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 Helia Healthcare Of Newton during CMS and state inspections, most recent first.
A resident with a history of multiple fractures, right patellar tendon rupture, and osteoporosis, who used a wheelchair for all locomotion, was transferred by two CNAs into a roommate’s wheelchair that lacked foot pedals. The CNAs did not initially recognize the chair was incorrect and pushed the resident while asking her to hold her feet off the floor. When the CNA turned the wheelchair around in the hallway after realizing the error, the resident could no longer keep her feet elevated, causing her right foot to drop, twist under the wheelchair, and result in discomfort. A mobile x-ray was initially read as an acute non-displaced tibia fracture, though an orthopedic follow-up later found no fracture and no current pain.
The facility failed to provide 8 hours of consecutive RN coverage, affecting all 36 residents. The Administrator acknowledged shifts without the required coverage, with the Director of Nursing working weekends but leaving for several hours on one occasion. Nursing schedules confirmed non-consecutive RN coverage on multiple dates, contrary to facility policy.
The facility failed to provide adequate staffing, affecting all 32 residents. Instances included a resident with severe cognitive deficits waiting an hour for toileting assistance and another resident with multiple health issues waiting over 15 minutes. Interviews revealed frequent staffing shortages, particularly on weekends and night shifts, with only one CNA and one nurse available at times.
The facility failed to provide the required 8 hours of daily RN coverage, affecting all 32 residents. Multiple days in June, July, and August 2024 lacked RN coverage. The administrator acknowledged the issue, citing difficulties in recruiting RNs, but mentioned recent hires to improve coverage.
The facility failed to maintain kitchen sanitation, potentially affecting all 32 residents. Observations included unsanitary conditions such as a dirty dish machine, food debris on surfaces, and improper food handling by a cook. The Dietary Manager admitted the cleaning schedule was not followed.
A facility failed to transmit a resident's MDS assessment within the required timeframe. The resident, with conditions including dementia and Alzheimer's, had an assessment completed in May, but it was not transmitted until September due to a misunderstanding by the MDS Nurse about transmission requirements for private pay discharges. The facility lacked a specific policy on MDS transmission, relying on the RAI manual.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's plan did not reflect the need for an alternative alert system due to a choking risk, while another's plan lacked updates for a new antipsychotic medication and non-pharmacological interventions. The facility did not provide a policy for updating care plans.
A facility failed to implement fall precautions for a resident with muscle weakness, gait abnormalities, and vascular dementia by not ensuring the call light was within reach. Despite a care plan requirement, the call light was observed out of reach on multiple occasions. A CNA mentioned the family’s concern about strangulation, and no alternative call light solution was provided, with staff checking on the resident every two hours.
A facility failed to ensure a resident was free from unnecessary medications by not implementing a Gradual Dose Reduction (GDR) for Risperidone, despite the absence of behaviors. The resident, diagnosed with vascular dementia and anxiety, was prescribed Risperidone 1 mg as needed, but there was no documentation of GDR attempts or recommendations. Behavior tracking showed no occurrences, and staff confirmed the absence of behaviors, yet the facility's system did not allow individualized tracking, and the care plan did not reflect any medication reduction efforts.
The facility failed to provide adequate direct care staffing, with multiple instances of only one CNA and one nurse available for 37 residents, leading to significant delays in call light responses and unmet care needs. Despite hiring new CNAs, the problem persisted, with staff frequently working double shifts and the MDS/Care Plan Coordinator also taking on CNA duties.
The facility failed to provide adequate direct care staffing, leading to delays in resident care and missed showers. On Easter Sunday, the Administrator and a Registered Nurse had to perform all resident care due to staff call-ins. Multiple staff and residents reported ongoing issues with insufficient staffing, impacting the quality of care provided.
The facility failed to provide a full-time DON, affecting all 36 residents. The former DON left without notice, and no replacement has been found. Other nurses and corporate staff have taken over some duties, but no one has been assigned to Infection Control Preventionist duties.
The facility failed to provide sufficient kitchen staff when one cook called in sick, leading the uncertified Administrator to prepare meals that did not fully adhere to the menu. This affected all 36 residents.
The facility failed to maintain proper sanitation and food safety standards in the kitchen, affecting all 36 residents. Observations revealed grime and food debris on various surfaces and equipment, improper food storage, and inadequate sanitization practices. The dietary manager and cook were unaware of how to check sanitizer levels, indicating a lack of training and adherence to policies.
The facility failed to serve the appropriate portions for a lunch meal according to the menu spreadsheet for four residents. The cook used a 4-ounce scoop instead of the specified 8-ounce ladle for the ham and au gratin potato casserole entree. The affected residents had various medical conditions and physician orders for a regular texture diet, but they received only half of the prescribed portion size during the observed meal service.
The facility failed to provide twice-weekly showers for three dependent residents due to staffing shortages and lack of proper documentation. Despite the administrator's claim that there were no issues, both residents and CNAs reported missed showers, highlighting a significant gap in meeting basic hygiene needs.
The facility failed to safely transfer a resident requiring a mechanical lift, as only one staff member was available for transfers despite the policy requiring two. Both the CNA and the resident confirmed that single-staff transfers occurred, although no negative outcomes were reported.
The facility failed to provide nutritional supplements according to physician's orders for four residents with various diagnoses. Observations revealed that these supplements were missing from lunch trays on multiple occasions, and the dietary manager confirmed a supply issue. One resident was unaware she was supposed to receive a supplement.
A resident with Diabetes Type 2 experienced a significant medication error when a registered nurse administered Insulin Lispro late, leading to elevated blood glucose levels. The nurse faced multiple distractions, causing the delay, and subsequently had difficulty contacting the physician for further instructions. The resident remained alert and oriented with no immediate negative effects reported.
Failure to Use Wheelchair Foot Pedals Resulting in Injury Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure a wheelchair had foot pedals in place before use, resulting in an injury event for one cognitively intact resident who relied on a wheelchair for locomotion and did not ambulate. The resident had a medical history that included COPD, chronic cough, muscle weakness, multiple fractures, a right patellar tendon rupture, and age-related osteoporosis. The resident’s MDS documented that she used a wheelchair and was not a walker, and both the DON and the physical therapist stated that the resident was supposed to have foot pedals on her wheelchair when it was in use. On the morning of the incident, two CNAs assisted the resident out of bed and to the bathroom, then mistakenly placed her into her roommate’s wheelchair instead of her own. The roommate’s wheelchair did not have foot pedals attached. The CNAs did not initially recognize that the wheelchair was the wrong one, and when the resident questioned the absence of foot pedals, one CNA believed the pedals might be in the dining room. The CNA then began to push the resident in the wheelchair without foot pedals, asking the resident to hold her feet up off the floor during transport. While being pushed in the wheelchair without foot pedals, the CNA realized the resident was in the wrong chair and turned the resident around in the hallway to return to the room for the correct wheelchair. The resident, who already had chronic right knee issues, was unable to continue holding her feet up, and her right foot dropped to the floor, twisted slightly under the wheelchair, and caused discomfort. The nurse evaluated the resident afterward, and a mobile x-ray was obtained, which was initially read as showing an acute non-displaced tibia fracture related to the leg getting caught behind the wheelchair. An orthopedic follow-up later documented that no fracture was seen on the most recent x-ray and that the resident was not having pain at that visit.
Failure to Provide 8 Hours of Consecutive RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 36 residents residing in the facility. The Administrator, identified as V1, acknowledged that there were shifts without the required 8 hours of RN coverage. V1 mentioned that the Director of Nursing, V2, had been working weekends to ensure RN coverage, but on one occasion, V2 left the facility for several hours before returning, resulting in non-consecutive RN coverage hours. V1 was unaware that the RN coverage hours needed to be consecutive. A review of the nursing schedules for December 2024, January 2025, and February 2025 confirmed the lack of consecutive RN coverage on several dates. Specifically, on December 7, 2024, only four hours of RN coverage were provided, and on December 8, 2024, only two and a half hours were covered. Additionally, on December 21 and 22, 2024, only five hours of RN coverage were documented. The facility's policy requires scheduling a registered nurse for 8 consecutive hours each day, which was not adhered to, as evidenced by the employee timecard showing non-consecutive hours worked by V1 on February 16, 2025.
Inadequate Staffing Leads to Delays in Resident Care
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its residents, affecting all 32 residents. The report highlights specific instances where residents experienced delays in receiving assistance due to insufficient staffing. For example, one resident with a history of cerebral infarction, chronic obstructive pulmonary disease, and congestive heart failure, who is totally dependent on staff for activities of daily living, had to wait over 15 minutes for assistance with toileting after activating the call light. Another resident with severe cognitive deficits and dependent on staff for various needs experienced a delay of an hour for toileting assistance during a family member's visit. Interviews with staff and family members revealed that there were times when only one CNA and one nurse were available to care for the entire facility, particularly on weekends and night shifts. The facility's administrator acknowledged that staffing shortages occur, especially during certain shifts, and that corporate guidelines limit the number of CNAs that can be scheduled based on the resident census. The facility's nursing and CNA schedules for several months documented multiple instances where staffing was insufficient, with only one CNA and one nurse on duty for the entire facility during various shifts.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 32 residents residing in the facility. The deficiency was identified through a review of the nursing schedules for June, July, and August 2024, which documented multiple days without RN coverage. Specifically, there was no RN coverage on 06/19/2024, 06/29/2024, 07/13/2024, 07/14/2024, 07/17/2024, 07/27/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/17/2024, and 08/18/2024. The facility administrator acknowledged the lack of RN coverage on certain shifts and stated that the facility uses agency nurses to fill in gaps. The administrator also mentioned that it has been challenging to recruit RNs, but recent hires should improve coverage. The administrator verified the accuracy of the nursing schedules for the months in question.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which could potentially affect all 32 residents. During an initial kitchen tour, several issues were observed, including a layer of flaky dried matter on top of the dish machine, a scoop with a handle found inside the bulk thickener touching the food item, and dusty bottom shelves of stainless steel tables with old/dried food debris. Additionally, bulk food containers were sticky to the touch with dried spills, and a container on the cook's table holding various utensils and seasonings had crumbs and food debris at the bottom. The steam table had dried/black food substance burnt to the bottom of all inserts, and the side of the stove had old/dried food spills. The floor under the stove and cook's stainless steel table had spilled food, food debris, and paper products, and the kitchen floor was unswept with food and paper products scattered everywhere. The stove top was full of old dried spilled food on the burners and under the burners near the flame. Further observations included a cook, V10, pureeing the lunch meal without washing hands or using gloves, and using a scoop from the bulk food thickener without a clean barrier. V10 also placed the measuring cup on the table without a clean barrier and returned the scoop to the container after use. Additionally, V10 was observed stirring cherries on the stove with a spatula picked up off the stove top burner without a clean barrier. The Dietary Manager, V4, acknowledged that the cleaning list was supposed to be completed weekly but was not done, and could not confirm how long it had been since the stove was cleaned.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that assessments were successfully transmitted within 14 days of completion for a resident. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, benign prostatic hyperplasia, and essential hypertension, had an admission assessment on May 3, 2024, and a discharge assessment completed on May 24, 2024. However, the Minimum Data Set (MDS) Nurse initially did not transmit the assessment, mistakenly believing it was not required for a private pay discharge. This misunderstanding was later corrected, and the assessment was transmitted on September 11, 2024. The facility's administrator was initially unaware of the requirement to transmit the MDS and planned to consult the corporate office for clarification. The facility did not have a specific policy regarding MDS transmission, relying instead on the Resident Assessment Instrument (RAI) manual as their guideline. The Centers for Medicare & Medicaid Services (CMS) MDS 3.0 Nursing Home Final Validation Report confirmed the late submission of the resident's assessment. According to the RAI Manual, nursing homes are required to submit MDS records for all residents in Medicare- or Medicaid-certified beds, regardless of the pay source.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to update comprehensive care plans for two residents, R15 and R21, leading to deficiencies in their care. R15, who has multiple diagnoses including major depressive disorder and dementia, had a care plan addressing fall prevention. However, the care plan did not reflect the family's request to avoid using a standard call light due to the risk of choking, nor did it include an alternative alert system for R15 to request assistance. This oversight was confirmed by both the Administrator and a Certified Nurse Assistant, who noted the absence of an updated care plan to address these specific needs. Similarly, R21, diagnosed with Parkinson's disease and major depressive disorder with psychotic features, had a care plan that did not include the recent addition of an antipsychotic medication, Seroquel, which was prescribed months prior. The care plan also lacked individualized non-pharmacological interventions for managing behaviors. The Minimum Data Set Coordinator acknowledged that the care plan had not been updated to reflect these changes. The facility did not provide a policy or procedure for updating comprehensive care plans, contributing to these deficiencies.
Failure to Implement Fall Precautions for a Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident, identified as R15, by not ensuring the call light was within reach. R15, who has a diagnosis of muscle weakness, gait abnormalities, and vascular dementia, was admitted on an unspecified date and has a care plan addressing fall risks with a goal to remain injury-free. The care plan, initiated on 8/18/22, specifically requires the call light to be within reach at all times. However, observations on 9/10/24 and multiple times on 9/11/24 revealed that R15 was in her recliner without the call light within reach, as it was placed on top of her personal refrigerator. A Certified Nurse Assistant (CNA) stated that the family did not want R15 to have a call light due to concerns about potential strangulation, and there was no alternative call light solution in place, with staff checking on her every two hours instead.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was free from unnecessary medications. R2 was admitted with a diagnosis of vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident was prescribed Risperidone 1 mg as needed, starting on 9/6/2023, with a scheduled Gradual Dose Reduction (GDR) evaluation due in December 2024. However, there was no documentation of any previous GDR attempts or recommendations, and the column labeled 'Last GDR' was left blank. The pharmacist, V11, stated that GDRs are reviewed every five months, but there was no evidence of such reviews in R2's medical record. Additionally, behavior tracking for R2 from 8/13/2024 to 9/12/2024 showed no occurrences of behaviors, and staff interviews confirmed the absence of behaviors. Despite this, the facility's tracking system did not allow for individualized behavior tracking, and R2's care plan did not reflect any behaviors or attempts to reduce psychotropic medications. The Minimum Data Set Coordinator, V2, noted that R2's previous behaviors had improved, but there was no documentation of this improvement or any related medication reduction efforts. The facility's document titled 'Gradual Dose Reduction Schedule' indicated that there should be an attempt to reduce antipsychotic and anxiolytic medications during the first year of use, which was not adhered to in R2's case.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its 37 residents. The report documents multiple instances where only one CNA and one nurse were available to care for all residents, particularly during evening and overnight shifts. This staffing shortage led to significant delays in responding to call lights, with some residents reporting waits of up to an hour. The facility's administrator acknowledged the staffing issues but stated that they were unable to mandate staff to work or secure additional CNAs from the staffing agency. Despite hiring three new CNAs, the problem persisted, with staff frequently working double shifts and the MDS/Care Plan Coordinator also taking on CNA duties to cover gaps in staffing. Several residents and their representatives expressed concerns about the inadequate staffing levels. One resident's Power of Attorney reported having to transfer the resident herself due to the lack of available CNAs, leading to the decision to discharge the resident to home care. Other residents confirmed the ongoing staffing issues, noting that call lights were often unanswered for extended periods, especially during night shifts. Staff members corroborated these accounts, describing the difficulty of meeting all resident care needs when working alone or with minimal support. The facility's corporate regional director of operations dismissed the concerns, attributing them to a perception issue rather than a real problem. However, the ombudsman confirmed receiving complaints about long call light response times and staffing shortages, indicating that these issues were ongoing. The facility's nursing and CNA schedules for April and May documented specific dates and times when only one CNA and one nurse were on duty, further substantiating the claims of inadequate staffing.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its 36 residents. On Easter Sunday, the facility experienced a significant staffing shortage when the two CNAs and one nurse scheduled for the 6am to 2pm shift called in sick. The Administrator and a Registered Nurse/Minimum Data Set Coordinator had to perform all resident care from 6:00am to 2:00pm. This resulted in residents not receiving timely care, such as having breakfast in bed and delays in getting dressed. Multiple staff members and residents reported that this was not an isolated incident, with several occasions where only one CNA and one nurse were available to provide care, leading to missed showers and inadequate assistance with mechanical lift transfers. The facility's staff schedule for March 2024 documented several instances of insufficient staffing on the 10pm to 6am shift, further corroborating the ongoing issue of inadequate staffing levels. Residents and staff expressed concerns about the impact of the staffing shortages on the quality of care. One resident reported not receiving a shower, bath, or bed bath since admission, while another mentioned not getting showers twice a week due to the lack of staff. The Housekeeping Supervisor and Social Services Designee also confirmed witnessing instances of inadequate staffing. The Administrator stated that she had been requesting additional staff from corporate, and only recently received approval to use a staffing agency again. The Ombudsman noted that residents had complained about the facility being short-staffed, highlighting the widespread nature of the issue.
Failure to Provide Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide the services of a full-time Director of Nursing (DON), which has the potential to affect all 36 residents living at the facility. The former DON, V2, left the position without notice on 3/24/24, citing exhaustion from having to frequently work the floor in addition to her DON duties. Since V2's departure, the facility has not found a replacement, and other nurses and corporate staff have had to take over some of the DON duties. However, no staff member has been assigned to take over the Infection Control Preventionist duties previously handled by V2. Interviews with the facility's staff revealed that the remaining nurses, including V9, the Registered Nurse/Minimum Data Set Coordinator, are unsure who is performing the DON duties and are not interested in applying for the position due to staffing issues. The facility's administrator, V1, confirmed the lack of interested applicants and the challenges faced in maintaining the required nursing leadership. The deficiency was identified through interviews and record reviews, highlighting the facility's failure to comply with the requirement of having a full-time DON.
Insufficient Kitchen Staff and Uncertified Food Preparation
Penalty
Summary
The facility failed to provide sufficient kitchen staff to carry out nutrition services on the specified date. The long-term Dietary Manager had recently passed away, and a new Dietary Manager had just started. On the day in question, one of the two full-time cooks called in sick, and the other cook was scheduled to come in later in the day. As a result, the Administrator, who did not have certification in food sanitation, had to prepare breakfast and lunch for the residents. The breakfast provided did not fully match the menu, and lunch consisted of pizza and breadsticks instead of the planned meal. The Administrator did check food temperatures and followed some procedures, but the lack of certified staff was a significant issue. The menu for the day documented specific items for breakfast and lunch that were not fully adhered to. The Administrator acknowledged the deviation from the menu and the lack of certification in food sanitation. The facility's guidelines require a current Food Services Sanitation certificate and relevant job experience for the position, which the Administrator did not possess. This deficiency had the potential to affect all 36 residents living at the facility.
Failure to Maintain Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen, which has the potential to affect all 36 residents. Observations revealed that all cabinets in the kitchen were covered with grime, floors were sticky with dried food debris, and various kitchen equipment, including the steam table, drawers, and shelves, were dirty. The cooler doors, microwave, and stove were also noted to be grimy and covered with food debris. Additionally, open bins containing food items were found to be contaminated, and plastic silverware was stored in unsanitary conditions. The cook was observed using a thermometer without proper sanitization, and the dietary manager and cook were both unaware of how to check the sanitizer levels in the dish machine and sanitizing bucket, indicating a lack of training and adherence to the facility's cleaning and sanitation policies. Further inspection of the dry food storage area revealed that shelving and floors were covered with grime, and several food items were stored open to air, increasing the risk of contamination. The facility's Cleaning and Sanitation Policy and Machine Ware Washing Policy were not being followed, as evidenced by the lack of proper sanitization practices and the absence of a documented kitchen cleaning schedule. The dietary manager and cook both admitted to not knowing how to check the dish machine or sanitizer bucket, and the cook stated that he had never been trained on these procedures.
Inadequate Meal Portions Served
Penalty
Summary
The facility failed to serve the appropriate portions for a lunch meal according to the menu spreadsheet for four residents. During an observation of the lunch service trayline, the cook used a 4-ounce scoop to portion the ham and au gratin potato casserole entree, while the menu spreadsheet specified an 8-ounce ladle for regular texture diets. The affected residents had various medical conditions, including Atherosclerotic Heart Disease, Hypertension, Heart Failure, Anxiety Disorder, a left femur fracture with surgical repair, and Alzheimer's Disease. All four residents had physician orders for a regular texture diet, but they received only half of the prescribed portion size during the observed meal service.
Failure to Provide Twice-Weekly Showers
Penalty
Summary
The facility failed to provide twice-weekly showers for three dependent residents, R4, R12, and R13, as required. R4, who has diagnoses including Anxiety Disorder, Hypertension, and Osteoarthritis, did not receive the mandated showers on multiple weeks in March and April 2024. R4 reported that she missed a scheduled shower due to a lack of hot water and was not offered an alternative. R13, admitted with a Left Femur Fracture, did not receive any showers or bed baths since her admission, and no staff asked if she wanted one. R12, diagnosed with Congestive Heart Failure, Major Depressive Disorder, and Osteoporosis, only received two showers in March and April 2024. R12 attributed the lack of showers to staff shortages, a sentiment echoed by CNAs V7 and V13, who confirmed that staffing issues often prevent residents from receiving their scheduled showers. The facility's administrator, V1, claimed there were no issues with residents not receiving twice-weekly showers, suggesting that staff might be forgetting to document them. However, the ombudsman, V6, confirmed that R12 had complained about not receiving the required showers. The CNAs acknowledged the problem, citing insufficient staffing as the primary reason for the missed showers. This discrepancy between the administrator's statement and the staff's accounts highlights a significant gap in the facility's ability to meet the residents' basic hygiene needs.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident requiring the use of a mechanical lift. The resident, identified as R13, has a history of Cervical Spine Fusion following a Wedge Compression Fracture and is dependent on two or more staff members for transfers, as documented in the Minimum Data Set and Physical Therapy Evaluation. Despite this requirement, it was found that at times there is only one nurse and one CNA per shift, leading to situations where a single CNA has had to perform mechanical lift transfers alone, contrary to the facility's policy. Both the CNA and the resident confirmed that these single-staff transfers have occurred, although no negative outcomes were reported by either party. The facility's Mechanical Lift Policy, dated 9/8/23, clearly states that two staff members are required when transferring a resident with a mechanical lift to ensure safety and security. However, the interviews and record reviews revealed that this policy was not consistently followed, leading to a deficiency in providing adequate supervision and safe transfer practices for residents requiring mechanical lifts. This lapse in adherence to policy was identified during a survey conducted on 4/4/24 and 4/10/24.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements according to physician's orders for four residents. During lunch trayline observation, it was noted that residents who were supposed to receive liquid nutritional supplements did not have them on their trays. Specifically, residents with diagnoses such as Atherosclerotic Heart Disease, Hypertension, Alzheimer's Disease, and Arthritis were affected. The dietary manager confirmed that the facility did not receive the nutritional supplements they had ordered, and the administrator mentioned that staff could use petty cash to buy needed food items or prepare liquid supplements using a recipe. One resident, who was alert and oriented, stated she was not aware she was supposed to be getting a supplement as she had never received one. The failure to provide these supplements as ordered by physicians was observed on multiple occasions, indicating a systemic issue in the facility's dietary management and supply chain processes. This deficiency directly impacted the nutritional care of the residents involved.
Failure to Ensure Timely Administration of Insulin
Penalty
Summary
The facility failed to ensure residents are free from significant medication errors, specifically for one resident with Diabetes Type 2 and Diabetic Neuropathy. The resident had a physician's order for Humalog U-100 Insulin per sliding scale and Insulin Lispro to be administered three times daily. On the day of the incident, the registered nurse was observed administering the morning dose of Insulin Lispro late due to multiple distractions. The resident's blood glucose level was 172 at 6:00 am, and the insulin was administered much later than the prescribed time. Subsequently, the resident's blood glucose level spiked to 424, prompting the nurse to contact the physician for further instructions. The physician ordered a recheck in one hour, but due to technical difficulties and the physician's office being closed for lunch, the nurse could not immediately follow up. The resident's blood glucose level remained elevated until the physician was contacted again, and new orders were received to administer additional insulin before supper. The Medication Administration Record and Nursing Progress Notes documented the late administration and subsequent high blood glucose levels. The resident was observed to be alert and oriented, with no immediate negative effects reported. The facility's policy on medication administration emphasizes the 'Five Rights' of medication administration, which were not adhered to in this instance. The registered nurse involved in the incident terminated her employment abruptly on the day of the surveyor's interview. The deficiency highlights a significant lapse in the timely administration of medication, leading to elevated blood glucose levels in the resident.
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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 Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Ridgeview | 13.2 mi | ★★★★★ | 26 | 0 |
| Helia Healthcare Of Olney | 17.2 mi | ★★★★★ | 4 | 0 |
| Richland Nursing & Rehab | 17.9 mi | ★★★★★ | 9 | 1 |
| Greenup Rehab And Nursing | 18.2 mi | ★★★★★ | 6 | 0 |
| Robinson Rehab And Nursing | 22.5 mi | ★★★★★ | 21 | 0 |
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