeding bag, and R37's incontinence brief was not changed in a timely manner, with his lunch tray left out of reach. R56 was found with open wounds on her buttocks that were not covered with dressings, and her wound care orders were not properly transcribed. Additionally, R48 and R57 experienced medication administration errors, with medications being administered late or unavailable. The facility's failure to implement its emergency staffing policy and utilize agency staff contributed to these deficiencies. The staffing coordinator confirmed that the facility does not use agency staff, despite having a contract with an external agency. The restorative nurse and aides were frequently pulled from their duties to cover staffing shortages, impacting the delivery of restorative care. The facility's timecard report showed that several staff members clocked in late, further exacerbating the staffing issues.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to several food safety and hygiene protocols, which could potentially affect all 111 residents receiving oral nutrition. Observations revealed that staff did not perform hand hygiene upon entering the kitchen, as evidenced by the Administrator in Training not knowing the location of the handwashing facility and admitting to not washing hands due to being in training. Additionally, the Dietary Supervisor confirmed that handwashing is expected upon kitchen entry to prevent pathogen transmission. Temperature logs for food storage were incomplete, with missing entries for both coolers and freezers on specific dates. This lapse in monitoring could compromise food safety, as maintaining appropriate storage temperatures is crucial. Furthermore, a gallon of milk was found without an open date, and a dietary aide's hair was not fully covered, which could lead to cross-contamination. The Dietary Supervisor acknowledged these oversights, emphasizing the importance of labeling and hair coverage to prevent contamination. The facility also exhibited maintenance issues, such as a clogged kitchen drain that had been problematic for three years, causing water backflow during dishwashing. The Dietary Supervisor and a dietary aide confirmed the ongoing issue, which poses a hazard to staff. Additionally, the kitchen ceiling paint was disintegrating, potentially affecting both staff and residents due to particle inhalation. The facility's sanitation practices were also lacking, with missing entries in the POTS and PANS Sanitization Log, indicating that the solution's potency was not consistently checked. These deficiencies highlight significant lapses in maintaining a safe and hygienic environment for food preparation and service.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by an overflowing dumpster with one of its lids open. This was observed on January 13, 2025, when the Dietary Supervisor noted that the dumpster was overflowing with black and white trash bags, and one of the three lids was open. The Dietary Supervisor confirmed that the black trash bags originated from the Dietary department, while the Maintenance department was responsible for managing the dumpster. On January 15, 2025, the Maintenance Director acknowledged that the dumpster lid should always be closed to prevent pests like rats and flies from entering and potentially migrating into the building. The facility's Waste Management Policy and Safe Food Handling - Dumpster Policy both emphasize the importance of keeping the dumpster lid closed and ensuring all trash bags are inside the dumpster to prevent the spread of infection.
Infection Control Deficiencies in Isolation and Hand Hygiene
Penalty
Summary
The facility failed to properly implement its infection prevention and control program, as evidenced by several deficiencies observed during a survey. A resident, identified as requiring contact isolation due to ESBL (Extended Spectrum Beta Lactamase) in the urine, did not have appropriate isolation signage posted on their door. The signs were improperly secured, causing them to dangle upside-down and display only the blank side. This led to a chaplain entering the resident's room without wearing the necessary personal protective equipment (PPE). Despite the resident being listed on the facility's isolation log, there was a lack of communication and awareness among staff and visitors regarding the resident's isolation status. Additionally, the facility failed to ensure proper hand hygiene practices during dining services. A Certified Nursing Assistant (CNA) was observed setting up meal trays for residents without performing hand hygiene between tasks, despite handling a resident's wheelchair. The Infection Preventionist confirmed that staff are expected to use hand sanitizer available in the dining room to prevent the spread of germs. The residents involved had severe cognitive impairments, with one diagnosed with heart failure, cardiac arrhythmia, and anxiety disorder, and another with anorexia, heart failure, and Type 2 Diabetes Mellitus. These lapses in infection control practices have the potential to affect all residents in the facility.
Failure to Follow Self-Administration Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the self-administration of medication by residents, affecting three residents and potentially impacting all residents on the second floor. The policy requires a self-administration review, a physician's order, and a care plan for residents who self-administer medication. However, these steps were not followed for residents R13, R66, and R84. Observations revealed that these residents had medications at their bedside without proper labeling or documentation, and there was no evidence of a physician's order or a care plan allowing them to self-administer. Resident R66 was found with an unlabeled inhaler on their bedside table, which they claimed to use independently without staff instruction. Similarly, resident R84 had an inhaler and a bottle of iron on their window ledge, which they used as needed. Both residents' order summaries did not include orders to self-administer medication, and their care plans lacked documentation for self-administration. Resident R13 was found with a nasal spray in their pocket, but there was no order or care plan for self-administration, and their cognitive status was noted as severely impaired. The facility's Director of Nursing acknowledged the importance of completing self-administration reviews, obtaining a doctor's order, and care planning for the safety of the residents. However, the facility failed to conduct the required assessments semi-annually, as evidenced by the lack of documentation for R13 between 2021 and 2025. The facility's policy and residents' rights documentation emphasize the need for cognitive, physical, and visual assessments to ensure safe self-administration, which were not adequately performed in these cases.
Medication Administration Delays and Documentation Issues
Penalty
Summary
The facility failed to administer and document medications within regulatory requirements for seven residents. On multiple occasions, medications were dispensed and prepared for administration well past their scheduled times. For instance, an LPN was observed dispensing medications for a resident that were scheduled for 8:00 am at 9:46 am, and another resident's medications scheduled for 9:00 am were dispensed at 11:44 am. The LPN acknowledged the delay and attributed it to inefficiency. Additionally, the EMAR system highlighted these delays by marking the medications in red, indicating late administration. The Director of Nursing was present but did not assist in the medication administration process. Another nurse reported that a resident consistently refused medications, yet the documentation of these refusals was not completed promptly. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances. This lack of adherence to the policy and regulatory requirements led to the deficiency noted by the surveyors.
Hazardous Environment Due to Inadequate Supervision and Unsafe Practices
Penalty
Summary
The facility failed to maintain a safe environment free from hazards for two residents, which could potentially affect all 39 residents on the third-floor unit. During a survey, a clear cup with a thick, gold liquid was observed on a resident's sink, visible from the hallway. The resident was unable to identify the substance, and a CNA speculated it might be soap from the shower room pumps. The CNA acknowledged that if another resident consumed the liquid, it could be harmful. Additionally, three razors were observed on another resident's nightstand, visible from the hallway. The resident stated that staff provided the razors for shaving and disposed of them in the garbage after use. The LPN was unaware of the facility's policy regarding razors and acknowledged the potential risk if another resident accessed them. The DON confirmed that residents should be supervised while shaving, and razors should be discarded in a sharps container after use. The presence of razors and chemicals in residents' rooms without proper supervision and disposal procedures highlights the facility's failure to ensure a hazard-free environment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, which was identified during a survey. Controlled medications for two residents were found unsecured in an unlocked medication refrigerator, contrary to the requirement that such medications be double-locked. This was observed during an audit of the third-floor medication room, where Lorazepam and Morphine sulfate were found with the names of two residents. The LPN acknowledged that the medication refrigerator should be locked, as well as the medication room door, to ensure safety. Additionally, the facility did not label insulin and eye medications with open and expiration dates for four residents, and expired insulin was found on a medication cart. During an audit of the first-floor medication cart, several insulin pens and eye medications were found without the necessary labeling, and an expired insulin pen was noted. The Director of Nursing confirmed that expired medications should be removed to prevent administration errors, and the purpose of labeling is to ensure patient safety by knowing when medications expire after opening. The facility lacked a policy regarding the storage of controlled substances, which contributed to these deficiencies.
Deficiencies in Monitoring Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerators used by residents for storing perishable items. Observations revealed that several residents' refrigerators lacked daily temperature logs, had temperatures recorded outside the safe range, and exhibited significant ice build-up. For instance, R49's refrigerator had not been logged for six days, and R15's refrigerator was found to be at 76F, well above the safe temperature range. Staff members, including housekeeping and nursing personnel, were unclear about their responsibilities and the required temperature range for safe food storage. The facility's policy mandates that nursing staff are responsible for daily checks of residents' personal refrigerators for proper labeling, temperature recording, and storage. However, interviews with staff members such as V13 and V14 indicated a lack of awareness and adherence to these procedures. V13, responsible for monitoring refrigerator temperatures, was unsure of the correct temperature range and had not reported issues like ice build-up to the manager. Similarly, V14 was unable to confirm the required temperature range, highlighting a gap in staff training and communication. Residents affected by these deficiencies included those with chronic conditions such as COPD, asthma, and dementia, which could make them more vulnerable to foodborne illnesses. For example, R3's refrigerator lacked a thermometer, and the temperature log was pre-signed for future dates, indicating a failure in accurate monitoring. The Director of Nursing acknowledged that the responsibility for monitoring these refrigerators was shared between housekeeping and nursing staff, but the lack of consistent oversight and documentation posed a risk to resident safety.
Failure to Maintain Homelike Environment Due to Missing Window Coverings
Penalty
Summary
The facility failed to provide a homelike environment by not replacing missing window coverings for a resident, identified as R51, which affected their comfort and privacy. During an observation, it was noted that R51 was sitting in a recliner near the windows, with sunlight directly hitting their eyes due to missing vertical blinds on one of the windows. The left window had approximately six-inch gaps between five vertical blind panels, and there was no roll-down curtain to block the sun. The right window, although missing some vertical blind panels, had a roll-down curtain that was closed, effectively blocking the sun. R51 expressed a desire for shades and questioned whether they would have to pay for them. The Maintenance Director, identified as V32, acknowledged that the blinds were pulled down by a former resident and admitted that they were supposed to replace them. Despite conducting rounds 2 to 3 times a day, V32 had not replaced the missing blinds or installed a roller blind for the left window. R51, who has a history of type 2 diabetes mellitus, seizures, dementia, anxiety disorders, and falls, was noted to have moderate cognitive impairment with a BIMS score of 8. The facility's policies emphasize the importance of maintaining a clean, safe, and comfortable environment, yet the failure to replace the window coverings compromised the resident's right to a dignified and homelike environment.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents, each with significant self-care deficits. One resident, diagnosed with dementia and hemiplegia, was observed with unkempt hair, a long beard, and nails, indicating a lack of personal hygiene care. Despite the resident's confusion and inability to perform self-care, the necessary grooming assistance was not provided, as confirmed by a chaplain who translated the resident's responses. Another resident, also with dementia, was found with a soiled incontinence brief and an untouched meal tray placed out of reach, suggesting neglect in both personal care and feeding assistance. The staff's inconsistent acknowledgment of the resident's need for feeding assistance further highlights the deficiency. A third resident, diagnosed with dementia and generalized weakness, was left in bed in a nightgown, with no clear indication of when her incontinence brief was last changed. The resident's family member expressed concern over the lack of care, emphasizing the resident's usual routine of being up and dressed by the time of their visit.
Deficiencies in Pressure Ulcer Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper functioning and use of pressure ulcer prevention and treatment measures for three residents. One resident's low air loss mattress was found unplugged, leading to deflation, which could exacerbate an existing unstageable wound on the sacrum. The Director of Nursing acknowledged that the mattress was sometimes mistakenly unplugged when the bed was moved, indicating a lapse in ensuring the equipment was consistently operational. Another resident did not have PRN wound care orders for a hydrocolloid dressing on the sacrum, which was observed to be falling off and adhered to itself. The resident's care plan noted a risk for skin impairment due to bladder incontinence, yet the dressing was not maintained properly, and the resident's incontinence brief was found moderately saturated with urine, suggesting inadequate monitoring and care. A third resident had treatment orders for a hydrocolloid dressing on the left buttock, but these orders were not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR). The resident had open areas on both buttocks, but neither was covered with a dressing at the time of observation. The Wound Care Nurse confirmed the presence of stage 2 wounds on both buttocks and noted a change in treatment orders, yet the facility failed to ensure these orders were documented and followed, leading to inadequate wound care management.
Failure to Label G-Tube Feeding Bag
Penalty
Summary
The facility failed to adhere to its gastrostomy feeding policy, resulting in a deficiency related to the labeling of a gastrostomy tube (g-tube) feeding for a resident. During an observation, it was noted that the g-tube feeding bag for a resident was not labeled with the required information, including the resident's name, type of feeding, date, and time the infusion started. A registered nurse confirmed that they had hung the bag that morning but did not label it as per the facility's policy. The facility's policy, dated June 2014, mandates that the container be labeled with the resident's name, formula name, concentration flow rate, date, and time, which was not followed in this instance.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to properly label, date, and contain oxygen equipment for two residents, leading to potential infection control issues. Resident R3, diagnosed with chronic obstructive pulmonary disease (COPD) and asthma, was observed with oxygen tubing hanging across the bed and touching the floor, dated from several months prior and not contained in a bag. Similarly, Resident R109, with diagnoses including obesity and cardiac arrhythmia, had oxygen tubing hanging across the oxygen concentrator and touching the floor, also undated and uncontained. Both residents reported not having bags to store their oxygen tubing when not in use. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged that the oxygen tubing should be stored in a bag to prevent contamination and potential infection. The facility's policy requires oxygen equipment to be changed and dated weekly and covered when not in use, which was not adhered to in these cases. The failure to follow these procedures was confirmed through observations and interviews, highlighting a lapse in maintaining infection control standards for oxygen equipment.
Failure to Obtain Physician's Order for Dialysis
Penalty
Summary
The facility failed to obtain a physician's order for a resident who requires dialysis, affecting one resident in a sample of 64. The resident, identified as R3, was admitted with diagnoses including dependence on renal dialysis, chronic kidney disease stage 5, and renal sclerosis. Despite being cognitively intact with a BIMS score of 13, R3's Active Physician Order Sheet did not include orders for hemodialysis. The Director of Nursing (DON) explained that it is the admitting nurse's responsibility to verify and carry out orders from the sending facility, including dialysis orders, upon a resident's admission. The facility's documentation showed that R3 received dialysis on specific days, but there was no physician's order to support these treatments. The DON acknowledged that the dialysis orders were missed, which could lead to the resident missing dialysis and deteriorating. The facility's procedure for dialysis care requires verifying a physician's order, which was not done in this case, leading to the deficiency.
Medication Unavailability for Two Residents
Penalty
Summary
The facility failed to adhere to its medication ordering policy, resulting in the unavailability of prescribed medications for two residents. For one resident, Cetirizine 5mg, scheduled for daily administration, was not dispensed on the morning of January 14, 2025, as the medication was not available. The LPN searched for the medication but confirmed its absence. For another resident, Fenofibrate 54mg and Trulicity 1.5mg/0.5ml, both scheduled for administration, were not dispensed as they were not available. The LPN acknowledged that the pharmacy had not sent these medications and confirmed that they would be sent later that day. The facility's policy requires medications to be ordered 72 hours before the last dose, which was not followed in these instances.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 46.15% error rate. This deficiency was observed during a survey where 12 medication errors occurred out of 26 opportunities. Two residents were directly affected by these errors. The errors included late administration of medications and unavailability of prescribed medications. Specifically, one resident's medications were administered 1.75 hours late, and one medication was unavailable. Another resident's medications were administered 2.75 hours late, with two medications unavailable due to the pharmacy not sending them. The Licensed Practical Nurse (LPN) involved acknowledged the errors and the reasons behind them, such as the pharmacy's failure to deliver certain medications and the late administration of others. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances. The surveyor's observations and interviews with the LPN highlighted these deficiencies in medication administration practices.
Medication Administration Errors in Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to improper medication administration practices. One resident, diagnosed with unspecified convulsions and Parkinson's disease, had physician orders for Divalproex and Levetiracetam to be administered twice daily. However, on a specific date, the medications were dispensed 1.75 hours after the scheduled time, which was outside the regulatory requirement of administering medications within one hour before or after the scheduled time. The LPN acknowledged the delay and the EMAR highlighted the late administration in red. Another resident, with diagnoses of type II diabetes mellitus and hypertension, had physician orders for Lisinopril, Metformin, Glipizide ER, and Trulicity. On the same date, the resident's blood sugar was recorded at 341, and the 9:00 am medications were dispensed approximately 2.75 hours late. Additionally, Trulicity was not available for administration, and the LPN had to contact the pharmacy to confirm its delivery. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances.
Failure to Provide Timely Pain Management Due to Medication Stock Issues
Penalty
Summary
The facility failed to manage a resident's pain effectively due to the unavailability of the prescribed Norco medication. The resident, who has a history of peripheral vascular disease, leg pain, and a vascular wound, was left without his Norco pain medication for over 24 hours. This resulted in the resident experiencing severe pain, rated as 8 out of 10 on a numerical pain scale. The resident reported that the Norco medication, which was supposed to be administered every 6 hours as needed, was not given because the facility ran out of stock, and the nurses did not attempt to retrieve it from the medication convenience box. The investigation revealed that the facility's medication ordering policy was not followed, as the Norco was not reordered in a timely manner. The Director of Nursing (DON) confirmed that the last Norco tablet was administered at 11:50 AM on the previous day, and the medication was reordered only after the last pill was given. The facility's policy requires medications to be reordered before the last pill is used to prevent running out. Additionally, the medication convenience box, which serves as a temporary source for medications, was not stocked with Norco, and the nurse was unable to access it due to a lack of a correct password. The pharmacy was responsible for restocking the medication convenience box but failed to include Norco 10/325 MG tablets. The Director of Clinical Services and the pharmacy confirmed that the Norco supply was on its way to the facility, but the delay resulted in the resident not receiving the necessary pain management. The nurse practitioner emphasized the importance of timely medication administration to manage the resident's pain effectively, highlighting the facility's failure to adhere to its pain management policy.
Inadequate Pressure Ulcer Care and Incorrect LALM Settings
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for three residents. The facility did not have enough Wound Care Nurses to meet the needs of the residents, resulting in delayed incontinence care and failure to administer prescribed treatments. Additionally, staff were not aware of the required settings for Low Air Loss Mattresses (LALM), leading to incorrect settings for the residents reviewed. One resident, with a history of dementia, multiple sclerosis, and diabetes, developed a facility-acquired stage 4 pressure ulcer on the sacrum with tailbone exposure and a suggestion of osteomyelitis. The resident's care plan included the use of an air loss mattress, but the LALM was set incorrectly. The resident was found with a soiled incontinence brief and a bowel movement on the sacrum dressing, indicating a lack of timely incontinence care. The treatment administration record showed multiple days where wound care was not documented. Another resident, with dementia and chronic kidney disease, developed a stage 3 pressure ulcer. The LALM was set incorrectly for this resident as well, and the incontinence brief was found wet and soiled with urine. The treatment administration record for this resident also showed a missed documentation of wound care. A third resident, with diabetes, also had a stage 3 pressure ulcer and was found with an incorrectly set LALM and a soiled incontinence brief. The facility's policy on LALM did not include specific settings, contributing to the issue.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to meet the needs of residents, as evidenced by multiple call-offs and late arrivals of CNAs and nurses on both day and evening shifts. On the day in question, three CNAs called off for the day shift, and one nurse and two CNAs called off for the evening shift. Additionally, several CNAs arrived late for their shifts, further exacerbating the staffing shortage. This resulted in only two CNAs being available to care for 38 residents on the 2nd floor, with one of them being a restorative aide pulled from her usual duties. The staffing shortage led to inadequate care for residents, as observed by the surveyor. One resident was found with long, thick, discolored fingernails and a soiled incontinence brief, indicating a lack of personal hygiene care. Another resident was left in a wheelchair for approximately four hours with a soiled incontinence brief and a cloudy urinary catheter, suggesting insufficient monitoring and care. A third resident was found repeatedly requesting water, which was not available in the room, and had a wet incontinence brief, indicating neglect in basic care needs. The facility's staffing issues were compounded by the lack of a clear policy for addressing call-offs and the non-use of agency staff, despite the facility's emergency staffing policy allowing for such measures. The Director of Nursing and other staff members acknowledged the staffing challenges but did not provide a clear solution or explanation for not utilizing agency staff. The facility's failure to maintain adequate staffing levels and provide necessary care to residents was evident in the observations and interviews conducted by the surveyor.
Inadequate Staffing Leads to Missed Restorative Care
Penalty
Summary
The facility failed to provide appropriate restorative care to maintain or improve the range of motion for three residents, R1, R2, and R3, due to inadequate staffing and failure to follow policy procedures. On the second floor, there were only two CNAs available for 38 residents, and one of them, who was supposed to be a Restorative Aide, was pulled to perform general CNA duties due to staffing shortages. This resulted in the absence of restorative care for the residents on certain days, as documented in the care plans and nursing rehab documentation. Specifically, R1 and R2 did not receive their scheduled Active Range of Motion (AROM) exercises, and R3 did not receive Passive Range of Motion (PROM) exercises on specified dates. The facility's Restorative Nursing Program, which aims to promote the highest practicable physical, mental, and psychosocial well-being, was not adhered to as restorative care was not provided as scheduled. The Restorative Nurse confirmed that if documentation is blank, it indicates that the care was not provided. The failure to provide restorative care as directed has the potential to affect all 38 residents on the second floor, as the program is designed to preserve function and promote optimal improvement. The report highlights the facility's inability to ensure that staff were available to provide the necessary restorative care, leading to a deficiency in maintaining the residents' range of motion and mobility.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADL) for two dependent residents, R2 and R3. R3, who has moderate cognitive impairment and is dependent on staff for personal hygiene and toileting, was observed with long, unkempt facial hair and excessively long, thick, discolored fingernails. Additionally, R3's incontinence brief was found to be soiled with urine, indicating a lack of timely incontinence care. The care plan for R3 required assistance with all ADLs, including personal hygiene and appropriate cleansing after each incontinent episode, which was not adhered to by the staff. R2, who has severe cognitive impairment and requires extensive assistance with ADLs, was found in bed repeatedly requesting water, which was not available in the room. Upon receiving water, R2 drank it immediately, suggesting extreme thirst. Furthermore, R2's incontinence brief was also found to be soiled with urine, despite the facility's policy requiring CNAs to check and change briefs every two hours. The facility's failure to implement care plan interventions and adhere to their ADL policy resulted in inadequate care for these residents.
Failure to Reschedule Neurology Appointment for Resident
Penalty
Summary
The facility failed to ensure they had a policy for scheduling and rescheduling appointments, which led to a missed Neurology appointment for a resident diagnosed with Multiple Sclerosis. The resident was scheduled for a Neurology clinic appointment on November 11, 2024, but did not attend because she was hungry. The Director of Nursing (DON) acknowledged the missed appointment but did not reschedule it. The resident's daughter expressed concerns about the missed Neurology appointments, which were communicated to the DON, but no action was taken to address these concerns. The facility's Social Service Director confirmed that the concerns were documented and shared with the nursing staff, but there was no follow-up from the DON. The Admissions Director, responsible for scheduling transportation for appointments, confirmed that there was no rescheduled Neurology appointment for the resident. Additionally, the facility administrator admitted via email that there was no policy in place for scheduling or rescheduling appointments, contributing to the unresolved status of the resident's care concerns.
Failure to Follow Catheter Care Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the care of residents with indwelling urinary catheters, leading to a deficiency in the care of a resident with neuromuscular dysfunction of the bladder. The resident's care plan required monitoring, recording, and reporting signs and symptoms of urinary tract infections (UTIs) to a physician. However, the facility did not transcribe physician orders for catheter care onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR), resulting in the exclusion of necessary catheter treatments and cleaning orders. Observations revealed that the resident's catheter tubing was coated with a white, purulent substance, and the urine was cloudy, indicating potential issues that were not reported to the physician as required. Interviews with facility staff, including registered nurses and certified nursing assistants, highlighted a lack of knowledge and adherence to the facility's urinary catheter care policy. Staff were unable to confirm when the resident's catheter bag was last changed, and there was confusion about the standard frequency for changing urinary drainage bags. The Director of Nursing and Medical Director provided inconsistent information regarding the standard practice for catheter and drainage bag changes. The facility's urinary catheter care policy outlined specific conditions under which catheters and tubing should be removed and reinserted, but these guidelines were not followed, contributing to the deficiency.
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 1,728 citations issued within 25 miles in the last 12 months — including the 28 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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winston Manor Cnv & Nursing | 0.8 mi | ★★★★★ | 11 | 1 |
| Pavilion Of Logan Square, The | 1.2 mi | ★★★★★ | 14 | 0 |
| Avantara Lincoln Park | 2.2 mi | ★★★★★ | 9 | 0 |
| Little Sisters Of The Poor | 2.2 mi | ★★★★★ | 0 | 0 |
| St Joseph Village Of Chicago | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Center Home Hispanic Elderly.
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.