Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Helia Southbelt Healthcare during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow required food handling and storage practices, including a dietary aide plating meals from a steam table without a visible hairnet and multiple boxes of food items stored directly on the dry storage room floor instead of on shelves at least six inches above the floor. The dietary manager acknowledged the boxes had not been put away after delivery due to short staffing and confirmed the facility does not use clear hairnets, contradicting the aide’s claim. Facility policies require hair coverings to be worn at all times in the kitchen and food and supplies to be stored off the floor, and the administrator stated he expects dietary staff to comply with these policies for all residents.
A resident with severe cognitive impairment, tracheostomy status, and acute respiratory failure decannulated herself, had unsuccessful trach replacement attempts, and was transitioned to nasal cannula, and also received wound care that generated an external bill. The family member, listed as emergency contact and POA, reported not being informed of the resident’s wound or that the resident had been removing her trach tube, learning of the wound only after receiving a bill. The DON and ADON were unsure whether the family or physician had been notified of these changes, despite a facility policy requiring immediate notification of the resident, physician, and representative for significant changes in condition or status.
A resident with severe cognitive impairment, anxiety, dementia, tracheostomy status, and a history of grabbing and pulling at medical devices repeatedly removed her trach collar and other respiratory equipment, and ultimately decannulated herself. Progress notes documented multiple episodes of pulling off the trach collar and vent mask, causing skin tears and repeated disruption of respiratory support, while staff primarily continued to monitor and reposition her. Although staff used an abdominal binder for the G-tube and kept items out of reach, there were no documented care plan interventions specifically addressing her ongoing behavior of pulling at the tracheostomy tube, despite facility policy requiring identification of non-pharmacologic interventions for problematic behaviors.
A resident with nicotine dependence and a history of non-compliance repeatedly smoked in non-designated areas, including his room and hallways, despite being assessed as an unsafe smoker. Staff frequently found ashes, smelled smoke, and observed the resident with cigarettes and lighters, which were supposed to be secured per facility policy. The facility's ongoing awareness and repeated education did not prevent the resident from continuing to smoke in unauthorized areas, resulting in a deficiency related to accident hazards.
Incorrect Contracture Care and Left Hand Wound: A resident with multiple chronic conditions and moderate cognitive impairment had a care plan that identified the wrong hand as contracted and did not reflect hospital instructions to keep the fingers apart. The resident was later observed with a tightly contracted left hand, foul odor, no device to reduce pressure between the fingers and palm, and a worsening infected wound with ongoing pain. The DON confirmed the left hand was the contracted hand, while the care plan documented the right hand.
Improper Medication Storage and Unlabeled Insulin: Surveyors found open multi-dose insulin pens and vials in medication carts without required open or expiration dates, including one vial with blank dating information. They also found loose, scattered pills in multiple med carts, and an LPN stated she could not identify the pills or who they belonged to. An open bottle of calcium was also found in a cart with an expired use-by date.
Food and drink were not served at a palatable, attractive, or safe appetizing temperature for 5 of 5 residents reviewed. Cognitively intact residents and one moderately cognitively impaired resident reported cold food, poor taste, reduced portions, and poor quality in both the dining room and when delivered. Surveyors observed cauliflower at 122 degrees Fahrenheit and described it as cold, bland, and lacking flavor. The Administrator stated food should taste good and be served at appropriate temperatures, and the facility had no policy for food palatability.
Kitchen sanitation, food labeling, and hand hygiene failures were observed in the dietary area. The handwashing sink was dirty and lacked paper towels, food storage areas contained overflowing trash and wet, soiled items, and multiple foods in the walk-in refrigerator were unlabeled or improperly dated. During meal service, a dietary worker handled raw and prepared foods, equipment, and the oven with the same gloves, and another dietary aide touched dirty surfaces and resident trays without hand hygiene or gloves.
Failure to perform hand hygiene during meal service. A dietary aide delivered lunch trays to 5 residents without washing hands before serving, between residents, or after each resident. An LPN, CNA, and Nurse Manager stated hand hygiene is expected before, between, and after tray service, and facility policies required proper handwashing at appropriate times.
A resident who was cognitively intact and dependent on oxygen, suctioning, trach care, and an invasive vent was coughing in bed, grimacing, and asking staff for help when RTs and an RN were nearby at the end of the hall. One RT dismissed the concern, staff continued talking instead of responding, and the resident stated she felt ignored and disrespected while reporting vent-related throat itchiness and discomfort that respiratory treatments helped relieve.
Incomplete Care Plans for Hand Injury, Falls, and Weight Loss: A resident with multiple chronic conditions had a care plan that did not address a left hand contracture, severe pain, or ordered wound-related interventions after hospital evaluation, and the resident was later observed with a tightly contracted, foul-smelling hand. Another resident assessed as high fall risk had a fall documented, but the care plan did not reflect the event or added fall interventions. A third resident with severe cognitive impairment had significant wt loss and a diet downgrade to pureed textures, but the care plan was not updated to reflect the diet change or wt loss.
Unsafe resident transfers and inadequate supervision were observed for two residents. One resident who required a full body/Hoyer lift was swung during transfer and struck a leg on the lift bar, causing grimacing and signs of pain. Another resident who needed a gait belt and 2 assists was transferred with only partial staff contact, including being helped up by an arm and walking without staff contact. Staff interviews and facility policies confirmed that both residents were supposed to receive hands-on, properly assisted transfers.
Incomplete perineal care was provided to a resident who was incontinent of bowel and bladder and dependent on staff for toileting. A CNA assisted with removal of a heavily soiled brief, but the resident only wiped under the abdominal fold and the CNA cleansed the buttocks without washing the labia, perineum, or thighs. The RN stated all areas of incontinence should be cleaned, and the facility policy required front-to-back cleansing of the perineal area, including the labia, perineum, thighs, and rectal area.
A resident with cognitive impairment and a history of substance abuse and hallucinations, identified as at risk for abuse, was involved in a physical altercation with another resident outside the facility. The incident escalated to physical contact before staff intervened, indicating a failure to prevent resident-to-resident abuse despite existing policies and risk identification.
A resident dependent on staff for transfers and requiring a mechanical lift did not consistently receive timely assistance due to ongoing issues with lift availability and dead batteries. Staff and the ombudsman confirmed that mechanical lifts were often not working, leading to delays in care and unmet resident needs, with no facility policy in place for battery maintenance.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A resident with severe cognitive impairment developed a skin tear on her ankle, and while treatment was initiated and documented, there was no evidence that the responsible party was notified of the wound's deterioration or new treatment orders. Family members discovered the wound during a visit, and staff could not confirm or document timely notification, contrary to facility policy.
A resident with multiple chronic conditions did not receive her scheduled morning medications as required, after an LPN left the medications in her room and later removed them without ensuring ingestion or consulting the physician about late administration. The MAR was inaccurately signed as if the medications were given, contrary to facility policy requiring direct observation and immediate documentation.
A resident with quadriplegia experienced verbal and physical abuse by staff at an LTC facility. A nurse removed a wound dressing after a verbal exchange, and a respiratory therapist threatened the resident during suctioning. Both staff members were terminated following the incidents.
A facility failed to provide adequate incontinent care for three residents, leading to a deficiency. One resident, cognitively intact, was not properly cleansed or dried after toileting. Another, severely cognitively impaired, was cleaned with the same portion of a towel for different areas and not dried. A third resident, with a history of UTIs and Alzheimer's, was also inadequately cleansed and not dried. The facility's policy requires separate washcloths and thorough drying, which was not followed.
A resident with glaucoma did not receive their prescribed Latanoprost eye drops as the facility failed to document and administer them according to professional standards. Despite the MAR indicating administration, the pharmacy records showed no refills for April and November, leading to a discrepancy. LPNs believed the medication was available, but the DON noted the lack of refills, highlighting a failure in medication administration policy adherence.
Two residents at a facility experienced falls due to inadequate fall precautions and failure to use a gait belt during transfers. One resident, who was cognitively impaired, was transferred without a gait belt, resulting in a fall. Another resident, also at risk for falls, did not receive timely interventions after a fall, leading to a broken nose. The facility did not adhere to its Falls Management Policy, resulting in deficiencies in care.
A resident with dementia and heart failure missed a medical appointment due to the facility's failure to provide timely transportation. The transportation schedule book was missing, leading to overcrowded schedules and missed appointments. The facility had only one van, and the resident's appointment was the third to be rescheduled, resulting in the doctor refusing to see them.
A resident with glaucoma did not receive their prescribed Latanoprost 0.005% eye drops for two months due to the facility's failure to refill and deliver the medication. The pharmacy did not refill the prescription, and the nursing staff did not notify the pharmacy for refills, leading to a lapse in administration as per the physician's orders.
A resident with glaucoma had inconsistent documentation of Latanoprost eye drop administration. The MAR indicated daily administration, but pharmacy records showed no refills. LPNs claimed the medication was available, but the DON noted discrepancies, highlighting a failure to maintain accurate medical records.
A resident with hemiplegia and depression was reportedly slapped by a CNA during care, leading to the CNA's termination. The incident was witnessed by another CNA, who confirmed the resident's account. The facility's investigation found inconsistencies in the CNA's story, while the resident's account remained consistent.
A resident with complex medical needs was not permitted to return to the facility after hospitalization, exceeding the bed-hold policy. Despite the facility's policy to readmit residents, the resident was discharged due to being out for over 30 days and an investigation involving a threat by his ex-wife. There was no documentation of unmet needs or communication with the resident or family about the discharge, leading to a deficiency in the facility's actions.
A resident with obstructive sleep apnea and other health conditions was not provided with a BiPAP machine at bedtime as ordered. Observations showed the resident sleeping without the device, despite a physician's order for its nightly use. The care plan lacked documentation for the BiPAP, and the facility's policy emphasizes the importance of these devices for respiratory care.
The facility failed to update its facility-wide assessment to reflect current resident acuity levels and population, including a new specialty area for ventilator/tracheostomy care. This oversight, confirmed by the Administrator, affects all 104 residents.
The facility failed to prevent abuse among residents and inappropriate staff behavior. A resident with dementia repeatedly abused another resident, resulting in injuries. Additionally, a CNA was reported for kissing residents without consent, and another staff member made inappropriate comments and offered alcohol to a resident. These incidents highlight deficiencies in the facility's care and supervision protocols.
The facility failed to provide adequate activities for four residents with cognitive impairments, despite their care plans indicating preferences for group and independent activities. Observations showed these residents were often left without engagement, such as sitting idly or sleeping in common areas. The Activity Director mentioned offering sensory groups, but issues like a missing TV remote hindered activity provision. The Social Service Director noted challenges in redirecting residents, highlighting the facility's failure to meet activity needs.
The facility failed to maintain safe food temperatures for therapeutic diets, affecting several residents. Residents reported consistently cold breakfast food, and observations during lunch service showed mechanical soft beef tips served at 110°F, below the safe holding temperature. The issue was noted in Resident Council Meeting Minutes, indicating a recurring problem.
A facility failed to provide physician-ordered wound care for a resident with a chronic ulcer and open wound on the buttock. The resident, who is cognitively intact, reported inconsistent dressing changes, particularly at night, leading to periods without proper wound coverage. An LPN acknowledged issues with night shift treatments, while the DON was unaware of these concerns. The facility's Wound Management Program emphasizes skin integrity management.
A resident with multiple medical conditions experienced an undesirable weight loss, leading to a physician's order to increase tube feeding from 40ml/hr to 50ml/hr. Despite this, observations showed the feeding continued at the incorrect rate. Staff interviews confirmed the order change, highlighting a failure to adhere to the facility's tube feeding policy.
The facility failed to implement fall interventions for several residents, leading to multiple falls and injuries. A resident with Alzheimer's experienced falls due to missing interventions like a canoe mattress and reminder signs. Another resident with hemiplegia fell in a cluttered room without proper footwear. A cognitively impaired resident lacked non-slip socks, and a resident with a fractured humerus had no floor mat. These deficiencies highlight a systemic issue in following care plans.
A resident with Type 2 Diabetes was not provided insulin for the first five days of admission, leading to a significant medication error. The resident's discharge paperwork indicated the need for sliding scale insulin, but no diabetic medication was ordered during this period. Blood sugar levels ranged from 138 to 397, and the oversight was acknowledged by an LPN and a pharmacist.
The facility failed to maintain proper food temperatures during meal service, affecting all 114 residents. Observations revealed that food temperatures were not consistently checked or recorded, and the warming cart was not functioning properly. Residents reported receiving cold meals, and staff acknowledged the issue. The facility's meal service process was inefficient, contributing to delays and inappropriate food temperatures.
A resident with severe cognitive impairment missed nine doses of his prescribed Glaucoma medication, Brimonidine/Timolol, due to discrepancies in medication administration and availability. The medication was supposed to be kept at the bedside for self-administration, but this was not always feasible given the resident's condition. The facility's DON acknowledged the issue, and both a covering Primary Care Physician and a pharmacist confirmed that this constitutes a significant medication error.
Improper Food Handling and Storage Practices in Dietary Services
Penalty
Summary
Surveyors identified that the facility failed to store and prepare food in a manner that prevents potential contamination for all residents. During breakfast service, a dietary aide (V6) was observed plating food from the steam table without wearing a hairnet, despite initially stating she was wearing one. Later, the dietary manager (V4) clarified that the facility does not purchase clear hairnets and that the hairnets used have thin black webbing, indicating V6 was not in compliance with the requirement to wear a visible hair covering. In the dry storage room, surveyors observed several stacks of food and supply boxes, including bread, brown sugar, dry cereal, apple juice, potato chips, jelly, syrup, and non-dairy creamer, stored directly on the floor rather than on shelves at least six inches above the floor as required by facility policy. V4 stated these boxes had been delivered the previous day and had not been put away due to short staffing. The administrator (V1) stated he expects all dietary staff to wear hairnets in the kitchen and to store food according to policy. Facility policies revised January 2012 require the kitchen to be maintained in a clean and sanitary condition with hairnets or hair coverings worn at all times, and food and supplies to be stored six inches above the floor on clean racks or shelves. The daily census documented 94 residents living in the facility at the time of the survey.
Failure to Notify Representative and Physician of Significant Change in Condition and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative and physician of significant changes in condition and treatment. The resident had multiple serious diagnoses, including intracerebral hemorrhage, unspecified dementia, tracheostomy status, and acute respiratory failure, and had a BIMS score of 00 indicating severe cognitive impairment. The resident’s care plan identified a risk for respiratory difficulties related to respiratory failure and included an intervention to notify the physician of any changes. Progress notes documented that the resident decannulated herself, respiratory therapy attempted three times to replace the tracheostomy, the stoma closed quickly, and the resident was then placed on 3 L/min nasal cannula with continued monitoring. The facility’s policy on change in condition required immediate notification of the resident, physician, and resident representative when there is a significant change in physical, mental, or psychosocial status. The resident’s family member, who was listed as emergency contact and power of attorney, reported that after the resident’s death they received a bill from a wound care company for treatment and removal of something from a wound, but the family had not been notified of any wounds or related treatment. The family member also stated they were not notified that the resident had been removing her tracheostomy tube and described the communication as horrible. The DON and ADON both stated they were unsure if the family or physician had been notified of any changes in the resident’s condition. One LPN reported not being familiar with the resident but stated she generally notifies families of changes, while another LPN stated the resident had a history of pulling at her tracheostomy tube and other devices and that after the resident extubated herself and was placed on oxygen and moved to another hallway, she (the LPN) always notified the family and physician of changes. However, there was no documentation or confirmation that the resident’s representative and physician were notified of the decannulation event or the wound care, leading to the cited failure to follow the facility’s notification policy.
Failure to Implement Preventative Measures for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures for a resident with a known history of attempting self-extubation of a tracheostomy tube. The resident was an 84-year-old female with diagnoses including intracerebral hemorrhage, anxiety disorder, unspecified dementia, tracheostomy status, acute respiratory failure, depression, hypertension, atrial fibrillation, and type 2 diabetes. On admission, she had a tracheostomy with ventilatory support, severe cognitive impairment per MDS (BIMS score of 00), left-sided weakness from a prior stroke, and a history of grabbing and pulling at items within reach, including her gastrostomy tube. Her care plan identified anxiety and risk for respiratory complications related to respiratory failure, but there were no documented interventions addressing her behavior of pulling at the tracheostomy tube. Progress notes show repeated episodes of the resident removing or attempting to remove respiratory equipment. On the evening of admission, documentation indicated she pulled off her trach collar three times, with RT noting they would continue to monitor. The following morning, staff documented that she was extremely restless, had to be repositioned multiple times, and tried multiple times to remove the vent mask, causing two skin tears on her upper right chest. Later that same morning, it was documented that she had pulled herself off the trach collar four times and emptied the humidity water bottle twice, with staff moving the O2 tank and water bottle to the foot of the bed and continuing to monitor while her O2 saturation remained in the mid-90s. Subsequent documentation shows that the resident ultimately decannulated herself, with RT unsuccessfully attempting three times to replace the trach before the stoma closed, after which she was placed on nasal cannula oxygen. Notes also indicate she continued to remove her nasal cannula, though her oxygen saturations generally remained within normal limits. Interviews with the DON, MDS/Care Plan Coordinator, and an LPN confirmed that the resident had a history of pulling at her tracheostomy tube, feeding tube, and other items, and that she was very anxious. The LPN reported that an abdominal binder was used over the G-tube site and items were kept out of her reach, but stated there was nothing they could do to keep her from pulling at the tracheostomy tube and that it was inevitable she would pull it out. Despite the facility’s Problematic Behavior Management Clinical Protocol requiring identification and implementation of non-pharmacologic interventions for problematic behaviors and assessment of whether a resident is a danger to themselves, there was no documentation of specific preventative interventions for the resident’s repeated attempts to remove her tracheostomy tube.
Failure to Prevent Unauthorized Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure that a resident only smoked in designated, safe areas and that tobacco and smoking supplies were kept in secure locations, as required by facility policy. The resident, who was cognitively intact and independently ambulatory, had a history of type 2 diabetes mellitus, cerebral infarction, and nicotine dependence. Despite being assessed as a potentially unsafe smoker and having a care plan indicating non-compliance with smoking protocols, the resident repeatedly smoked in his room and other non-designated areas. Multiple staff members, including the administrator, DON, nurse manager, CNAs, and RNs, reported finding ashes, smelling smoke, and observing the resident with cigarettes and lighters in his room and hallways. Progress notes documented several instances where the resident's room and bathroom smelled of smoke, ashes were found, and the resident was caught with smoking materials. The facility's smoking policy required that smoking materials be secured at the nurses' station and prohibited smoking in resident rooms, allowing it only in designated outdoor areas. Despite repeated education and reminders from staff, the resident continued to access and use tobacco products in unauthorized areas, sometimes obtaining cigarettes and lighters from outside the facility or visitors. The facility was aware of the ongoing issue, as documented in interviews and progress notes, but the non-compliance persisted, resulting in a failure to maintain a safe environment free from accident hazards related to smoking.
Incorrect Contracture Care and Unaddressed Left Hand Wound
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for hand contracture management and treatment for R34. R34’s record documented diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness. Her MDS dated 7/4/25 documented that she was moderately cognitively impaired. Her care plan documented contractures of the right hand and included interventions such as proper positioning, medications as ordered, observation for pain or increased stiffness, gentle ROM during daily care, and turning and repositioning as needed. On 9/15/25, R34 requested to go to the hospital because of pain in her left hand and stated the pain was unbearable. EMS transported her to the hospital, where the after-visit summary documented finger pain and diagnoses of deformity of the left hand and injury to the left finger, with instructions to keep the fingers apart as much as possible so they would not injure each other. The care plan was not updated to reflect any intervention to keep the fingers apart. A wound evaluation and management summary from the same date documented a wound on the left plantar hand with infection, a wound size of 3.2 x 2.1 x 0.3 cm, light serous exudate, and treatment orders including antifungal OTC, silver sulfadiazine, and gauze sponge. On 9/22/25, R34 was observed lying in bed with her left hand tightly contracted, with a foul odor coming from the hand and no devices in place to reduce pressure between her fingers and palm. Her right hand was not observed to be contracted as documented in the care plan. On 9/24/25, R34 stated her left hand hurt all the time and the pain had worsened since the hospital visit, and a foul odor was again noted from the left hand. The DON later confirmed that the left hand was the contracted hand, while the care plan documented the right hand as contracted. The Regional Nurse stated she expected the facility care plan staff to identify the correct extremity with contractures and implement appropriate contracture care interventions, including hand rolls or hand splints, and the facility’s ROM/Contracture Care policy required individualized contracture care to be reflected in the care plan and followed consistently.
Improper Medication Storage and Unlabeled Insulin
Penalty
Summary
The facility failed to properly store medications and label insulin vials and pens. During inspection of the 400 Hall medication cart, surveyors found an open and partially used 250-unit multi-dose Lispro pen with no name and no open or expiration date, an open and partially used 250-unit multi-dose Glargine pen with no open or expiration date, an open and partially used multi-dose Glargine vial with no open or expiration date and a blank label for open date, expiration date, and initials, and an open and partially used multi-dose Lantus vial with no open or expiration date. The facility’s medication storage policy stated that medications are to be stored safely, securely, and properly, and that when the original seal of a manufacturer’s container or vial is broken, the nurse shall place a date-opened sticker and enter the date opened and new expiration date. Surveyors also found loose and scattered pills in multiple medication carts. In the 400 Hall cart, a row of medication cards contained about 200 loose pills of varying shapes, sizes, and colors, and the LPN stated she could not identify all of the pills or who they belonged to. Additional loose pills were found in the 100 Hall back cart, the Front 100 Hall cart, the 500 Hall cart, and the 200 Hall cart. In the 300 Hall cart, an open bottle of Oyster Shell Calcium 500 mg was found with a use-by date and no other expiration date identified; the LPN stated the bottle was open, in use, and expired and should not have been in the cart. The regional nurse stated that multidose vials and pens are to have an open and expiration date and that spilled, loose, or scattered medications should be destroyed.
Food Served Cold and Unappetizing
Penalty
Summary
Food and drink were not served in a palatable, attractive, and safe appetizing temperature for 5 of 5 residents reviewed for Food and Nutrition Services, including R17, R11, R43, R71, and R73. The residents’ records showed that R17, R11, R43, and R71 were cognitively intact, and R73 was moderately cognitively impaired. Resident Council Meeting Minutes documented concerns about dietary portion sizes, real fish, soggy fries, and menu changes. During interviews, R17 stated the food is sometimes cold when it gets to her and could taste better. At the Resident Council Meeting, R21, R43, R71, and R73 stated the food tastes bad and is cold, with reduction in portion sizes and poor quality of food, and that the food is cold both in the dining room and when delivered. During observation, cauliflower was served at 122 degrees Fahrenheit and was described as cold, bland, and having no flavor. The Administrator stated the food should taste good and be at appropriate temperatures and that the facility did not have a policy for food palatability.
Kitchen sanitation, food labeling, and hand hygiene failures during meal service
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen conditions and failed to ensure food was properly labeled and dated. During the initial kitchen tour, the handwashing sink was dirty, there were no paper towels in the dispenser, and there was dirt, a slimy film, and rust around the faucet. In the same area, a bait trap had been stepped on and was lying on the floor by the trash can, the trash can lid had dirty marks, and an empty bucket with a hole in the top contained pink liquid with dirt on the lid. In the food storage room, a large wheeled trash can was overflowing with dirty towels and blankets, and a dirty rag was thrown into it. In the walk-in refrigerator, water was on the floor near the door, a saturated towel with brown stains was lying between the wall and a food rack, and water was running from the front of the walk-in freezer toward the refrigerator. Multiple food items were observed without proper labeling or with dates that did not match expected storage practices, including parmesan garlic sauce dated 07/05/25, uncooked hamburger meat dated 09/16/25 with blood drainage on the tray, raspberry whipped dessert dated 09/14, two sealed containers of unlabeled fruit dated 09/08, and an unlabeled vegetable tray dated 09/08 containing pickles, onions, and tomatoes. The honeydew melon also appeared to have a slimy film coating it. During noon meal service, staff handled food and equipment without proper hand hygiene or glove changes. One dietary worker wore gloves while cutting pork loin, then turned off an oven timer and returned to serving food with the same gloves on and no hand hygiene or glove change. The same worker later placed tongs on the steam table counter, handled other food items, and returned the tongs to the meat pan without cleaning them. The worker also went into the walk-in refrigerator with gloves on, retrieved the container with pickles, onions, and tomatoes, and resumed serving food without hand hygiene or changing gloves. Another dietary aide touched dirty counters and carts and then touched multiple resident food trays without hand hygiene and without gloves. The dietary manager, regional nurse, and administrator stated that food should be labeled and dated, the kitchen should be clean and sanitary, and staff should perform hand hygiene.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Provide and implement an infection prevention and control program was not followed when hand hygiene was not performed for 5 of 5 residents reviewed for infection control, including R39, R28, R53, R81, and R82. The residents’ face sheets documented their admissions to the facility on [DATE]. On 9/22/25 at 12:06 PM, V6, a dietary aide, pushed out the meal cart for the main dining room and delivered lunch plates to R39, R28, R53, R81, and R82 without performing hand hygiene before serving, between residents, or after each resident. On 9/24/25 at 1:16 PM, V13, an LPN, stated hand hygiene is supposed to be completed every time a food tray is passed. On 9/24/25 at 1:23 PM, V33, a CNA, stated hand hygiene is supposed to be completed before, in-between, and after serving each resident. On 9/24/25 at 2:40 PM, V22, the Nurse Manager, stated hand hygiene is expected to be completed in between each tray by staff. The facility’s Safe Food Preparation and Handling policy dated 1/2012 documented that hands will be washed properly, frequently, and at appropriate times, and the Handwashing policy dated 4/2015 documented that hands should be thoroughly washed before and after providing resident care.
Failure to Respond Promptly and Respectfully to a Resident Requesting Help
Penalty
Summary
The facility failed to promote respect and dignity for one resident who was cognitively intact and required oxygen therapy, suctioning as scheduled and as needed, tracheostomy care, and an invasive mechanical ventilator. The resident’s care plan identified a risk for respiratory complications and directed staff to observe for signs and symptoms of pain, provide medications as ordered, provide suctioning as ordered and as needed, and provide respiratory/trach care as ordered. On 9/22/25 at 9:50 AM, the resident was coughing in bed, did not stop coughing, appeared concerned and grimacing, and stated she needed help from staff. The surveyor notified the RTs and an RN, who were standing at the end of the hall a couple rooms away, but one RT remained seated and said, “oh, she does that all the time,” while the RN asked the resident if she wanted RT and told the other RT she needed her. The RTs continued sitting and talking at the end of the hall while the resident remained in her room asking for help. At 9:53 AM, the resident stated she felt ignored and disrespected, and said her vent was causing itchiness and discomfort in her throat and that respiratory treatments helped relieve it. The RTs continued talking at the end of the hall until the resident’s call light went on at 10:09 AM, when the RT then went to respond. Staff interviews later stated that resident requests for assistance should be responded to immediately or as soon as possible, and that it would not be acceptable to continue talking to a coworker instead of checking on the resident.
Incomplete Care Plans for Hand Injury, Falls, and Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 3 residents reviewed for care plans. For one resident with diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness, the care plan addressed a right hand contracture but did not address a left hand contracture. The resident was moderately cognitively impaired and required assistance with all ADLs. After the resident requested hospital transfer for severe left hand pain, the hospital discharge instructions included keeping the fingers apart as much as possible to avoid injury, but the care plan was not updated to include interventions to prevent further injury or to address the left hand contracture. The resident was later observed with the left hand tightly contracted, with a foul odor, no device separating the fingers, and ongoing pain and worsening symptoms were documented. For another resident with COPD, hypertensive heart disease, chronic kidney disease, diabetes mellitus, schizoaffective disorder, pre-glaucoma, history of falling, and idiopathic epilepsy with seizures, the MDS documented severe cognitive impairment and need for assistance with all ADLs. The resident was assessed as a high fall risk, and after a fall in which the resident rolled from bed to the floor mat and crawled back into bed, the progress note documented a side rail tag reminder intervention. However, the care plan did not document the fall or include an intervention to reduce the resident’s risk of further falls. For a third resident with hemiplegia and hemiparesis following cerebral infarction, anemia, hypertension, unspecified convulsions, dementia, and diaphragmatic hernia, the MDS documented severe cognitive impairment and need for assistance with ADLs including eating. The resident’s weight decreased from 138.4 lbs. to 115.2 lbs., and a progress note documented that the diet had been downgraded to pureed texture with regular liquids due to persistent difficulty masticating advanced textures. The care plan still listed a 2 gm sodium, low cholesterol, low fat diet with thin liquids and did not address the diet change or the documented 16.67% weight loss, despite the resident receiving speech therapy and being monitored by a registered dietitian.
Unsafe Resident Transfers and Inadequate Supervision
Penalty
Summary
The facility failed to properly and safely transfer 2 of 5 residents reviewed for safety, including one resident who was dependent on staff for bed-to-chair transfers and another resident who required substantial to maximal assistance with transfers. One resident’s care plan did not address transfers, while the resident’s transfer assessment directed use of a full body/Hoyer lift for all transfers. During an observed transfer, two CNAs used the full body lift, but the resident was raised above the bed and allowed to swing back and forth without staff contact, and the resident’s left leg hit the machine bar, causing facial grimacing, squinting, and scowling. Staff then continued the transfer by moving the resident across the room and lowering the resident into the reclining wheelchair. The second resident’s care plan documented need for assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and the transfer assessment documented use of a gait belt with 2 assists for all transfers. During an observed toileting transfer, a CNA assisted the resident to stand by grabbing the resident’s right arm, walked the resident into the bathroom with no staff contact, and later allowed the resident to stand using a cane and towel bar, again without staff contact. Staff interviews stated that the resident should have been transferred with two staff actively participating, with one staff operating the machine or assisting and the other guiding the resident while maintaining contact during the transfer. The facility’s safe patient handling and gait belt policies also described use of lift equipment or gait belts for resident transfers.
Incomplete Perineal Care for an Incontinent Resident
Penalty
Summary
The facility failed to perform complete incontinence care for a resident who was incontinent of bowel and bladder and dependent on staff for toileting. The resident’s care plan documented that the resident was at risk for impaired skin integrity related to incontinence and decreased mobility, and directed staff to provide incontinence care as needed. During observation, the resident was seen walking to the bathroom with a heavily soiled incontinent brief hanging between the resident’s legs. A CNA assisted the resident with removing the soiled brief and the resident sat on the toilet. The CNA then wet a towel, applied soap, and handed it to the resident, who wiped under the abdominal fold twice. After the resident stood, the CNA wiped the resident’s buttocks and then applied a clean brief. The CNA did not cleanse the resident’s labia, perineum, or thighs. The CNA stated that the resident cleans her front and staff clean the back. The regional nurse stated that all areas of incontinence are expected to be cleaned. The facility’s perineal care policy required washing the perineal area from front to back, including separation of the labia, cleansing of the perineum and thighs, and thorough drying.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with a history of psychoactive substance abuse, bilateral blindness, and hallucinations, who was identified as moderately cognitively impaired and at risk for abuse or neglect, was involved in a physical altercation with another resident. The incident occurred outside the facility, where an argument escalated, resulting in one resident being hit in the groin and subsequently slapped in the face by the other. Staff members, including a CNA and two LPNs, witnessed or were informed of the altercation and intervened to separate and assess the residents. The event was documented in the resident's progress notes and reported to facility administration and the police. The facility's abuse prevention policy emphasizes the establishment of a resident-sensitive and secure environment to prevent abuse and neglect. Despite this policy, the incident demonstrates a failure to prevent resident-to-resident abuse, as the altercation occurred and physical contact was made before staff intervention. The involved resident's care plan had previously identified them as being at risk for abuse or neglect, yet the measures in place were insufficient to prevent the incident.
Failure to Ensure Timely Assistance with Mechanical Lift Transfers Due to Equipment Issues
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including severe obesity, osteoarthritis, and limited mobility, did not consistently receive required assistance with transfers using a mechanical lift. The resident was dependent on staff for transfers and had a care plan specifying the use of a mechanical lift. However, both the resident and staff reported ongoing issues with the availability and functionality of the mechanical lifts, particularly due to dead batteries and a lack of working equipment. The resident described having to wait an hour and a half to be transferred to bed because the lift was not charged, resulting in distress and unmet care needs. Staff interviews confirmed that problems with mechanical lifts had persisted for months, with frequent difficulties finding a working lift and delays in obtaining new batteries. The ombudsman and staff corroborated that the issue was ongoing and affected residents' ability to be transferred as needed. The facility administrator acknowledged there was no policy regarding battery maintenance for the equipment. Facility policies required the use of mechanical lifts for residents with limited mobility and emphasized residents' rights to dignity and timely care, but these were not consistently upheld due to equipment failures and lack of procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Accident-Free 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. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident with a history of dementia, chronic kidney disease, and Alzheimer's disease. The resident was admitted with significant cognitive impairment and communication deficits, requiring staff to communicate with family to determine the best approach for care. On a specific date, the resident developed a skin tear on her right ankle, and treatment orders were initiated and documented in the Medication Administration Record. However, there was no documentation that the resident's Power of Attorney (POA) was notified of the wound's deterioration or the new treatment orders, despite the facility's policy requiring such notification and documentation. Interviews with staff and the resident's family member revealed inconsistencies regarding when and if the POA was informed about the change in the resident's condition. The family member discovered the wound during a visit and was not previously informed about its presence or the treatment being provided. Staff members were unable to confirm the exact date of notification, and the Director of Nursing and Administrator acknowledged the lack of documentation regarding notification of the POA. The facility's policy mandates that changes in condition be reported and documented promptly, but this was not followed in this instance.
Failure to Ensure Complete Medication Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that medications were completely administered and accurately documented for one resident. The resident, who was cognitively intact and had diagnoses including adrenocortical insufficiency, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and hypertension, was care planned for non-compliant behavior related to medication administration. On the day in question, the resident's Medication Administration Record (MAR) indicated that all morning medications were administered and signed off by an LPN, but the resident did not actually take the medications at the scheduled time. According to progress notes and interviews, the LPN left the resident's medications in her room, intending for her to take them on her own. When the nurse returned later, the medications were still present, along with a pill from the previous night. The nurse then removed the medications, refused to allow the resident to take them late, and documented the situation in a progress note. The resident and her daughter both reported that the medications were not taken as scheduled and that the nurse did not ensure ingestion or consult the physician about late administration, despite the importance of the medications for the resident's conditions. Facility policy required that medications be administered at the time they are prepared, with the nurse observing ingestion and documenting administration immediately afterward. The nurse's actions did not comply with this policy, as medications were left at the bedside without an order, ingestion was not observed, and the MAR was signed as if the medications had been given. The nurse also did not consult the physician regarding the possibility of late administration, despite the resident's medical needs.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to prevent physical and verbal abuse for a resident diagnosed with quadriplegia and dependent on a ventilator. The resident, who had a perfect BIMS score indicating full mental capacity, reported an incident involving a nurse who, after completing a wound dressing, removed it and discarded it in the trash following a verbal exchange. The nurse's actions were witnessed by a CNA, and the incident was reported to the facility's administration, leading to the nurse's termination. Another incident involved the same resident and a respiratory therapist (RT). The resident alleged that the RT was rough during suctioning and made verbal threats after the resident threatened to have his family retaliate. The RT was overheard by a nurse making threats to choke the resident, and the situation escalated to the point where the RT was removed from the room by staff. The RT was subsequently terminated for his actions. The facility's administrator acknowledged that the incidents were likely due to frustration and noted that the resident often used words to provoke staff. Despite this, the administrator emphasized the importance of protecting residents and took action by terminating the involved staff members. The facility's abuse prevention policy aims to create a resident-sensitive and secure environment, but these incidents highlight a failure to uphold this standard.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide complete incontinent care to prevent urinary tract infections for three residents. Resident 3, who is cognitively intact and requires assistance with toileting, was not properly cleansed by the CNA, who failed to clean the labia and urethra and did not dry the resident after toileting. Resident 4, who is severely cognitively impaired and dependent on staff, was not properly cleansed as the CNA used the same portion of a towel to clean both the groin and rectal areas, and failed to dry the resident. Resident 5, who has a history of urinary tract infections and Alzheimer's Disease, was also not properly cleansed as the CNA used a soiled towel to clean the rectum and buttocks and did not dry the resident. The facility's policy on perineal care, dated July 2017, specifies that separate washcloths and water should be used for cleaning different areas, and that residents should be thoroughly dried after care. However, the CNAs involved did not adhere to these guidelines, as they reused towels for different areas and did not dry the residents. The Director of Nurses confirmed that Resident 5 did not have an indwelling urinary catheter, contrary to the documentation, and the Administrator acknowledged that the same section of a towel should not be used for all incontinent care and that residents should be dried after care.
Failure to Document and Administer Eye Drops as Prescribed
Penalty
Summary
The facility failed to ensure that a resident's prescription eye drops were documented as administered according to professional standards. The resident, who was diagnosed with glaucoma, had a physician's order for Latanoprost 0.005% eye drops to be administered in both eyes at bedtime. However, the facility's pharmacy records indicated that the eye drops were not refilled for the months of April and November 2024, despite the Medication Administration Record (MAR) documenting that the medication was administered on those days. Interviews with the pharmacy technician confirmed that the medication was not refilled or delivered during these months, suggesting a discrepancy between the MAR and the actual availability of the medication. Licensed Practical Nurses (LPNs) who documented the administration of the eye drops stated that they believed the medication was available and administered as per the physician's orders. The Director of Nurses (DON) also noted the lack of refills and expressed confusion over how the staff documented the administration of the eye drops without the pharmacy refilling them. The facility's Medication Administration Policy requires medications to be administered as prescribed and in accordance with good nursing principles, which was not adhered to in this case.
Failure to Implement Fall Precautions and Use Gait Belt
Penalty
Summary
The facility failed to ensure the use of a gait belt during a one-person transfer for a resident, R11, who was at high risk for falls. R11, who was severely cognitively impaired and required substantial assistance with transfers, was observed being transferred without a gait belt by a CNA. During the transfer, R11's feet slid, and the CNA fell on top of him, resulting in R11 hitting the bathroom wall. The CNA initially attempted to lift R11 without assistance and later called for help from another CNA and a Physical Therapy Assistant. The incident was not immediately reported as a fall, and the resident's Power of Attorney was misinformed about the nature of the incident. Another resident, R7, who was also at risk for falls due to cognitive impairments, experienced a fall that resulted in a broken nose. The care plan for R7 included modifying the wheelchair seat to prevent further falls, but this intervention was not implemented. Additionally, after a subsequent fall, the intervention of 15-minute safety checks was delayed by two days. The facility's Director of Nursing acknowledged that fall interventions should be implemented promptly after falls. The facility's Falls Management Policy emphasizes the importance of assessing and managing resident falls through prevention, investigation, and implementation of interventions. However, the facility failed to adhere to this policy by not implementing necessary fall precautions and interventions for both R11 and R7, leading to deficiencies in the care provided to these residents.
Failure to Provide Timely Transportation for Medical Appointments
Penalty
Summary
The facility failed to provide timely and reliable transportation for a resident, identified as R2, who was scheduled for a medical appointment. R2, who was admitted with diagnoses including dementia, heart failure, and weakness, required substantial assistance with mobility and used a wheelchair. The resident's appointment on November 18, 2024, was missed because the transportation was late due to another appointment running over time. This was the third time R2's appointment had to be rescheduled, and the doctor refused to see the resident when they arrived late. The transportation issues were compounded by the disappearance of the transportation schedule book, as stated by the transportation driver, V4. This led to multiple resident appointments being missed or rescheduled due to overcrowding of the schedule and limited transportation resources, with only one van available. The facility administrator, V1, acknowledged that the previous transportation driver was terminated, and the schedule went missing, resulting in missed appointments for R2. The facility's policy on resident rights emphasizes the importance of providing access to necessary services, which was not upheld in this instance.
Failure to Refill and Deliver Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Latanoprost 0.005% eye drops, was refilled and delivered for administration as per the physician's orders. The resident, who was diagnosed with glaucoma, had a physician's order for the eye drops to be administered in both eyes at bedtime. However, the pharmacy did not refill or deliver the medication for the months of April 2024 and November 2024, leading to a lapse in administration. The Pharmacy Order Entry Technician confirmed that the prescription was not refilled or delivered during these months, and the Director of Nurses acknowledged that the nurses are responsible for notifying the pharmacy for medication refills. The facility's Medication Administration Policy requires medications to be administered as prescribed, but the failure to reorder the medication resulted in a deficiency in meeting the resident's pharmaceutical needs.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with glaucoma. The resident's Physician's Order Sheet (POS) indicated a prescription for Latanoprost eye drops to be administered at bedtime. However, the facility's pharmacy records showed that the medication was not refilled for the month of April 2024, despite the Medication Administration Record (MAR) documenting that the medication was administered daily. Similarly, in November 2024, the MAR showed inconsistent documentation, with some days marked as administered, some as therapeutic leave, and others left blank, despite the pharmacy not refilling the medication. Interviews with Licensed Practical Nurses (LPNs) revealed that they documented the administration of the medication based on its availability at the facility, contradicting the pharmacy's records. The Director of Nurses (DON) acknowledged the discrepancy, noting that the lack of refills should have prevented accurate documentation of administration. This inconsistency in documentation indicates a failure to maintain accurate medical records in accordance with professional standards, as required by the facility's Medication Administration Policy.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by a Certified Nursing Assistant (CNA). R2, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and depression, was reported to have been slapped by the CNA during an incident in the bathroom. The incident occurred when R2 was in her wheelchair, and the CNA allegedly became agitated, resulting in the CNA slapping R2. This was corroborated by another CNA who witnessed the event and reported that the CNA's claim of being slapped by R2 was false. The facility's investigation revealed inconsistencies in the CNA's account of the incident, while R2's account remained consistent. The facility's abuse prevention policy defines abuse as the willful infliction of injury or punishment causing physical harm or mental anguish. Despite the CNA's claim that R2 had slapped her, the evidence and witness statements supported R2's account of being slapped by the CNA. The facility's administrator decided to terminate the CNA's employment following the investigation.
Facility Fails to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R5, to return to the nursing home after hospitalization, which exceeded the bed-hold policy. R5, a 48-year-old male with a complex medical history including acute respiratory failure, quadriplegia, and stage 4 wounds, was sent to the hospital at his request for wound care. Despite the facility's policy to readmit residents to the first available bed in a semi-private room after hospitalization, R5 was not allowed to return due to an ongoing investigation related to a threat involving his ex-wife. The facility's records and interviews reveal that R5 had been out of the facility for over 30 days, leading to his discharge based on the facility's policy. However, there was no documentation of a specific need that could not be met at the facility, nor were there attempts to meet those needs. Additionally, there was no physician documentation or communication with R5 or his family regarding the discharge or the bed-hold policy. The facility's staff, including the Administrator and Social Service Director, stated that R5 was discharged due to being out of the facility for over 30 days, but this reasoning was not familiar to the Ombudsman, who insisted that the facility had to take him back. Interviews with various staff members, including the Director of Nursing and the Admissions Coordinator, indicated that R5 had multiple complaints and refusals of care, and the facility had made several attempts to accommodate his needs. However, the facility cited an investigation involving R5 and his ex-wife as a reason for not allowing his return. The Social Worker and R5's mother expressed concerns about the facility's ability to meet R5's needs and the lack of communication regarding his discharge. The facility's actions and inactions led to a deficiency in permitting R5 to return after hospitalization, as required by their policy.
Failure to Apply BiPAP Machine as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required the use of a BiPAP machine at bedtime. Observations revealed that the resident, who has diagnoses including congestive heart failure, type II diabetes mellitus, and obstructive sleep apnea, was not wearing the BiPAP machine as ordered. The resident was observed sleeping without the device on multiple occasions, despite having a physician's order specifying its use nightly at bedtime with specific inspiratory and expiratory pressure settings. The resident's care plan did not include documentation regarding the use of the BiPAP machine, indicating a lack of proper care planning for the resident's respiratory needs. The facility's policy on CPAP/BiPAP support outlines the importance of using these devices to improve oxygenation and ensure resident comfort and safety. The administrator acknowledged that the night nurses and respiratory therapy staff are responsible for applying the machines, yet the deficiency occurred, highlighting a failure in adhering to the prescribed respiratory care protocol.
Failure to Update Facility Assessment for Resident Acuity and Population
Penalty
Summary
The facility failed to complete an updated facility-wide assessment to accurately reflect the current resident acuity levels and population. This deficiency was identified during a review of the facility assessment dated from January 2023 through December 2023, which did not document the updated resident acuity and population necessary to develop an appropriate care plan. The facility recently added a new specialty area for ventilator/tracheostomy care and treatment, which was not included in the current resident population assessment. During an interview, the Administrator confirmed that the facility does not have an updated facility assessment. This oversight has the potential to affect all 104 residents residing in the facility, as documented by the Centers for Medicare and Medicaid Services form 671.
Failure to Prevent Abuse and Inappropriate Behavior in LTC Facility
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving resident-to-resident abuse and inappropriate staff behavior. Resident R34, who has a diagnosis of dementia and moderate cognitive impairment, was involved in several incidents of physical aggression towards resident R77, who also suffers from severe cognitive impairment and dementia. These incidents included hitting R77 with objects such as a wet floor sign and a broom, resulting in injuries like lacerations and cuts. Despite R34's documented history of harmful behavior and R77's wandering and impulsive tendencies, the facility did not effectively manage or prevent these interactions, leading to repeated abuse. In addition to resident-to-resident abuse, the facility also failed to prevent inappropriate behavior by staff members. CNA V21 was reported to have kissed residents R54 and R63 without their consent, which was considered odd and unprofessional behavior. R54, who is dependent on a ventilator, and R63, who has ALS, both reported feeling uncomfortable with the CNA's actions. Despite the lack of prior reports of inappropriate behavior by V21, the incidents were substantiated by other staff members and residents, indicating a failure in monitoring and managing staff conduct. Furthermore, the facility faced issues with another staff member, V20, who was reported to have made inappropriate comments and offered alcohol to resident R67. This behavior was reported by both the resident and his son, leading to the termination of V20. The facility's abuse prevention program policy outlines the need for identifying residents with increased vulnerability to abuse, yet the repeated incidents suggest a lack of effective implementation of these measures. The facility's failure to protect residents from abuse and inappropriate staff behavior highlights significant deficiencies in their care and supervision protocols.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities for four residents, each with varying degrees of cognitive impairment and specific activity preferences. Observations revealed that these residents were often left without engagement or stimulation, despite documented care plans indicating their enjoyment of both group and independent activities. For instance, one resident with moderate cognitive impairment and a preference for spiritual activities and socializing was observed sitting idly in the dining room and hallway without any activities. Another resident with severe cognitive impairment and behavioral issues was found sleeping in the dining room with no activities occurring. This resident's care plan highlighted a preference for music and social interaction, yet there was no evidence of such activities being provided. Similarly, a resident with moderate cognitive impairment and a history of enjoying games and church activities was observed sleeping in the dining room with no sound from the TV, indicating a lack of engagement. Additionally, a resident with severe cognitive impairment and a preference for reading and crafts was observed sleeping or facing away from the TV, with no activities taking place. The resident's daughter expressed a desire for more involvement in activities. The Activity Director mentioned offering sensory groups and outdoor activities but acknowledged issues such as a missing TV remote, which hindered activity provision. The Social Service Director noted challenges in redirecting residents with dementia, further highlighting the facility's failure to meet the residents' activity needs.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures for therapeutic diets, affecting seven residents who were reviewed for food procurement, storage, preparation, and service. During a group meeting, several cognitively intact residents reported that their breakfast food was consistently served cold. Additionally, observations during lunch service revealed that mechanical soft beef tips were served at 110 degrees Fahrenheit, which is below the safe holding temperature, to residents on mechanical soft diets. These residents included those with varying levels of cognitive impairment, as documented in their Minimum Data Sets and Physician Order Sheets. The facility's Resident Council Meeting Minutes from earlier in the year also documented complaints about cold food, indicating a recurring issue. Despite the facility's policy requiring hot food to be cooked or heated to temperatures above 165 degrees Fahrenheit, the observed temperatures during meal service did not meet these standards. The Dietary Manager acknowledged the issue of cold purees and mechanical soft foods, but the report does not detail any immediate corrective actions taken at the time of the deficiency.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for a resident with a chronic non-pressure related ulcer and an open wound on the left buttock. The resident, who is cognitively intact, had a physician's order to cleanse the wound with normal saline, apply Silver Silvadene, collagen powder, and calcium alginate, and cover it with a dry dressing daily. However, the treatment was not completed on two specific dates, and there was no physician order to hold the dressing change on those dates. The resident expressed concerns about the inconsistency in dressing changes, stating that the dressing was changed during the day but not at night, leading to periods where the wound was left uncovered. The resident reported that the dressing had only been changed once in the past week, and if it became dirty during the day, the day shift refused to replace it. A Licensed Practical Nurse acknowledged that sometimes night shift treatments were not completed, and the Director of Nurses was unaware of any concerns regarding night shift treatment completion. The facility's Wound Management Program emphasizes the importance of managing resident skin integrity through prevention, assessment, and intervention.
Failure to Administer Correct Tube Feeding Rate
Penalty
Summary
The facility failed to administer tube feeding at the rate ordered by the physician for a resident with multiple medical conditions, including Amyotrophic Lateral Sclerosis, Protein-Calorie Malnutrition, Gastrostomy Status, and Dysphagia. The resident, who relies on tube feeding for more than 51% of their nutrition, experienced an undesirable weight loss, prompting a dietician to recommend an increase in the tube feeding rate from 40ml/hr to 50ml/hr. This recommendation was documented in the resident's progress notes and a new physician order was issued to reflect the change. Despite the updated order, observations on multiple occasions revealed that the resident's tube feeding was still being administered at the previous rate of 40ml/hr instead of the prescribed 50ml/hr. Interviews with facility staff, including a registered nurse and the Director of Nurses, confirmed that the tube feeding order had been changed and that nurses are responsible for ensuring the correct rate is administered. The facility's tube feeding policy requires checking the physician's order to determine the correct type and rate of feeding, which was not adhered to in this case.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions as care planned for several residents, leading to multiple incidents of falls and injuries. Resident 1, who was admitted with diagnoses including Alzheimer's disease and dementia, experienced several falls due to the lack of implemented interventions such as a canoe mattress, reminder signs, and dycem in her wheelchair. Despite being cognitively intact, Resident 1 was found on the floor multiple times, resulting in injuries such as a hematoma and fractures, indicating that the care plan interventions were not in place or followed by the staff. Resident 2, with diagnoses including hemiplegia and heart disease, was also at risk for falls. The care plan required a clutter-free environment and proper footwear, but observations revealed a cluttered room and the resident ambulating barefoot. This lack of adherence to the care plan led to falls, resulting in injuries such as skin tears and a hematoma. The resident reported not receiving assistance with organizing her room or being educated on maintaining a clutter-free environment, further highlighting the facility's failure to implement necessary interventions. Resident 4, who is severely cognitively impaired, was found on the floor wearing regular socks instead of the non-slip socks required by the care plan. Similarly, Resident 5, with a history of falls and a diagnosis of a fractured humerus, did not have a floor mat beside her bed as documented in her care plan. These observations indicate a systemic issue within the facility where care plan interventions for fall prevention were not consistently implemented, leading to repeated falls and injuries among residents.
Failure to Administer Insulin to Diabetic Resident
Penalty
Summary
The facility failed to provide insulin for the first five days of admission for a resident with Type 2 Diabetes, resulting in a significant medication error. The resident, who was moderately cognitively impaired, was admitted to the facility from another state and was documented to have Type 2 Diabetes without complications. Upon admission, the resident's discharge paperwork from an out-of-state medical center indicated the need for sliding scale insulin. However, the facility did not order any diabetic medication from the time of admission until five days later. During this period, the resident's blood sugar levels ranged from 138 to 397, indicating a lack of proper diabetic management. The oversight was acknowledged by a Licensed Practical Nurse, who stated that the sliding scale was not sent over, and a pharmacist confirmed that not receiving the long-acting insulin was a significant medication error. The facility's policy required that the attending physician provide necessary information for immediate care, including medication orders, which was not adhered to in this case.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures during meal service, affecting all 114 residents. Observations revealed that food temperatures were not consistently checked or recorded before and during meal service. For instance, a cook was seen transferring food from the stove to the steam table without checking temperatures, and the temperature logbook had not been updated since February 2024. Additionally, the warming cart used for meal delivery was not functioning properly, and meals were delivered uncovered, leading to complaints from residents about cold food. Interviews with residents and staff highlighted ongoing issues with food temperature. Residents reported receiving cold meals, and staff acknowledged the problem, noting that food was often not hot enough when served. The dietary manager admitted to assuming that cooks were checking temperatures, but there was no documentation to confirm this. Furthermore, the facility's policy required food to be cooked above 165 degrees and chilled below 40 degrees, but these standards were not consistently met. The facility's meal service process was inefficient, contributing to the problem. Trays were not organized in order, causing delays in delivery as staff had to search for the correct tray for each resident. This inefficiency, combined with the lack of proper temperature checks and documentation, resulted in meals being served at inappropriate temperatures, as confirmed by a test tray that showed food temperatures well below the required levels.
Significant Medication Error Due to Missed Glaucoma Medication Doses
Penalty
Summary
The facility failed to ensure that medications were provided and administered correctly for a resident (R2) with severe cognitive impairment, resulting in a significant medication error. R2 missed nine doses of his prescribed Glaucoma medication, Brimonidine/Timolol, over a period of time. The resident's care plan did not document the need for Glaucoma medication, and there were discrepancies in the Medication Administration Records (MAR) for January, February, and March. The medication was supposed to be kept at the bedside for the resident to self-administer, but due to the resident's cognitive impairment, this was not always feasible. The facility's Director of Nursing (DON) acknowledged that the medication was not always available and that the family insisted on keeping it at the bedside, despite the resident's condition. The report includes statements from various staff members and pharmacists, indicating that the medication was sent to the facility multiple times, but there were still instances where the medication was not administered. The DON mentioned that the medication was out of stock during a weekend and that they used separate bottles of eye drops that were not expired but had been opened. The covering Primary Care Physician and a pharmacist both confirmed that missing doses in a skilled nursing facility is unacceptable and constitutes a significant medication error.
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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 Belleville
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 | 1.3 mi | ★★★★★ | 10 | 0 |
| Nexus Pavilion At Belleville | 1.7 mi | ★★★★★ | 8 | 0 |
| Evercare Of Swansea | 1.7 mi | ★★★★★ | 8 | 1 |
| Bria Of Belleville | 2.1 mi | ★★★★★ | 13 | 0 |
| Evervella Of Swansea | 2.9 mi | ★★★★★ | 20 | 0 |
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