Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Evercare Of Swansea during CMS and state inspections, most recent first.
A resident with cognitive impairment, confusion, and lack of safety awareness was allowed to leave the facility unsupervised after signing himself out, with staff failing to verify his responsible party status, destination, or return time. The resident was later found by police several hours later, confused and injured near a highway, and required emergency medical care. Staff interviews revealed incomplete assessments, lack of documentation, and inadequate supervision contributed to the incident.
An LPN and an RN failed to perform hand hygiene before and after glove changes and did not use required PPE during wound care for multiple residents. The LPN provided wound care without an isolation gown or EBP signage/supplies, and the RN changed gloves without hand hygiene while handling wound products and dressings for a resident with wound care orders. Residents stated that nurses did not wear isolation gowns when changing dressings.
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 there was insufficient monitoring in the area.
A resident did not receive the necessary behavioral health care and services required, as the facility failed to provide appropriate interventions and supports.
Surveyors observed improper food storage and labeling, including uncooked meat stored above ready-to-eat items, expired dairy products, and undated prepared foods in both facility and resident refrigerators. A resident reported that staff do not have time to clean out her refrigerator, and the Dietary Manager confirmed that discard dates were missing on some items. These findings were not in accordance with the facility's food storage policy.
Unsanitary and poorly maintained areas were observed throughout the facility, including dirty floors, trash and food debris in hallways and the dining room, a shower room with dried feces and broken fixtures, and an employee bathroom with missing ceiling tiles, water stains, exposed wiring, and standing water. Staff reported frequent toilet overflows, flooding in multiple areas, and mold in the laundry area, while residents described sticky, dirty floors, puddling water, and reduced housekeeping coverage.
Several cognitively intact residents reported a persistent shortage of clean towels and wash cloths, resulting in delays in bathing and the need for families to supply linens. CNAs and the DON confirmed the ongoing linen shortage, with staff attributing the issue to possible improper disposal or hoarding. The facility's policy requires adequate linen supplies, but this was not met, affecting residents' daily hygiene and comfort.
A resident with moderate cognitive impairment and multiple medical conditions was unable to access a telephone in private because the phones were located at the nurse's station and used by staff for work-related calls. The resident was told to finish his call due to other residents waiting and staff needing the phone, which did not align with the facility's policy granting residents the right to private phone use.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility.
A CNA was allowed to work with residents without the facility completing a required criminal background check, relying instead on a background check from a previous employer. The staff member transferred from a sister facility and began working before the facility conducted its own screening, contrary to the facility's abuse prevention policy. This lapse was confirmed by the Administrator and DON.
A resident with alcohol-induced dementia and moderate cognitive impairment, who frequently gave out his debit card to staff for purchases, had his card used by a CNA to pay personal rent. The care plan did not address the resident's risk for abuse or neglect, and staff interviews confirmed the resident's pattern of giving out his card. The incident was substantiated through investigation and bank records, revealing a failure to protect the resident from misappropriation of property.
A resident with multiple chronic conditions provided money and gifts to two CNAs, including paying bills and transferring funds via cash app. Despite staff awareness and prior notification to administration, the allegation of exploitation was not immediately reported to the Executive Director, and the Administrator only learned of the situation from surveyors. This resulted in a deficiency in timely abuse reporting procedures.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in an environment that posed risks for resident safety.
The facility did not ensure that the Medical Director attended the required QAPI meeting, as shown by the absence of the Medical Director's signature on the attendance record and confirmation from the Administrator. Facility policy requires representation from all areas, including the Medical Director, on the QAA committee.
Multiple observations revealed unsanitary and hazardous conditions throughout the facility, including dirty floors, broken tiles, malfunctioning toilets, and pest infestations. Residents and staff reported ongoing issues with cleanliness, plumbing, and maintenance, while interviews confirmed that management was aware of these problems but had not resolved them. The environment was further compromised by exposed wiring, poor lighting, and mold in shower areas, affecting all residents.
The facility did not provide evidence of mandatory infection control training for staff, and no policy regarding such training was available. The Administrator was unaware of when staff were last trained, and the Infection Preventionist, an LPN, had no documentation of training. This deficiency potentially affected all 57 residents currently residing in the facility.
The facility did not implement or document a nurse aide training program to ensure at least 12 hours of annual continued competence, and leadership could not provide evidence or policy regarding such training for nurse aides, affecting all current residents.
The facility did not implement or document a behavioral health training program for staff, despite serving residents with various psychiatric and mood disorders and having no policy in place for such training. The administrator and VP of Clinical Services were unable to provide evidence of prior training or a relevant policy, affecting all residents currently residing in the facility.
The facility did not report allegations of abuse involving two residents to the state agency within the required 2-hour timeframe. In both cases, staff either failed to recognize or delayed reporting the allegations, and internal investigations were initiated without timely external notification. Documentation and staff interviews showed a lack of understanding of abuse reporting requirements and the facility's own policy.
Two residents with significant medical conditions reported incidents of staff being rough or abusive during care, but the facility failed to conduct thorough investigations. In both cases, there was incomplete documentation, delayed or insufficient interviews, and a lack of follow-through with required procedures, including interviewing other residents assigned to the accused staff. The care plans did not reflect the residents' risk for abuse, and staff did not consistently follow the facility's abuse prevention policy.
A resident with multiple chronic conditions and impaired mobility did not receive physician-ordered PT and OT services. The resident remained bed bound, reporting no therapy had been provided, while the therapy director confirmed the order was missed and the administrator could not locate a relevant policy.
Multiple residents and staff observed mold and musty odors in communal shower rooms, bathrooms, and a medication room, with black and orange substances present on surfaces. The DON and maintenance director confirmed the presence of mold, and the facility lacked a housekeeping supervisor at the time. Despite facility policy requiring immediate cleaning, the mold was not addressed, resulting in unsanitary conditions for residents using these areas.
The facility failed to provide information, obtain consents, and offer influenza vaccinations to four residents. One resident, moderately cognitively impaired, had no documentation of information or consent for the vaccine. Another resident, with no cognitive deficits, reported not receiving vaccines and expressed a desire for them, yet lacked documentation of information or consent. A severely cognitively impaired resident with a POA also lacked documentation. A resident with no cognitive deficits had a record of receiving the vaccine but no documentation of information or consent. The DON acknowledged seeing consents but not vaccine administration, and the Regional Nurse Consultant mentioned ongoing efforts to determine residents' vaccine status.
The facility failed to provide information, obtain consents, and offer COVID-19 vaccinations to four residents. Despite some residents having paper chart entries showing vaccine dates, there was no documentation of information or consent in their medical records. The DON and Regional Nurse Consultant acknowledged the issue, citing recent changes in facility ownership.
Two residents experienced significant medication errors due to the unavailability of prescribed medications. One resident missed doses of Metoprolol Tartrate for several days, while another missed Warfarin doses. The LPN and DON acknowledged the issues, with the pharmacist noting the severity of missing Warfarin. The facility's policy requires medications to be administered by a licensed nurse, which was not adhered to in these cases.
The facility failed to provide an RN for at least eight hours daily and lacked a full-time DON, affecting all 39 residents. The facility was without a DON from late November until early January, and multiple days lacked RN coverage. An LPN reported working alone during a COVID outbreak, highlighting staffing issues.
The facility failed to provide sufficient staffing, resulting in delayed assistance for residents. A resident dependent on staff for daily activities had to wait over two hours to get out of bed due to short staffing. Another resident's call light went unanswered for over 30 minutes, causing concern for their family. Staff confirmed the facility was operating with fewer CNAs than usual, impacting care delivery.
A resident with dementia and other medical conditions was not assessed after being lowered to the floor during a transfer, resulting in a delayed diagnosis of a tibial plateau fracture. Despite signs of injury, the resident was not sent for evaluation until days later. The facility's fall policy was not followed, as there was no documentation or immediate assessment of the incident.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, affecting all 40 residents. This issue arose after the DON left without notice, and no replacement was hired. The only other RN works only 3 days a week, and the facility does not use agency RNs for coverage unless needed for IV medications. The facility lacks a formal RN staffing policy, leading to multiple days without RN coverage.
The facility failed to administer medications to four residents on the 200 Hall due to a lack of nursing staff. An LPN reported the absence of a nurse, but the issue was not resolved in time. An agency nurse later refused to administer the missed medications, and the residents did not receive their necessary medications, which included treatments for chronic conditions.
A failure to administer medications occurred when residents on a specific hall did not receive their prescribed doses due to a staffing issue. An LPN discovered the absence of a nurse and informed the administrator, but the agency nurse who arrived later refused to administer the missed medications. This affected residents with chronic conditions, including diabetes and hypertension, who missed critical doses of their medications.
The facility failed to store, prepare, and serve food safely, risking food-borne illness for 35 residents. Observations included improper food labeling, thawing, and storage, as well as hygiene violations by dietary staff. A turkey was left to thaw improperly, and the kitchen was found to be unclean, with staff not wearing beard nets.
The facility failed to maintain an effective infection control program, as evidenced by incomplete documentation of causative organisms for infections and inadequate implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A resident with a gastrostomy tube did not have appropriate PPE used during medication administration, and there was a lack of signage and PPE availability for EBP.
The facility failed to provide mechanically altered diets as prescribed for residents with specific dietary needs. During a breakfast service, a dietary aid served ground ham without necessary moisture, such as gravy or sauce, to residents on a mechanical soft diet. This was inconsistent with the facility's policy and physician orders, which required such modifications to facilitate oral intake for residents with conditions like cerebral infarction and Alzheimer's disease.
The facility failed to implement an effective infection prevention and control program, leading to inappropriate antibiotic use in four residents. Antibiotics were prescribed based on symptoms without obtaining cultures, contrary to the facility's Antibiotic Stewardship Program Policy. Staff interviews revealed a lack of consistent adherence to the policy, contributing to the deficiency.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to follow a prescribed diet and lack of personnel to perform a swallow test. The resident's weight dropped from 120 pounds to 101 pounds over several months. The dietician's monitoring was interrupted due to a payment issue, and the facility did not re-weigh the resident upon readmission, contributing to the deficiency.
The facility failed to properly store and label medications, with issues including an undated insulin pen, illegible medication labels, and expired supplements not removed from storage. Food was also improperly stored with medications, contrary to facility policy.
A facility failed to prevent abuse for three residents, leading to physical altercations involving a resident with a history of aggressive behavior. Despite known risks, the facility's interventions were insufficient, resulting in repeated incidents of violence. Staff interviews revealed inconsistencies in understanding and executing abuse prevention protocols.
The facility failed to repair roof damage, leading to water leakage in several unoccupied rooms and common areas. The administrator acknowledged the issue but had not sought repair bids, hoping for resolution through a potential sale. Staff confirmed the leaks, and a contractor assessed the need for a new roof. The facility's policy requires a safe and comfortable environment, which is compromised by the current conditions.
Failure to Supervise Cognitively Impaired Resident Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with fluctuating cognitive impairments, resulting in the resident leaving the facility unsupervised. The resident, who had diagnoses including Parkinson's, diabetes, bipolar disorder, schizophrenia, and dementia, was noted to have episodes of forgetfulness, confusion, impaired vision, and a lack of safety awareness. Despite these conditions, the resident was allowed to sign himself out of the facility with no documentation of his destination, who he was with, expected return time, or what he was wearing. Staff were unaware of his whereabouts for several hours. Multiple staff interviews revealed that the resident was new to the facility, and several staff members did not know his cognitive status or medical history. The assigned LPN admitted to not completing or documenting the required initial clinical assessment and did not update the resident's record to reflect his confusion and lack of safety awareness. The agency nurse who facilitated the resident's sign-out did not verify whether the resident had a power of attorney, did not check his medical record for responsible party status, and did not inquire about his plans or ensure he had necessary medications. Other staff members were either not assigned to the resident or were preoccupied with other duties, resulting in a lack of supervision and monitoring on the resident's hall. The resident was later found by police several hours after leaving the facility, sitting confused and lethargic by a busy highway, with multiple abrasions, bruises, and signs of exposure to cold. He was transported to the emergency room, where he was found to be disoriented, unable to provide his name or location, and required medical treatment for his injuries and dehydration. The facility did not notify the resident's family or report the incident to the state, and there was confusion among staff regarding responsibility for the resident's safety once he had signed himself out.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene before and after glove changes and failed to wear personal protective equipment during wound care for 3 of 3 residents reviewed for infection control. An LPN provided wound care to one resident’s left and right calves while wearing gloves but without donning an isolation gown for enhanced barrier precautions, and there was no signage on the resident’s door or supplies for enhanced barrier precautions. During the care, the LPN removed an old dressing, cleansed open areas, and handled wound products and dressings without hand hygiene or glove changes between tasks. The same LPN also entered another resident’s room, donned gloves without hand hygiene, and did not wear a gown for enhanced barrier precautions; there was no signage on the door or supplies present. She cleansed a wound on the back of the resident’s left calf and applied skin prep with the same gloved hands. In a separate observation, an RN performed wound care for a third resident, including cleansing with Dakin’s solution and applying mupirocin ointment, calcium alginate, and a bordered gauze dressing, while changing gloves without hand hygiene between steps and handling multiple wound care items with the same gloved hands. Residents interviewed stated that nurses did not wear isolation gowns when changing their dressings, and the records documented enhanced barrier precautions for wounds.
Failure to Maintain Accident-Free 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, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents in need. The lack of appropriate behavioral health care and services was directly noted during the survey process.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
The facility failed to store food in a manner that prevents foodborne illness, as evidenced by multiple observations of improper food storage and labeling practices. In the kitchen's refrigerator/freezer, uncooked beef patties were stored directly above a box of popsicles, creating a risk of cross-contamination. In the standing refrigerator, a tub of sour cream was found with a past Best By date, and several containers of prepared foods, including hamburger patties, banana pudding, chocolate pudding, and tuna, were either not labeled or lacked discard dates. The Dietary Manager acknowledged that discard dates were not written on some labels. Additionally, in the dry storage room refrigerator, a package of turkey was found with a future Use By date, but the report does not specify if this was an issue. A resident's personal refrigerator contained expired items, including a carton of milk and two protein shakes, as well as a Styrofoam container with a meal ticket dated well before the inspection. The resident stated that staff do not have time to clean out her refrigerator. The facility's policy requires all foods to be covered, labeled, and dated with an expiration or use-by date, and for storage areas to be maintained in a clean, safe, and sanitary manner. The administrator confirmed that dietary staff are expected to follow food service policies.
Unsanitary and Poorly Maintained Facility Environment
Penalty
Summary
The facility failed to provide a clean and safe, sanitary environment for residents, with observations showing trash, stains, debris, and unsanitary conditions in resident care and common areas. During tour observations, a room on the 100 hallway had a large brown smear on the floor in front of the first bed and trash scattered on the floor. The main hallway had a large pink stain in front of the dining room and black scuff marks along the hallway. In another room on the 200 hallway, a dirty urinal was lying on the floor, a box of incontinent briefs was sitting on the floor, and a bag of trash was tied to the handrail outside the room door. The dining room and shower areas were also observed to be unclean and in disrepair. The dining room floor had salt and pepper packets, sugar packets, an orange peeling, and a large red Kool-Aid spot on the floor, along with an old Styrofoam container holding old food and multiple black skid marks across the floor. The shower room on the 200 hallway had no towels or washcloths, dried feces in the toilet bowl, a broken toilet-paper dispenser with no cover, no handrail by the toilet, and a baseboard that had fallen off and was lying on the floor. In the employee bathroom on the 200 hallway, two ceiling tiles were missing and broken, one tile was bulging, two had water stains, a large trash can contained about 3 inches of water, and exposed duct work, pipes, and wiring were present. Additional observations and interviews documented ongoing water intrusion, flooding, and mold concerns in multiple areas of the facility. A resident’s floor was sticky and visibly dirty with wheelchair marks, and the 100-hall flooring was also sticky and visibly dirty. A resident reported a big puddle in the middle of the floor that had required blankets to soak up water and said it happened again after about a week. Another resident stated the facility was dusty and that housekeeping staffing had been cut due to budget. Staff interviews described toilets on the 200 hallway backing up and overflowing often, with BM and urine spilling onto the floor, and housekeeping staff reported flooding in bathrooms, the kitchen, and the laundry. A laundry staff member reported flooding in the laundry room when it rains and showed an area with missing plaster and black mold on a board and on the wall behind it. Resident council minutes also documented trash being left in the hallway until the end of the shift and that the 200 hallway needed more attention and toilets needed to be cleaned regularly.
Failure to Maintain Adequate Clean Linen Supplies
Penalty
Summary
The facility failed to provide adequate clean linen supplies for four cognitively intact residents, resulting in a lack of towels and wash cloths necessary for daily hygiene and bathing. Multiple residents reported that there were not enough towels and wash cloths available, with some stating that their families had to bring in these items from outside the facility. Residents also reported delays in receiving showers, sometimes waiting up to two weeks, due to the shortage of clean linens. These observations were corroborated by staff, who confirmed the frequent absence of towels in the clean utility closet and attributed the shortage to possible improper disposal or hoarding of linens. Interviews with CNAs and the DON revealed ongoing issues with linen management, including suspicions that some towels were being thrown away or kept in residents' rooms. The facility's own policy requires that clean linens be stored to prevent contamination and that laundry personnel ensure adequate supplies are available on each unit. Despite this policy, the facility was unable to maintain sufficient clean linen supplies, directly impacting residents' ability to maintain personal hygiene and comfort.
Failure to Provide Private Telephone Access
Penalty
Summary
The facility failed to provide reasonable access to a telephone in an area where calls could be made without being overheard for one resident. The resident, who was moderately cognitively impaired and had diagnoses including depression, hypertension, and heart failure, became upset when he was unable to use the phone because a nurse was already using it. The resident reported that an LPN would not allow him to use the phone at the nurse's station, and the LPN confirmed that she asked the resident to finish his call due to other residents waiting and the need to make important nursing calls. The Director of Nursing acknowledged that phones for resident use were located at the nurse's stations, which were also used by staff for work-related calls, and stated that the facility should have phones available for residents to use. The facility's policy documented that residents have the right to use a phone in privacy.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is included in the report.
Failure to Complete Required Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to implement its written policy regarding abuse prevention by not ensuring that required criminal background checks were completed prior to allowing direct care staff to work with residents. Specifically, a Certified Nursing Assistant (CNA) was employed and worked at the facility without a new criminal background check being conducted by the facility, despite the CNA having a background check from a previous employer. The CNA transferred from a sister facility and began working without the facility completing its own screening process. Interviews with the Administrator and Director of Nursing confirmed that the facility did not follow its established procedures for onboarding and background checks, as outlined in its abuse prevention policy. At the time of the deficiency, there were 52 residents residing in the facility.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with alcohol-induced dementia and moderate cognitive impairment from misappropriation of property. The resident, who required assistance with personal care and was known to frequently give out his debit card to staff and others to make purchases, had his debit card used without authorization. The facility's records and interviews revealed that the resident's debit card was used on multiple occasions in various cities, including a transaction to pay rent for a certified nursing assistant (CNA) employed at the facility. The resident was unable to recall to whom he had given his card or the circumstances surrounding the transactions. Staff interviews confirmed that the resident regularly asked staff and others to make purchases for him using his debit card, and it was common knowledge among staff that he would give out his card. The facility's care plan did not address the resident's risk for abuse or neglect, despite his cognitive impairment and behavior. The investigation determined that a staff member used the resident's debit card for personal expenses, which was corroborated by bank statements and a reverse search of the transaction. The staff member implicated was subsequently terminated, but the incident demonstrated a failure to prevent misappropriation of resident property as required by facility policy.
Failure to Timely Report Alleged Exploitation of Resident
Penalty
Summary
The facility failed to immediately report allegations of exploitation involving a resident to the Executive Director as required. The incident involved a resident with a BIMS score of 15 and multiple diagnoses, including Major Depressive Disorder, COPD, Type 2 Diabetes with Hyperglycemia, hypertension, and chronic congestive heart failure. Documentation and interviews revealed that the resident had provided money, gifts, and other financial benefits to two Certified Nurse's Aides (CNAs), including paying bills, giving gifts, providing house keys, and transferring money via cash app. One CNA confirmed receiving money for coffee and donuts, while another staff member reported that the administration had been informed of these actions prior to a change in facility ownership. The Administrator stated that they only became aware of the abuse allegation when informed by surveyors, and that the CNA involved had already been terminated for tardiness. The facility's abuse policy requires the prevention, identification, investigation, and reporting of abuse, neglect, and misappropriation of property in accordance with federal and state requirements. However, the failure to promptly report the allegations to the Executive Director constituted a deficiency in the facility's abuse reporting procedures.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings included all required members, specifically the Medical Director. During the last QAPI meeting, as evidenced by the attendance record dated 4/25/25, the line for the Medical Director's attendance was left blank, and the Administrator confirmed that the Medical Director was not present due to the meeting being scheduled at the last minute. The facility's own policy requires that each area, including the Medical Director, be represented on the Quality Assessment and Assurance (QAA) committee. At the time of the survey, the facility census showed 57 residents residing in the facility.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and well-maintained environment for all residents, as evidenced by multiple observations of unsanitary and hazardous conditions throughout the building. Surveyors documented the presence of brown sticky substances, dirt, debris, dried feces, and urine in resident rooms and restrooms. Several rooms had toilets that were not functioning, with signs indicating they were out of order, and plumbing issues were reported by both staff and residents. Floors and cove bases were observed with significant buildup of dirt, stains, and residue, and in many areas, the flooring was damaged, with missing or broken tiles, chipped concrete, and uneven surfaces. These conditions were present in both private and common areas, including shower rooms, hallways, and the dining room, where missing cove base and crumbling drywall were also noted. Interviews with residents, staff, and the ombudsman confirmed ongoing concerns about the cleanliness and maintenance of the facility. Residents reported seeing mice, dead insects, and flies, and expressed distress about the state of their living environment. Staff members, including CNAs and housekeepers, stated that the facility was filthy, that plumbing frequently backed up, and that housekeeping was unable to keep up with the cleaning demands due to persistent maintenance issues. The Housekeeping/Laundry Supervisor and other housekeepers indicated that the floors required stripping and scraping, but there was no dedicated floor technician, and management was aware of these issues but had not taken sufficient action. The ombudsman and a resident's power of attorney also reported repeated complaints to facility leadership about the poor condition of the building and lack of timely repairs. Additional hazards were observed, such as exposed electrical wires, missing light fixture covers, poorly lit hallways, loose hand railings, and damaged furniture. Mold and black residue were noted in shower rooms, and a large fan covered in dust was found blowing air onto the food preparation area in the kitchen. Facility records, including Resident Council minutes and the facility's own policy, documented that maintenance and housekeeping were understaffed and unable to keep up with the required upkeep. The facility's failure to address these environmental deficiencies affected all residents, including those who were cognitively intact and able to articulate their concerns, as well as those with cognitive impairments.
Failure to Implement Infection Control Training Program
Penalty
Summary
The facility failed to implement a mandatory infection control training program for its staff as part of its infection prevention and control program. During interviews and record reviews, the Administrator was unable to provide evidence of recent staff training on infection control and was unaware of when such training last occurred. Additionally, the Vice President of Clinical Services confirmed that there was no available policy regarding infection control training. The facility's assessment documented that it has 90 licensed beds for long-term care nursing services, including care for infectious organisms, and the current census showed 57 residents residing in the facility. The designated Infection Preventionist is a Licensed Practical Nurse, but no documentation of infection control training was available for review.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to implement a nurse aide training program that ensures continued competence equivalent to at least 12 hours per year, as required. During interviews and record reviews, the Administrator was unable to provide evidence of recent nurse aide training and was unaware of when staff last received such training. Additionally, the Vice President of Clinical Services confirmed that there was no available policy regarding nurse aide training. At the time of the survey, the facility had 57 residents and 90 licensed beds for long-term care nursing services, but lacked documentation or reproducible evidence to support that nurse aide training had occurred.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement a behavioral health training program for its staff, as required by its own facility assessment and regulatory standards. During interviews and record reviews, the administrator was unable to provide evidence that staff had received behavioral health training, nor could she recall when such training last occurred. The administrator confirmed that staff would receive behavior training at an upcoming meeting, but no documentation was available to show that training had previously taken place. Additionally, the Vice President of Clinical Services confirmed that there was no policy regarding behavior training available. The facility assessment documented that the facility accepts and serves residents with a range of psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and behaviors requiring intervention, with an average of 40-60 residents needing behavioral health services. At the time of the survey, the facility census was 57 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the administrator immediately and to the state agency within the required 2-hour timeframe for two residents. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA hurt her arm and abused her during a transfer. The CNA who witnessed the allegation did not report it to other staff, believing the accused CNA was not rough with residents. The LPN documented the resident's statement and performed a skin assessment, then notified the DON. However, there was no documentation in the resident's progress notes about the abuse allegation, and the DON did not report the incident to the state agency, instead documenting a 'soft file' and initiating an internal investigation the following day. In the second case, a resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive and intentional. The resident reported the incident to the DON, who stated that the initial report was about unmet needs and staff attitude, not abuse. The resident later reported the incident to the administrator, who delayed reporting to the state agency because the staff member's identity was unknown. The abuse investigation was not started until several days after the initial report, and the resident continued to be assigned to the same CNA despite her request for a change. In both cases, the facility's documentation did not reflect timely reporting of the abuse allegations to the state agency as required by federal and state regulations. Staff interviews revealed a lack of understanding of the definition of abuse and the facility's abuse reporting policy. The facility's abuse prevention program requires immediate reporting of suspected abuse, but this protocol was not followed in these instances.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, both of whom had significant medical conditions and reported incidents involving staff. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA was rough during a transfer, resulting in the resident landing on the floor. The resident described the incident as not accidental and stated that the CNA was frustrated and had previously had confrontations with her. Documentation in the progress notes and initial abuse investigation report indicated that the resident complained of being hurt, but there was no detailed follow-up on what the resident meant by being hurt. Additionally, the investigation did not include interviews with other residents cared for by the accused CNA, and there was a lack of documentation regarding the resident's risk for abuse in her care plan. In the second case, another resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive. The resident reported the incident to the DON, who did not initiate an immediate investigation or suspend the CNA. The CNA was not asked to provide a written statement at the time, and the resident continued to be assigned to the same CNA after the allegation. The administrator was unaware of the definition of abuse and did not report the allegation to the state agency promptly, as she was still trying to identify the staff member involved. The investigation into this incident was delayed and only began after further reporting by the resident. Both cases revealed deficiencies in the facility's abuse investigation process, including incomplete documentation, lack of timely and thorough interviews, and failure to follow the facility's abuse prevention policy, which requires prompt and comprehensive investigations and interviews with other residents assigned to the accused staff. The care plans for both residents did not document their risk for abuse, and staff did not consistently follow procedures for reporting and investigating abuse allegations.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as ordered by a physician for a resident who was bed bound. The resident's medical record documented diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, Morbid Obesity, and musculoskeletal symptoms. The care plan identified impaired physical mobility, and the Minimum Data Set (MDS) indicated the resident required substantial to maximal assistance for mobility and that other mobility assessments were not attempted due to medical or safety concerns. Despite a physician's order for PT and OT evaluation and treatment, the resident did not receive these services. During interviews, the resident reported not having received physical therapy during the year and expressed a desire to get out of bed, stating that staff told him they could not assist him without therapy involvement. The Director of Therapy confirmed that the therapy department had not worked with the resident and was unaware of why the therapy order was missed. The facility administrator was unable to locate a policy regarding following physician orders. These findings demonstrate that the facility did not implement the physician's order for specialized rehabilitative services for the resident.
Failure to Maintain Sanitary Shower and Bathroom Areas Due to Mold
Penalty
Summary
The facility failed to maintain clean and sanitary shower rooms and bathrooms, resulting in the presence of mold and musty odors in multiple areas used by residents. Observations revealed black, slimy, and orange substances on shower walls, shower heads, and bathroom floors in both the 100-hall and 200-hall shower rooms, as well as in a medication room. Several staff members, including CNAs, a laundry aide, and a housekeeper, confirmed noticing mold in shower rooms, resident rooms, and bathrooms. Residents also reported seeing mold and smelling musty odors, particularly in the 100-hall shower room and adjacent areas. The facility's own maintenance director and DON acknowledged the presence of mold after accompanying surveyors to the affected areas. The DON also confirmed that a significant number of residents use the communal shower rooms, which were found to be contaminated. The facility lacked a housekeeping supervisor at the time, with the DON temporarily overseeing housekeeping duties. Despite the facility's policy requiring immediate cleaning and notification when mold is found, the mold remained present and was not addressed prior to the survey. Facility policy and CDC guidance provided in the report highlight that mold and mildew are expected to be controlled through routine deep cleaning, and that exposure to mold can cause health effects, especially in individuals with respiratory conditions or compromised immune systems. The failure to maintain a clean, safe, and homelike environment as required resulted in unsanitary conditions for residents using the affected shower rooms and bathrooms.
Failure to Provide Information and Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to provide information, obtain consents, and offer influenza vaccinations to four residents reviewed for immunization. Resident 1, who is moderately cognitively impaired, had no documentation in their medical record regarding the provision of information or consent for the influenza vaccine, despite a previous vaccination recorded in 2020. Resident 2, who has no cognitive deficits, reported not receiving any vaccines during the winter and expressed a desire for them, yet there was no documentation of information or consent for the flu vaccine in their medical record. Resident 3, who is severely cognitively impaired and has a Power of Attorney (POA), also lacked documentation of information or consent for the flu vaccine in their medical record. Resident 5, who has no cognitive deficits, had a record of receiving the influenza vaccine in 2023, but there was no documentation of information or consent in their medical record. The Director of Nursing, who recently started, acknowledged seeing consents for various vaccines but not the administration of the vaccines. The Regional Nurse Consultant mentioned that the facility was recently acquired and that they were still working on determining the vaccine status of residents. The facility's policy states that residents or their representatives should be provided with education about immunizations and that consent for the influenza vaccine is valid for the duration of the resident's stay, with annual administration unless contraindicated or already received.
Failure to Provide COVID-19 Vaccine Information and Obtain Consent
Penalty
Summary
The facility failed to provide information, obtain consents, and offer COVID-19 vaccinations to four residents reviewed for COVID-19 immunization. Resident 1, who is moderately cognitively impaired, had no documentation in their medical record indicating that the facility attempted to provide information or obtain consent for the COVID-19 vaccination, despite a paper chart entry showing a vaccine date. Resident 2, who has no cognitive deficits, reported not receiving any vaccines and expressed a desire for vaccination, yet there was no documentation of information or consent in their medical record. Resident 3, who is severely cognitively impaired and has a Power of Attorney (POA), also lacked documentation of information provided to the POA or consent obtained for vaccination, despite a paper chart entry showing a vaccine date. Similarly, Resident 5, who has no cognitive deficits, had no documentation of information or consent for vaccination in their medical record, despite a paper chart entry showing a vaccine date. The Director of Nursing and Regional Nurse Consultant acknowledged the lack of vaccine administration and documentation, citing recent changes in facility ownership and plans to address the issue.
Significant Medication Errors Due to Unavailability
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in missed doses of critical medications. One resident, diagnosed with hypertension and congestive heart failure, did not receive their prescribed Metoprolol Tartrate for several days due to the medication running out at the end of February. The medication was ordered on March 3rd and arrived on March 5th, but the resident missed doses on March 1st, 2nd, 3rd, and 7th. The resident confirmed not receiving their heart medication for a few days, and the LPN acknowledged the delay in medication availability. Another resident, with diagnoses including congestive heart failure and hypertension, missed doses of Warfarin on March 5th, 6th, and 7th. The resident reported being out of Warfarin for a couple of days, and the DON, who had been in the position for three weeks, was unaware of the missing medications. The pharmacist emphasized the significance of missing Warfarin, an anticoagulant, as a major medication error. The facility's policy mandates that medications be administered by a licensed nurse per the physician's order, highlighting a failure in adherence to this policy.
Deficiency in RN Staffing and DON Availability
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for a minimum of eight hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis. This deficiency was identified through interviews, observations, and record reviews. The facility had been without a DON since November 27, 2024, and although a new DON was offered the position on December 13, 2024, she did not start until January 6, 2025. On January 15, 2025, it was observed that the facility was staffed with only three Certified Nursing Assistants (CNAs) and one Licensed Practical Nurse (LPN) at the start of the day, with the administrator stepping in to pass medications due to an agency nurse and the DON calling off. The facility's schedule for December 2024 and January 2025 showed multiple days without an RN on duty, including December 20, 23, 24, 26, 28, 29, 31, and January 1, 3, 7, 9, 12, 14, and 15. An LPN expressed concerns about staffing, particularly during a recent COVID outbreak when 75% of the building was positive, and she had to work alone at night. The facility's nurse staffing policy states that sufficient licensed and unlicensed nursing staff should be provided to maintain the highest practical wellbeing of each resident, but this was not adhered to, affecting all 39 residents in the facility.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by the experiences of three residents. One resident, who is dependent on staff for all activities of daily living and transfers, reported having to wait until 9:20 AM to be assisted out of bed, despite normally getting up at 7:00 AM. This delay was attributed to the facility being short-staffed, with priority given to residents who eat in the dining room. The resident expressed anxiety about the wait, fearing an anxiety attack due to the delay. Another resident, who requires substantial assistance for activities of daily living, reported that call lights are sometimes not answered promptly when the facility is understaffed. The resident's daughter corroborated this, stating that during a visit, she had to wait at least half an hour for assistance after activating the call light. She expressed concern about the lack of staff available to respond to residents' needs, feeling compelled to visit daily to ensure her parent's well-being. A third resident, who is generally independent but requires minimal assistance with toileting and hygiene, also noted that call lights are not answered promptly when staffing is insufficient. Staff interviews confirmed that the facility was operating with fewer CNAs than usual, making it challenging to provide adequate care. The facility's staffing records showed multiple instances where the staffing pattern did not meet the expected levels, indicating a recurring issue with maintaining sufficient staff to meet resident needs.
Failure to Assess Resident After Fall Leads to Delayed Fracture Diagnosis
Penalty
Summary
The facility failed to physically assess a resident after a fall, resulting in a delay in identifying a tibial plateau fracture. The resident, who has a history of dementia, cerebrovascular accident, seizures, hypothyroidism, and hypertension, was involved in an incident on 11/22/2024 where she was lowered to the floor by a CNA during a transfer. The CNA reported that the resident locked her arms on the wheelchair and had to be lowered to the floor, but there was no documentation of this fall or any assessment on file for that date. The resident's care plan indicated she was at risk for falls and required substantial assistance with transfers. Despite the resident's leg appearing swollen and bruised on 11/25/2024, it was not until 11/26/2024 that an X-ray was ordered, revealing a tibial plateau fracture. The resident was then sent to the hospital for evaluation. Interviews with staff revealed inconsistencies in communication and documentation, as the LPN on duty was not informed of the fall, and the CNA involved did not know the nurse's name to report the incident. The facility's fall policy emphasizes the need for immediate evaluation and intervention to prevent injury, which was not adhered to in this case.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which has the potential to affect all 40 residents residing in the facility. The deficiency arose after the Director of Nursing (DON) left without notice on November 15, 2024, and no new DON was hired. The Regional Nurse, who is not present every day, admitted that there is not RN coverage every day because the only other RN, who works in the facility, is available only 3 days a week. The facility does not use agency RNs for coverage unless there is a need for an RN to administer intravenous medications. The facility's schedules for November and December 2024 document multiple days without RN coverage. Additionally, the facility does not have a policy for RN staffing and attempts to follow regulations without a formalized plan.
Failure to Administer Medications Due to Staffing Issues
Penalty
Summary
The facility failed to administer ordered medications to four residents on the 200 Hall on the morning of December 15, 2024. This failure occurred because there was no nurse present on the 200 Hall to administer the medications. A resident reported that they did not receive their medications, which included critical medications for heart issues and mental illness. The medication administration records for the residents showed that their medications were not signed out as administered at the scheduled time. The residents had various diagnoses, including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Essential Hypertension, and Adult Failure to Thrive. The deficiency was further compounded by communication and staffing issues. The administrator was informed by an LPN that there was no nurse on the 200 Hall, but the issue was not resolved in time to administer the morning medications. An agency nurse arrived later but refused to administer the missed medications, and the LPN did not intervene further due to the agency nurse's attitude. The facility's policy requires medications to be administered by a licensed nurse per the physician's order, but this was not adhered to, resulting in the residents not receiving their necessary medications.
Medication Administration Failure Due to Staffing Issues
Penalty
Summary
The facility failed to administer prescribed medications to residents on the 200 Hall on the morning of December 15, 2024. This failure affected four residents, each with significant medical conditions requiring consistent medication management. Residents reported not receiving their medications due to the absence of a nurse on their hall, and the subsequent refusal of an agency nurse to administer the missed doses. This lapse in medication administration was confirmed through interviews with residents and staff, as well as a review of medication administration records. Resident 8, diagnosed with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and essential hypertension, did not receive their scheduled doses of Insulin Lispro and Glipizide, nor was their blood glucose monitored as ordered. Similarly, Resident 10, with chronic atrial fibrillation and a history of cerebral infarction, missed doses of Diltiazem, Isosorbide Mononitrate, Metoprolol Tartate, and Insulin Lispro. Resident 11, suffering from congestive heart failure and type 2 diabetes, did not receive Insulin Aspart and Metformin, and Resident 12, with hypertension and type 2 diabetes, missed doses of Basaglar, Glipizide, and Losartan Potassium. The facility's administrator, V1, was informed of the staffing issue on the 200 Hall but was not aware of the medication administration failure until later in the day. Licensed Practical Nurse V18, who was working on the 100 Hall, discovered the absence of a nurse on the 200 Hall and notified V1. Despite this, the agency nurse who arrived later refused to administer the missed morning medications, leading to the residents not receiving their necessary treatments. This incident highlights a significant breakdown in communication and responsibility among the nursing staff, resulting in a failure to meet the residents' medical needs as per their care plans.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents food-borne illness, potentially affecting all 35 residents. During an inspection, several issues were observed in the dry storage room and kitchen areas. Uncooked bacon was stored above fresh vegetables, and various food items, including deli meats and poultry, were not properly labeled or dated. The ice machine scoop was improperly stored with the handle directly on the ice, and the refrigerator was found to be dirty and sticky. Additionally, a turkey was left to thaw in a sink without running water, contrary to the facility's food thawing policy. The dietary staff, including the Dietary Manager and Dietary Aids, were observed not following proper food safety protocols. The Dietary Manager admitted to not having the oven hood professionally cleaned since February 2023 due to a change in ownership. Furthermore, staff members were not wearing beard nets while handling food, which is a violation of hygiene standards. The Registered Dietitian acknowledged the improper thawing method of the turkey, which was eventually discarded. These lapses in food safety and hygiene practices indicate a systemic issue within the facility's dietary department.
Inadequate Infection Control Program and PPE Use
Penalty
Summary
The facility failed to develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates, potentially affecting all 35 residents. The Infection Control Log for various months in 2024 lacked documentation of causative organisms for infections in several residents, including a urinary tract infection and a right lower extremity infection. The Infection Preventionist acknowledged that not all infections have cultures, which prevents identification of the organisms. The Administrator in Training expected the facility to obtain cultures and track organisms, but this was not consistently done. Additionally, there was a failure to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, such as a gastrostomy tube. A Licensed Practical Nurse administered medications without wearing the appropriate personal protective equipment (PPE), and there were no signs or PPE available indicating the need for EBP. The Infection Preventionist stated that gloves and a gown should be worn during such procedures. The Administrator in Training later acknowledged that residents with certain medical conditions should have been on EBP, and it was the Director of Nursing's responsibility to ensure proper signage and PPE availability.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet the individual needs of residents on a mechanical soft diet. During a breakfast service, a dietary aid, V7, was observed plating food without adding necessary moisture, such as gravy or sauce, to the mechanically altered meat for four residents. These residents, identified as R8, R9, R11, and R13, had specific dietary requirements due to their medical conditions, including cerebral infarction, Alzheimer's disease, Wernicke's encephalopathy, and other diagnoses. Despite the physician orders specifying a mechanical soft diet, the dietary aid did not adhere to these requirements, serving ground ham without the necessary moistening agents. The facility's policy on therapeutic and mechanically altered diets, which was revised in October 2024, mandates that such diets be ordered by a physician and planned by a dietitian to facilitate oral intake. However, during the breakfast service, no sauces, gravies, or broths were observed being used in the kitchen, and the dietary aid indicated that the addition of gravy depended on the type of meat. This practice was inconsistent with the facility's policy and the general guidance provided by the registered dietitian, V11, who confirmed that ground meats should typically be served with a sauce, broth, or gravy to meet the dietary needs of residents on mechanically altered diets.
Inadequate Antibiotic Stewardship in Infection Control
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, particularly in antibiotic stewardship, as evidenced by inappropriate antibiotic use in four residents. The facility's Infection Control Log lacked documentation of the type of infection or causative organism for residents treated with antibiotics. For instance, one resident was treated with Keflex for toe redness and warmness without obtaining a culture. Another resident was initially treated with Keflex for a right lower extremity infection, which was later changed to Clindamycin after a culture was obtained. Additionally, a resident with a urinary tract infection was treated with Keflex without a culture, and another resident was treated with Doxycycline without documentation of a causative organism. Interviews with facility staff revealed that antibiotics were sometimes prescribed based on symptoms rather than confirmed cultures. The Director of Nursing acknowledged that cultures were not always obtained, and the Infection Preventionist noted that providers occasionally ordered antibiotics based on symptoms. The Administrator in Training expressed an expectation for infections to be cultured to ensure appropriate antibiotic treatment. The facility's Antibiotic Stewardship Program Policy aims to optimize antibiotic use and reduce antibiotic resistance, but the lack of adherence to this policy contributed to the identified deficiencies.
Failure to Prevent Significant Weight Loss
Penalty
Summary
The facility failed to provide appropriate services to prevent significant weight loss for a resident with multiple medical diagnoses, including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Type 1 Diabetes Mellitus. The resident, who had severely impaired cognitive skills and required feeding assistance, experienced a considerable weight loss from 120 pounds in February to 101 pounds by May or June. The resident's sister-in-law reported that the facility did not follow the diet prescribed by the hospital, and the facility lacked personnel to perform a swallow test, resulting in the resident remaining on a pureed diet. The dietician evaluated the resident in February, noting specific caloric, protein, and fluid needs, and recommended monitoring and encouraging intake. However, the dietician did not monitor the resident in March due to a payment issue with the facility. The facility's administrator in training acknowledged that the resident should have been re-weighed upon readmission. The resident's care plan included monitoring for signs of dysphagia and malnutrition, but the facility failed to adequately address the resident's nutritional needs, leading to significant weight loss.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly store and label medications and dispose of expired medications for three residents. During an inspection of the medication cart on the 200 Hall, it was found that an insulin pen for one resident was not dated upon opening, and a bottle of Guaifenesin had an illegible label, making it unclear which resident it belonged to. The Licensed Practical Nurse initially misidentified the owner of the medication, indicating a lack of proper labeling and tracking. Further inspection of the medication rooms revealed additional issues. In the 200 Hall Medication Room, a box of frozen pizza was stored above a resident's medication, despite a sign indicating that no food or drink should be kept in the medication refrigerator. In the 100 Hall Medication Room, expired nutritional supplements were found, which had not been removed from the active medication storage area as required by the facility's policy. The Director of Nursing acknowledged the presence of food in the medication storage area, citing residents' limited income as a reason for storing food there temporarily.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for three residents, identified as R2, R5, and R8, in a sample of 14, placing them at risk for physical and psychological harm. R5, who has a history of schizophrenia, dementia, and aggressive behaviors, was involved in two separate incidents of resident-to-resident physical altercations. On one occasion, R5 picked up a wet floor sign and hit R2 in the head, resulting in a bruise and cuts that required medical attention. Despite being sent to the hospital for evaluation, R5 returned to the facility without any changes in medication or behavior management. In another incident, R5 slapped R8 in the face when R8 approached asking for food. Although no injuries were noted, the altercation was witnessed by staff, and both residents were separated. R5's care plan was updated to include 1:1 monitoring and medication review, but the facility's actions were insufficient to prevent further incidents. R5's cognitive impairments and history of aggressive behavior were not adequately addressed, leading to repeated episodes of violence against other residents. The facility's policy on abuse prevention emphasizes the importance of training staff to recognize and report abuse immediately. However, interviews with staff members revealed inconsistencies in their understanding and execution of these protocols. The facility's failure to implement effective interventions and monitoring for R5, despite his known aggressive tendencies, contributed to the ongoing risk of abuse for other residents. The lack of timely and appropriate responses to these incidents highlights deficiencies in the facility's abuse prevention and management strategies.
Facility Roof Damage and Water Leakage
Penalty
Summary
The facility failed to ensure that roof damage was repaired to prevent water leakage, which has the potential to affect all 34 residents. The administrator acknowledged that the facility has a flat roof that leaks during rain, leading to the use of buckets in affected rooms, which are currently unoccupied. Despite recognizing the need for a new roof, no bids for repair have been requested, and the facility is in the process of being sold, with hopes that new ownership will address the issue. Observations revealed multiple rooms and areas with water damage, including discolored ceiling tiles and streaks on walls. Interviews with staff, including the maintenance director and housekeeping personnel, confirmed the presence of leaks and the need for repairs. The maintenance director, who recently assumed the role, mentioned ongoing efforts to remodel and repair affected rooms but emphasized the necessity of a new roof. A third-party contractor assessed the facility and noted the requirement for a complete roof replacement. The facility's Resident Right Policy mandates a safe, clean, comfortable, and homelike environment, which is compromised by the current state of the roof.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Swansea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Paul's Senior Community | 0.7 mi | ★★★★★ | 10 | 0 |
| Nexus Pavilion At Belleville | 0.9 mi | ★★★★★ | 8 | 0 |
| Evervella Of Swansea | 1.2 mi | ★★★★★ | 20 | 0 |
| Bria Of Belleville | 1.2 mi | ★★★★★ | 13 | 0 |
| Helia Southbelt Healthcare | 1.7 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.