Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Loft Rehab Of Decatur during CMS and state inspections, most recent first.
A facility failed to answer resident call lights in a timely manner for multiple residents. A CNA was observed turning off a call light while telling a resident to wait because the assigned CNA was busy, another resident’s call light was found out of reach, and a family member reported a call light had been on for hours without response. Residents reported routine delays, including long waits for toileting assistance and unanswered lights after supper, and one resident said the delays caused urinary incontinence accidents. The record showed several affected residents had significant toileting and transfer assistance needs, and the facility policy required all staff to respond promptly to activated call lights.
Incontinence care was not provided per current standards for three residents. One resident’s family reported the resident had not been checked for incontinence in 15+ hours and was wearing two saturated briefs, while two other residents said they had recently been placed in double briefs at night without request. A CNA and the DON both stated residents are not to wear two briefs at the same time, and the residents’ care plans directed staff to keep them clean and dry and minimize moisture exposure.
Failure to Protect Residents from Physical Abuse by Another Resident: A resident with severe cognitive impairment and diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety physically assaulted two other residents. A CNA witnessed the resident strike one resident in the face and knock the resident’s glasses off, with the resident crying and later avoiding the aggressor; an LPN also witnessed the resident in another resident’s bed and open-handed smack that resident on the cheek. The aggressor had a documented history of aggression toward staff.
A resident at risk for pressure injuries developed bilateral heel DTIs that progressed to stage 3 and stage 4 ulcers after the facility did not timely implement heel offloading, pressure-relieving boots, or an appropriate mattress, and did not obtain a dietitian evaluation despite low nutritional markers and wound physician recommendations. During wound care, the wound physician also used the same gauze for both wounds and did not perform hand hygiene between treatments, contrary to policy.
QAA committee records showed missing attendance by required leadership and absent meeting minutes for two quarters. The Administrator provided attendance sheets for Q4 2025 and Q1 2026, but the Jan 2026 meeting did not show the Administrator present, and the Administrator confirmed not attending. No attendance sheets or QAA minutes were available for Q2 or Q3 2025, despite the facility’s QAPI policy calling for regular committee review.
Water Management Program Not Implemented: The facility failed to implement its water management plan by not documenting an annual risk assessment, control points, control measures, or testing protocols in the program binder. The IP/ADON and Maintenance Director stated an assessment had been done the prior year but could not locate it, and they were unable to complete a new assessment or identify risks when reviewed by surveyors. The facility census was 91 residents.
The facility failed to document narcotic counts at shift changes and failed to return or destroy discontinued antibiotics left in medication storage. During cart reviews, staff confirmed missing controlled-drug count entries for multiple shifts, and several residents’ controlled medications were present. In addition, antibiotics for current and discharged residents remained in the storage area after completion dates, and an LPN and DON confirmed these medications should have been returned or destroyed.
Medication labeling and storage were not maintained for several residents. An ADON was observed with unlabeled medication cups left in the top of a med cart for two residents, and multiple resident medications in the cart, including insulin, an ophthalmic solution, and an inhaler, were found without required dates. In addition, Tums were left in a medication cup on a resident’s bedside table even though the resident did not have a self-administration order, assessment, or care plan.
Failure to Address Wandering and Elopement Risk: A resident with severe cognitive impairment had documented wandering and exit-seeking behaviors, including trying to leave the facility, roaming the halls, and entering other residents’ rooms. The resident’s care plan, behavior tracking, CNA tasks, and elopement risk documentation did not identify wandering/exit seeking as targeted behaviors or include related goals and interventions, and the elopement risk binder did not contain the resident’s information.
A resident who required substantial to maximal staff assistance for bathing did not receive bathing as scheduled. The resident said bed baths were preferred over showers but also reported not being bathed weekly and not knowing the bath schedule. Record review showed the bath schedule and documentation prompts did not align, several entries did not show baths being provided, and there was no explanation for one missed bath date. A CNA confirmed the schedule and that bathing was only documented in this record.
Failure to provide podiatry services for a resident with DM. The resident stated a podiatrist was needed because the toenails were long, and observation confirmed the nails were long past the toes with a dressing on the right great toe. The record showed the resident had Type 2 DM, a right great toenail that fell off with swelling and redness, and no documentation of a podiatry visit after admission. The DON and Social Services Director stated the facility had changed podiatry companies, the resident was missed during a round, and the resident was later placed on the podiatry list.
Failure to Apply Ordered Splints and ROM Devices: The facility failed to apply ordered ROM devices for two residents with contractures. One resident was observed resting without a prescribed hand splint, and an LPN stated she was unaware of the brace order despite therapy notes and a physician order requiring it during rest. Another resident was observed without the ordered right elbow splint, palm protector, or right-hand splint; the resident stated staff had not been applying the devices, and a CNA reported never seeing them in use.
A resident with an indwelling urinary catheter received catheter care that did not follow the facility’s policy for female catheter care. CNAs cleaned the catheter tubing first, then wiped the labia and thighs while contacting the catheter during each wipe, rather than cleaning the tubing last. The resident was cognitively intact, required substantial to maximal assistance with toileting hygiene, reported intermittent catheter care and occasional diarrhea with incontinence, and had a documented UTI with MDRO organisms and repeated orders for IV Meropenem for UTI.
Inaccurate documentation of protective sleeve refusal. A resident with an order to wear protective arm sleeves while up in a wheelchair was observed multiple times without them, and the resident said staff did not offer the sleeves. However, the TAR documented the sleeves as applied every day, and the care plan did not include the intervention. The DON stated the sleeves are meant to prevent skin tears and abrasions and that staff should not sign them off if the resident is refusing.
A resident with gait abnormalities, muscle weakness, altered mental status, and moderate cognitive impairment had a care plan that included floor mats as a fall prevention intervention. Despite this, an RN reported that the floor mats were not in place when the resident fell from bed and was found on the floor beside the bed, complaining of head and neck pain and bleeding from the head. Hospital evaluation, including CT imaging, confirmed a head laceration and hematoma requiring staple closure. Facility leadership confirmed that fall mats had been implemented previously and should have been in place when the resident was in bed.
Surveyors found that multiple residents did not receive their ordered evening medications during one medication pass. A resident filed a complaint about not receiving evening meds, and the DON later confirmed that residents on one hall missed their scheduled doses. MAR review showed that several medications, including famotidine, potassium chloride, baclofen, gabapentin, atorvastatin, carvedilol, clonidine, doxazosin, Eliquis, fluticasone inhalation, and rosuvastatin, were not administered as ordered. The DON acknowledged that nurses are required to follow physician orders and notify the physician and nursing supervisor when medications are not given.
Two residents reported rough and undignified care by CNAs, including one resident with multiple comorbidities and moderate cognitive impairment who described rough handling during transfers and perineal care with associated bruising, and another cognitively intact resident with an upper extremity impairment who reported that a CNA was on the phone during care, was rude, rough, and belittling. The Social Service Director documented both concerns as grievances about staff approach, observed bruising on one resident, and acknowledged an allegation of rough care but did not ensure that these reports were treated and processed as potential abuse allegations. Instead, she addressed one CNA directly about phone use, did not fully relay the rough-care and belittling allegations to the DON or Administrator, and facility leadership later confirmed they were unaware of one resident’s grievance and that it had not been reported or investigated as possible abuse.
Two residents reported that CNAs provided rough and belittling care, causing bruising, neck pain, and fear of future rough treatment, and that staff were distracted by personal phone use during care. The Social Service Director documented both concerns as grievances related to staff approach, but did not treat the rough and abusive care allegations as potential abuse, relying instead on personal knowledge of the CNAs. An LPN and a PTA were also aware of one resident’s verbal and physical abuse allegations but did not report them to the Administrator or Abuse Prevention Coordinator, and the DON and Administrator later confirmed they were unaware of these abuse reports.
Multiple staff failed to report resident allegations of rough care, bruising, neck pain, and derogatory comments to the Administrator/Abuse Prevention Coordinator as required by the facility’s abuse policy. One resident with moderate cognitive impairment and significant ADL dependence reported that a CNA was rough during transfers, causing bilateral forearm bruising and neck pain, and stated she had informed social services, yet leadership reported no knowledge of the allegation while the CNA continued working. Another resident with no cognitive impairment reported to social services, an LPN, and therapy staff that a CNA was rough and rushed during care, remained on her phone, and belittled him as lazy, but the Social Service Director, who is related to the CNA, handled the matter informally and did not report it as possible abuse. The DON and Administrator stated they were unaware of these allegations, and timecards showed the implicated CNAs continued to work multiple shifts with access to residents without timely removal from duty or documented investigation.
A resident who was cognitively intact and required partial to moderate assistance with toileting reported that a CNA noticed feces from another resident on a toilet seat and told the resident to clean it using sanitary wipes before being allowed to use the bathroom. The CNA stated she would not help the resident until the feces was cleaned, threw the container of wipes toward the resident, and waited for the resident to comply. The resident reported feeling upset, embarrassed, and disrespected by this interaction, and the Administrator later confirmed the CNA did not treat the resident with dignity.
A cognitively intact resident’s right to be free from misappropriation of property was violated when a CNA removed a check from the resident’s personal checkbook kept in the room, wrote it for $975, and forged the resident’s signature to pay the CNA’s rent. The incident was identified through a state investigation and confirmed by the resident and the Administrator, who acknowledged that the CNA had taken and used the resident’s check without permission.
Two residents were transported in a facility van without being properly secured in their wheelchairs due to malfunctioning and missing seatbelts. One resident, who had multiple medical conditions and a history of falls, fell forward during abrupt braking and sustained fractures to the humerus, tibia, and fibula. The securement system was found to be broken and had been previously reported to administration but not repaired, leading to the incident.
A resident's Power of Attorney requested copies of the resident's medical records after the resident was transferred to another facility, but the records were not provided in a timely manner. The request, made through a lawyer, was acknowledged by Medical Records staff and forwarded to corporate, yet the records were not sent until much later, despite repeated follow-up by the family member.
The facility did not ensure a clean and comfortable environment for two residents, as evidenced by unmade beds, soiled linen, dirty dishes left in rooms, and unclean floors. One resident, who is cognitively intact, and another who is severely cognitively impaired and dependent on staff, both experienced lapses in housekeeping and bed-making. Staff and resident council meeting minutes confirmed that these deficiencies were ongoing and not addressed as required.
A resident with an indwelling urinary catheter was observed with unsecured catheter tubing and an uncovered drainage bag exposed to the hallway. Staff confirmed these observations and acknowledged that urinary output was not consistently documented every shift as required by physician orders and facility policy.
The facility did not report allegations of verbal and physical abuse involving a resident to the state survey agency as required by policy. The DON received these allegations from the resident's daughter and a CNA but failed to notify the state agency, and no documentation of such reporting was available.
Two residents experienced significant harm due to the facility's failure to promptly assess, notify physicians, and manage pain or changes in condition. One resident with severe cognitive impairment suffered untreated severe knee pain and swelling for several days before a femur fracture was identified and surgically repaired. Another resident, after an unwitnessed fall, did not receive timely neurological checks or post-fall assessments, leading to delayed recognition of a subdural hematoma and hip dislocation, both requiring hospital intervention. Staff did not follow established policies for assessment, documentation, and physician notification.
A resident with significant medical complexities who required Contact Guard Assist for ambulation fell and suffered a fractured humerus, facial contusion, and abrasions when a physical therapy aide, who was trailing behind with a wheelchair and oxygen tank, stepped away to untangle oxygen tubing and was unable to maintain contact or assist the resident, resulting in inadequate supervision and assistance.
Two residents did not receive timely and appropriate pressure ulcer care, including regular repositioning, incontinence care, wound assessment, and physician or dietitian notification. One resident developed multiple pressure ulcers, including a stage four coccyx wound, due to missed interventions and lack of monitoring, while another had an untreated buttock wound that was not promptly identified or managed by staff.
Two residents experienced verbal and emotional abuse from staff, including an LPN yelling at a resident for requesting pain medication and a CNA removing another resident's call light and treating him roughly. Both residents suffered emotional harm and distress as a result of these actions.
Multiple residents experienced harm due to the facility's failure to assess, monitor, and manage bowel and wound care. One resident with cognitive impairment and a history of bowel obstruction was not properly monitored for bowel movements, leading to hospitalization for bowel obstruction. Another resident with a surgical wound did not receive timely wound care or assessments, and wound care was not performed according to orders, resulting in infection and additional surgery. A third resident suffered from prolonged constipation and was hospitalized for fecal impaction, with no evidence of bowel management prior to the event.
A resident with multiple medical conditions experienced significant unplanned weight loss over several months. Staff did not notify the physician or registered dietician as required, nor did they implement new nutritional interventions, despite clear evidence of ongoing weight loss. The facility's policy for monitoring and responding to weight changes was not followed, and the resident continued to lose weight without appropriate assessment or intervention.
Two residents experienced unmanaged pain due to the facility's failure to accurately assess pain, notify physicians, and implement pain medication orders. One resident with cognitive impairment and a worsening pressure ulcer showed clear signs of pain that were not addressed, while another resident with a history of back surgery and chronic pain conditions suffered severe pain during care activities without timely administration of PRN pain medications. Staff did not follow care plans or pain management protocols, resulting in inadequate pain control.
The facility did not maintain adequate nursing staff to meet resident needs, leading to prolonged call light response times, delayed wound care, missed showers, and cold food service. Multiple residents and staff reported ongoing issues with insufficient staffing, resulting in unmet care needs such as delayed toileting and incomplete scheduled care.
The facility did not update the posted daily nurse staffing information for several days, as confirmed by the Interim Regional DON, with the same outdated staffing sheet remaining visible near the front entrance. This failure potentially affected all 97 residents, and additional concerns were noted regarding staffing, care routines, and call light wait times.
A facility with 150 beds and 97 residents did not employ a qualified full-time social worker as required. The staff member assigned to cover social services lacked the necessary degree in Social Work or Human Services, as confirmed by the administrator.
The facility did not carry out its water management plan, failing to document a risk assessment, establish testing protocols, or define corrective actions for controlling Legionella and other pathogens in the water system. The administrator confirmed there was no documentation or evidence of completed assessments, potentially impacting all residents.
Staff failed to document and manage resident funds according to facility policy, with cash found in medication carts and no sign-out sheets or records of deposits or withdrawals. An LPN reported keeping residents' money in the carts due to the business office being closed, and the business office manager was unaware of this practice.
Four residents who were dependent on staff for activities of daily living did not receive scheduled showers, shaving, nail care, or grooming as required. Observations included unclean hair, long and dirty nails, stained clothing, and missed showers, with documentation and staff interviews confirming the lack of care.
Multiple residents reported that their meals were cold, unappetizing, and not delivered promptly, with observations confirming that food trays remained on holding carts for extended periods and were served below the required temperature. Staff acknowledged delays in tray delivery and inadequate food temperatures, resulting in dissatisfaction among residents.
A resident requiring significant assistance with eating and having physical impairments was repeatedly observed with stained clothing, dirty fingernails, and unshaven facial hair after meals. Staff interviews indicated a lack of awareness and cited staffing shortages, resulting in a failure to uphold the resident's dignity as outlined in facility policy.
Two residents who required staff assistance were found without access to their call lights, with one unable to request help for cold food and the other reporting frequent inability to reach the call light, despite care plans and facility policy requiring call light accessibility.
A resident with a signed DNR order on their POLST form was incorrectly listed as full code in the facility's electronic medical record and physician's orders, despite the care plan reflecting the DNR status. Nursing staff relied on hospital records and the electronic profile, leading to a mismatch between the resident's advance directive and the documented code status.
A resident with mobility limitations due to a femur fracture, infection, and low back pain was left in a broken bed overnight, unable to reposition and experiencing discomfort. Despite staff being notified, no maintenance response occurred, and the bed remained nonfunctional until the issue was later acknowledged by the Regional Maintenance Director.
A resident reported being verbally abused by an LPN, and the administrator was informed of the incident by the resident's family member. Despite facility policy requiring immediate investigation and notification to the state agency within 24 hours, the administrator delayed both the investigation and reporting for several days.
A resident's family member reported to the administrator that an LPN was rude and caused the resident distress. The administrator did not notify the state agency of this verbal abuse allegation until several days after receiving the report, resulting in a failure to meet timely reporting requirements.
A resident's family member reported to the Administrator that an LPN was rude and caused the resident distress, but the Administrator did not begin investigating the alleged verbal abuse until several days after the initial report.
A resident with longstanding diagnoses of Generalized Anxiety Disorder and PTSD was admitted without a required PASARR Level II evaluation, as the initial Level I screening failed to identify any Significant Mental Illness. The DON later confirmed that the evaluation should have been coordinated, but the Level I assessment was not reviewed for accuracy at admission.
A resident with chronic heart failure and kidney disease did not receive daily weights as ordered by the physician, with multiple missed days documented over several months. Despite a significant weight gain, there was no evidence that the medical provider was notified as required. Staff interviews confirmed that daily weights and timely notification were necessary and expected.
A resident receiving both Eliquis and Clopidogrel did not have physician orders in place to monitor for bleeding risks associated with these medications. While the care plan addressed bleeding risk for some medications, it did not include Eliquis, and staff confirmed that required monitoring orders were missing.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for five residents reviewed for call lights. On 6/26/26, R8’s call light was observed on at 8:11 AM and still on at 8:15 AM when a CNA entered the room, turned it off, and told R8 that the assigned CNA was feeding other residents in the dining room and R8 would have to wait. Later that morning, R5 was observed sitting in a recliner watching TV with the call light on the floor out of reach. R1’s family member reported that on 6/11/26 R1 called at 3:44 AM stating the call light had been on since midnight and no one had answered it. R8 stated that when needing the bathroom, staff did not ask what was needed and that R8 was routinely put off, sometimes waiting what seemed like a lifetime. R8 also stated that waiting on staff had never caused an accident. R4 stated call lights were not answered in a timely manner and that this caused urinary incontinence accidents. R7 stated call lights do not get answered in a timely response, that some staff take longer than others, and that call lights are usually answered in 15 to 20 minutes; R7 also stated that after supper a light may be on at 7:00 PM and not answered until 8:00 PM, and that this happens all the time. The record review showed R1 had diagnoses including acute on chronic combined systolic and diastolic CHF, pancytopenia, acute and chronic respiratory failure with hypoxia, CKD, HTN, acute right heart failure, anemia, and NSTEMI, with a BIMS score of 14 indicating cognitive intactness. R4, R5, R7, and R8 had care needs involving toileting assistance, transfers, and lower body dressing, with R4 and R7 documented as cognitively intact and R5 moderately impaired. The facility’s policy stated that all staff who see or hear an activated call light are responsible for responding, response times should be a priority, and staff should listen to the resident’s request and respond accordingly. Resident council minutes also documented concerns that CNAs were entering rooms only to turn off call lights without providing needed assistance.
Incontinence Care Not Provided as Ordered
Penalty
Summary
Incontinence care was not provided per current standards of practice for three residents reviewed for incontinence care. One resident’s family member reported that the resident said they had not been checked for incontinence in 15 or more hours and was wearing two incontinence briefs; the family member observed both briefs were saturated with urine and asked staff to change the resident. Two other residents stated they had recently been placed in double incontinence briefs at night, and one of them said it was not by request. A CNA stated residents are not to have two incontinence briefs in place and that staff should report it to the DON if observed, and the DON stated residents are not to be wearing two incontinence briefs at the same time and staff are to report it to the lead CNA. The affected residents had care plans directing staff to keep them clean and dry and minimize skin exposure to moisture. One resident had diagnoses including acute on chronic combined systolic and diastolic CHF, CKD, anemia, and NSTEMI MI, with a BIMS score of 14 indicating cognitive intactness. The other two residents had diagnoses including muscle weakness, osteoporosis, arthritis, hypotension, COPD exacerbation, hemiplegia and hemiparesis following cerebral infarction, and cerebral edema, with BIMS scores of 08 indicating moderate impairment. The facility’s incontinence policy stated residents who are continent of bladder and bowel upon admission must receive appropriate treatment, services, and assistance to maintain continence unless their clinical condition makes continence impossible to maintain.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents R84 and R10 from physical abuse by another resident, R70. The facility’s Abuse, Neglect, Exploitation Policy dated 1/23/26 defines abuse as the willful infliction of injury, intimidation, or punishment that results in physical harm, pain, or mental anguish, and states staff will be trained to recognize behavioral symptoms that may increase the risk of abuse, including aggressive reactions, wandering/elopement behaviors, resisting care, outburst/yelling, and difficulty adjusting to new routines or staff. R70’s MDS documented severe cognitive impairment, and the active care plan listed dementia, psychotic disturbance, mood disturbance, and anxiety. R84’s MDS also documented severe cognitive impairment. On 3/22/26, a CNA witnessed R70 knock R84’s glasses off R84’s face in the hallway as they passed each other. The state report states R84 reported that R70 told R84 that R84 did not belong there and knocked the glasses off R84’s face. On 5/3/26, the CNA stated R70 swung at R84’s face and hit R84’s glasses off R84’s face, that the actions were intentional, and that R84 cried and had a red mark on the nose afterward; staff kept R70 and R84 separated for the rest of the night, and R84 avoided R70 afterward. R70 also had a documented history of aggression toward staff, including grabbing CNAs’ wrists, hitting their arms, and threatening to punch staff in the face. On 4/24/26, an LPN heard screaming for help and found R70 in R10’s bed and witnessed R70 open-handed smack R10 on the right side of the face. R10’s MDS documented severe cognitive impairment, and the active diagnoses included dementia, anxiety, and depression.
Failure to Prevent Heel Pressure Injuries and Maintain Aseptic Wound Care
Penalty
Summary
The facility failed to implement pressure-relieving interventions, evaluate nutritional status, and prevent cross contamination during pressure ulcer treatments for one resident who was at risk for pressure injuries. The resident had moderate cognitive impairment on admission, required dependence for rolling and turning in bed, and was assessed as at risk for developing pressure ulcers. Skin assessments documented intact skin in mid-December, but there was no documentation that pressure-relieving interventions were implemented at that time, and the resident’s treatment record did not show heel treatments before the heels broke down. On 12/25/25, the resident complained of heel pain and burning, and nursing documented drainage under the right heel, a darkened area on the right heel, and a fluid-filled blister with a darkened red area on the left heel. The wounds were identified as deep tissue injuries acquired that day. Subsequent wound evaluations showed deterioration: the right heel progressed from a stage two pressure ulcer to stage three and then stage four, while the left heel progressed to a stage three pressure ulcer with slough and necrotic tissue. The wound physician’s notes included recommendations for offloading, repositioning, floating the heels in bed, and use of pressure-offloading boots, and later added a dietitian consultation. The record showed the resident was not wearing pressure-relieving boots at times, and the boots were not added to the treatment record until after the heel wounds had already developed. The resident’s bed remained on a standard foam mattress, and there was no documentation that the resident refused the boots. The resident’s nutritional status was not evaluated by a dietitian after 12/22/25, despite a prealbumin level of 15 grams/liter and wound physician recommendations for dietitian involvement. During wound care observation, the wound physician used the same gauze and did not perform hand hygiene between wound treatments, despite the facility policy requiring hand hygiene after glove removal and when indicated. Staff interviews confirmed the boots and offloading measures were not implemented until after the wounds opened, the dietitian had not been notified of the wounds for months, and the resident’s wounds were considered avoidable by the physician.
QAA Committee Lacked Required Attendance and Missing Quarterly Minutes
Penalty
Summary
The facility failed to ensure required personnel attended Quality Assessment and Assurance (QAA) committee meetings and failed to provide documentation of its ongoing Quality Assurance & Performance Improvement Program meeting minutes for two quarters of 2025. During interview and record review, the Administrator provided QAA attendance sheets for the first quarter of 2026 and the fourth quarter of 2025, and stated the QAA team meets quarterly to discuss issues and concerns. The January 2026 QAA attendance sheet did not document the Administrator, owner, board member, or other leadership role individual as present, and the Administrator confirmed not attending that meeting. No documented attendance sheets or QAA meeting minutes were available for the second or third quarters of 2025, and the Administrator confirmed those records were not available. The facility census was 91 residents.
Water Management Program Not Implemented
Penalty
Summary
The facility failed to implement its infection prevention and control program by not carrying out its water management plan. The Water Management Program, revised 1/21/26, states that an annual risk assessment will be completed by the water management team to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems, with control points identified and documented in the program binder. It also states that control measures, testing protocols, and control limits will be established for each control measure, and that the team will regularly verify the program is being implemented as designed. On 5/5/26 at 9:25 AM, the Maintenance Director reviewed the Water Management Program Binder and found that it did not contain documentation of the annual risk assessment, identified control points, control measures for potential hazards, or testing protocols and control limits for each control source. Later that day, the Infection Preventionist/ADON and Maintenance Director stated that an annual risk assessment had been done the prior year, but they were unsure of the completion date and could not locate it. They also stated they started an assessment on 5/5/26 but were unable to complete it or identify any risks at that time. The facility's census was 91 residents.
Missing narcotic count documentation and retained discontinued antibiotics
Penalty
Summary
The facility failed to document that narcotic medications were counted at the beginning and end of each shift as required by its Controlled Drug Policy and Procedure. During review of the Northeast medication cart, the Substance Controlled Check form for May 2026 did not show required narcotic count documentation for multiple shift changes on 5/1/26, 5/2/26, 5/3/26, and 5/4/26. The ADON confirmed the missing entries, and the cart contained multiple controlled medications for residents including Buprenorphine patches, Lorazepam tablets, Tramadol tablets, Norco tablets, and Fentanyl patches. A separate review of the Southeast medication cart showed the Substance Controlled Check form for May 2026 was missing documentation that narcotics were counted on 5/1/26 by the nurse coming off the 6 AM to 6 PM shift. The LPN confirmed the missing entry. The cart contained controlled medications for several residents, including Fentanyl patches, Norco tablets, Tramadol tablets, and Lorazepam tablets. The facility also failed to destroy or return discontinued antibiotics and antibiotics left in the facility after discharge. In the South medication storage room, medication cards for current and discharged residents were observed with remaining antibiotic doses after the documented completion dates, including Cephalexin, Tetracycline, Amoxicillin-potassium clavulanate, and Cefuroxime. The LPN confirmed these medications should have been returned or destroyed after the antibiotic course was completed. The DON stated that medications no longer in use or for discharged residents should be sent back to the pharmacy the same day, and that the discharging nurse is responsible for ensuring this is done.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored for five residents reviewed for medication storage. The facility’s policy required multidose vials to be dated with the date opened and the initials of the first person to use the vial, and product labeling for Incruse Ellipta and Systane Complete PF required those medications to be discarded after specified timeframes once opened. During a review of the Northeast medication cart with the ADON, three unlabeled medication cups were found in the top of the cart containing medications for two residents. The ADON stated the residents were not yet ready to take the medications and confirmed the cups should not have been left unlabeled in the cart. At the same time, several resident medications in the cart were found without dates, including insulin lispro, insulin glargine, Systane Complete PF, and Incruse Ellipta, and the ADON confirmed they should have been dated.
Failure to Address Wandering and Elopement Risk
Penalty
Summary
The facility failed to re-assess elopement risk, identify wandering and exit-seeking as targeted behaviors, and develop a care plan for wandering/exit-seeking behaviors and risk for elopement for one resident with severe cognitive impairment. The resident’s active care plan did not include a problem, goals, or interventions related to wandering or elopement risk, and the last documented elopement evaluation stated the resident was at risk for elopement but did not include goals or interventions. The assessment also documented that the resident did not verbally express a desire to go home, did not pack belongings to go home, and did not stay near exit doors, while also noting that wandering behaviors likely affected the safety, well-being, or privacy of others. Nursing notes documented multiple behaviors consistent with wandering and exit seeking, including pulling the fire alarm twice while stating a desire to leave the facility and being up in a wheelchair overnight, confused, exit seeking, and roaming despite redirection. Behavior tracking for February through May 2026 did not identify wandering or exit-seeking as targeted behaviors, and the active CNA tasks only addressed physical and verbal aggression toward staff and residents. Staff interviews confirmed the resident wandered, roamed the halls, entered other residents’ rooms, and tried to go out the front door, and the social services director confirmed the elopement risk assessment was last completed on 3/2/26 and that the care plan did not address wandering or elopement risk. The elopement risk binder at the front desk did not contain the resident’s information, which the receptionist confirmed.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to provide bathing as scheduled for one resident who was unable to complete ADLs independently. The resident was cognitively intact and required substantial to maximal staff assistance for bathing. The resident stated that bed baths were received because showers were not preferred, but also stated that bathing was not occurring weekly and that there were no clear scheduled bath days. The facility’s ADL policy required bathing services to maintain grooming and personal hygiene, and the resident’s shower documentation showed baths were scheduled for Wednesday and Saturday evenings, while the documentation prompts were set for Tuesdays and Fridays. The record showed the resident was unavailable for one scheduled bath date and that several other entries were marked not applicable, but there was no documentation explaining why the resident was unavailable on the missed date. A CNA confirmed the bath schedule and stated that the shower documentation did not show baths being given on the listed dates, and that this was the only place bathing/showers were documented.
Failure to Provide Podiatry Services for a Resident with Diabetes
Penalty
Summary
The facility failed to provide podiatry services for one resident with Type 2 diabetes mellitus. The resident stated that a podiatrist was needed because the toenails were long, and on observation the resident’s toenails were long past the edge of the toes. The resident also had an adhesive dressing on the right great toe. The resident’s care plan documented diabetes, and the skin check documented that the right great toenail fell off with swelling and redness around the nailbed. A physician order was in place to cleanse the right great toe, apply Bacitracin ointment, and cover it with an adhesive bandage daily. The medical record did not contain documentation that the resident had been seen by a podiatrist after admission. The facility’s DON stated the facility had recently switched podiatry companies and that toenails were an issue, and the Social Services Director stated the new podiatry company had rounded once in April but did not see the resident because the podiatrist started on the opposite side of the building. The Social Services Director also stated the resident was on the podiatry list for May 27 and that consent and notes were being requested. The Administrator stated the resident was initially expected to be a short stay, so the resident was never seen by a podiatrist.
Failure to Apply Ordered Splints and ROM Devices
Penalty
Summary
The facility failed to apply range of motion devices used for contractures for two residents, R57 and R73, who were reviewed for range of motion. R57 was observed resting in a high back reclining chair with the right hand closed in a fist and bent toward the chest, and no splint was on the right hand. A licensed practical nurse later stated she was not aware R57 needed a brace and had never seen one, although the physician order dated 9/30/25 directed staff to apply a splint to the right hand when resting, with removal for meals per therapy. Therapy notes also documented that R57 required a resting hand splint on the right upper extremity during rest to prevent contractures and could safely wear the splint for up to four hours with minimal signs of redness, swelling, discomfort, or pain. R73 was observed sitting in a wheelchair with the right arm bent and the right hand resting on the chest, with the hand closed and nothing in it. Physician orders directed staff to monitor the right elbow splint upon application and removal for skin changes daily and as needed every shift, apply a palm protector at nighttime or as tolerated, and apply a right hand splint in the afternoon for up to four hours or as tolerated, with skin checks each evening shift. However, no splint was applied to the right elbow or right hand during observation, and the resident stated staff sometimes put lotion in the hand but had not been wearing the devices in a while. The resident later stated staff never applied the palm protector, right elbow splint, or right-hand splint, and a CNA stated she had never seen the palm protector or splints and could not find them in the room.
Cross Contamination During Catheter Care
Penalty
Summary
The facility failed to prevent cross contamination during urinary catheter care for one resident with an indwelling catheter. The facility’s catheter care policy for female residents directed staff to separate the labia, wipe front to back with a clean cloth, use a new part of the cloth or a different cloth for each side, and then, with a new moistened cloth, wipe the catheter starting at the urinary meatus and moving outward, with the catheter cleaned as the last step. During observation, two CNAs provided catheter care to the resident, and one CNA cleansed the urinary catheter tubing in a downward motion first, then used separate wipes to clean each inner labia and each inner thigh while contacting the catheter during each wipe. The catheter tubing was not cleaned last as required by the facility policy. The resident was cognitively intact and required substantial to maximal staff assistance with toileting hygiene. The resident stated staff do not clean the catheter daily, only intermittently, and also reported occasional diarrhea with incontinence and needing staff assistance with toileting. The resident’s physician order directed catheter care every shift. The record also showed a urine culture with greater than 100,000 CFU/mL of Klebsiella Pneumoniae ESBL and 70-99,000 CFU/mL of Pseudomonas Aeruginosa, and physician orders for Meropenem-Sodium Chloride for UTI on multiple dates. The DON confirmed the facility policy required cleaning the catheter tubing as the last step during female catheter care.
Inaccurate Documentation of Protective Sleeve Refusal
Penalty
Summary
The facility failed to accurately document the refusal of protective arm sleeves on the treatment administration record for one resident. The resident had a physician order dated 7/2/2025 to apply protective arm sleeves when up in a wheelchair as the resident allows, and the resident was observed multiple times sitting in a wheelchair without the sleeves on 5/3/2026, 5/4/2026, and 5/5/2026. When asked, the resident stated staff did not offer to apply the protective skin sleeves. Despite these observations, the resident’s April and May 2026 TAR documented that the protective skin sleeves were applied every day. The resident’s care plan dated 2/8/26 did not include interventions for the use of the skin sleeves. The DON stated the sleeves are intended to prevent skin tears and abrasions, that the intervention should be on the care plan, and that if the resident is refusing, staff should not sign it off.
Failure to Maintain Fall Mat Intervention Resulting in Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions as outlined in its Fall Prevention Program for a resident assessed as being at risk for falls. The facility’s policy dated 2/2/26 states that each resident’s fall risk will be assessed and interventions implemented to decrease the risk of falls and injuries. The resident had medical diagnoses including abnormalities of gait and mobility, lack of coordination, muscle weakness, and altered mental status. An MDS documented that the resident was moderately cognitively impaired and required moderate staff assistance for transfers. The resident’s care plan dated 1/7/26 identified risk for falls related to muscle weakness and included an intervention for floor mats to be placed on the side of the bed, implemented on 1/6/26. On 1/25/26, nursing notes documented that the resident was found on the floor on the right side of the bed in a fetal position, reporting that they had fallen from the bed and that their head and neck hurt, with blood noted on the right side of the head. A CT scan from that date showed mild subcutaneous soft tissue swelling and a hematoma in the right posterior parietal region, along with subcutaneous emphysema consistent with a laceration, and emergency room records documented a head laceration requiring five staples. The RN assigned to the resident during the overnight shift confirmed that at the time of the fall, the fall floor mats were not in place at the bedside, despite being a previously implemented intervention. The President of Clinical Services confirmed that fall mats had been put in place as a fall prevention intervention earlier in the month and that they should have been on the floor when the resident was in bed and at the time of the fall.
Multiple Residents Did Not Receive Ordered Evening Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in multiple omitted doses for three residents during one evening medication pass. The facility’s Medication Error Policy dated 2/2/26 requires that medications be administered as ordered and that any medication errors be reported to the physician, documented in the medical record, and reported to the appropriate supervisor. A Resident/Family Complaint Form dated 1/26/26 documents that one resident (R13) reported not receiving her evening medications on 1/23/26. During an interview on 2/5/26 at 11:48 a.m., the DON (V2) stated that residents on the Northeast Hall did not receive their evening medications on 1/23/26 and acknowledged that R13 filed a grievance about the missed medications. Record review of the January 2026 Medication Administration Records (MARs) confirmed that multiple ordered medications were not administered on the evening of 1/23/26. For R13, the MAR showed missed doses of Famotidine 20 mg, Fluticasone Propionate nasal spray, Potassium Chloride 20 mEq, Baclofen 10 mg, Diclofenac Sodium Gel 1%, and Gabapentin 1200 mg. For R14, the MAR showed missed doses of Atorvastatin 40 mg, Carvedilol 25 mg, Clonidine 0.1 mg, Doxazosin 4 mg, and Eliquis 2.5 mg. For R15, the MAR showed missed doses of Fluticasone Furoate inhalation 200-25 mcg and Rosuvastatin 5 mg. During the same 2/5/26 interview, the DON confirmed that nurses are required to administer medications per physician orders and to notify the physician and nurse supervisor when medications are not administered.
Failure to Ensure Dignified Care and Proper Response to Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignified care and proper handling of abuse allegations for two residents. One resident (R1), with essential hypertension, COPD, bipolar disorder, muscle wasting, unsteadiness, lack of coordination, a history of falls, moderate cognitive impairment, and limited upper extremity range of motion, was totally dependent for all ADLs except eating and required significant assistance with toileting and wheelchair use. R1 reported to the Social Service Director (V4) and her county case manager (V7) that a night-shift CNA, described by physical characteristics, was rough with her care, including during transfers from bed to standing and perineal care, and that she was afraid the CNA would be rough again. V4 observed bruises on the backs of both of R1’s arms, asked about their origin, and was told by R1 that a night CNA had been rough with her care, while V7 noted small, faded bruises on both forearms and R1’s report of a neck pull during transfer. A second resident (R3), cognitively intact with an upper extremity range of motion impairment and orders for a left arm sling and ongoing occupational therapy, required substantial/maximal assistance with upper and lower body dressing. R3 filed a grievance that a night-shift CNA was on her phone during care, was rude, and rough with care. R3 later stated that the CNA belittled him by calling him lazy and saying he did not need help, and that he reported this to nursing and therapy staff. An LPN (V16) confirmed that R3 reported the CNA was on the phone, belittling him, and rough with care, and stated she immediately informed the Director of Nursing. Despite these reports, the facility did not appropriately treat the allegations as potential abuse. For R1, although V4 acknowledged the allegation of rough care and stated it would be reported to the Administrator and investigated as possible abuse, the report documents that the concern was logged as a grievance related to staff approach and resolved the same day, without further detail of an abuse investigation in the cited findings. For R3, V4 documented the concern as a grievance about staff approach and contacted the CNA directly on her personal cell phone to address phone use, but did not report or investigate the allegation of rough and belittling care as potential abuse. V4 stated she did not consider the situation abuse because she knew the CNA personally and believed she was a good person, and she informed the DON only about phone use. Facility leadership, including the Interim Administrator/Abuse Prevention Coordinator (V1) and the DON (V2), later confirmed they were not aware of R3’s grievance and that the allegation was not reported or investigated as potential abuse.
Failure to Recognize and Report Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report resident allegations of abuse, including rough and belittling care, to the Administrator/Abuse Prevention Coordinator as required. One resident (R1), with moderate cognitive impairment, limited upper extremity range of motion, and total dependence for most ADLs, reported that a CNA with a ponytail was rough during care and transfers, causing bruises on both forearms and neck pain. R1 showed the surveyor quarter- and nickel-sized bruises with yellow halos on both forearms and described being grabbed behind the neck during a transfer, which made her cough and feel scared it could happen again. R1 stated she had told a “lady up in the front offices,” later identified as the Social Service Director (V4), who noticed the bruises and was told about the rough care, but no one followed up with R1 afterward. The facility’s January Concern Log documented a grievance from R1 on 01/14/26, recorded by V4 and the Business Office Manager, describing a “mean” CNA on night shift who was rough with care and that R1 wanted to discharge home. The concern was categorized as “Care-Staff Approach,” assigned to the Interim Administrator/Abuse Prevention Coordinator (V1), and marked resolved the same day. However, when the surveyor reported R1’s detailed allegation of rough care, physical abuse, and bruising on 01/16/26, V1, the DON (V2), and the Regional Nurse Consultant (V3) all stated they were not aware of any abuse allegations involving R1. Later, V4 confirmed she had received and logged R1’s grievance, including allegations that the CNA caused bruising and neck pain, and stated she reported it to V1, while a county Community Support Services Manager (V7) corroborated being present when R1 described the rough transfer, bruises, neck pulling, and fear of future rough care. A second resident (R3), cognitively intact and receiving aftercare following joint replacement surgery, also reported concerns about staff conduct that were not properly recognized or reported as possible abuse. The January Concern Log showed a grievance from R3 about a CNA on the phone during care, categorized as “Care-Staff Approach” and assigned to Social Service, with same-day resolution. V4 later stated that R3 had reported the CNA was on her phone, rude, and rough with care, and that she identified the CNA as V11. V4 acknowledged she only addressed the phone use with the CNA, did not consider the situation abuse because she knew the CNA personally, and did not report the rough care allegation to the Administrator. R3 told the surveyor he reported the incident to prevent other residents from receiving rushed or rough care and described the CNA belittling him by calling him lazy and saying he did not need the help. An LPN (V16) and a Physical Therapy Assistant (V14) both confirmed awareness of R3’s allegations of verbal and physical abuse but did not report them to the Administrator, citing uncertainty about who the Interim Administrator was at the time. The DON and Interim Administrator later confirmed they were not informed of R3’s grievance or abuse allegations.
Failure to Report and Act on Allegations of Rough Care and Derogatory Comments
Penalty
Summary
The deficiency involves multiple staff members failing to report allegations of rough care, bruising, neck pain, and derogatory comments to the Administrator/Abuse Prevention Coordinator as required by facility policy, resulting in delayed investigation and failure to remove the alleged staff perpetrators from resident care. One resident, who had moderate cognitive impairment, limited range of motion in both upper extremities, and was dependent for most ADLs, reported that a CNA with a ponytail was rough during transfers and care, causing bruises on both forearms and neck pain that made her cough and feel choked. During an interview, the resident showed bruises on both posterior mid-forearms, described as purple with yellow halo-like fading, and stated she was scared the CNA might hurt her again. The resident reported that she had told the Social Service Director about the rough care and bruising, and that the Social Service Director had noticed the bruises and said she would report the matter to her supervisor, but no one subsequently came to interview the resident about the allegation. The facility’s concern log documented a grievance from this resident indicating she was tired of a mean CNA on night shift who was rough with care, and this concern was assigned to the Administrator. The Social Service Director later confirmed that she had received and recorded this grievance, including the resident’s report that the CNA was rough with care, caused bruising to both forearms, and caused neck pain, and stated she reported the allegation to the Interim Administrator/Abuse Prevention Coordinator. However, the Interim Administrator/Abuse Prevention Coordinator, the DON, and the Regional Nurse Consultant all stated they had no reported allegations of abuse regarding this resident. The CNA identified by the resident continued to work a full shift after the grievance was documented and was not suspended until days later, after the surveyor reported the allegation to facility leadership. A second resident, cognitively intact and receiving care following joint replacement surgery, reported to the Social Service Director that a CNA had been rough with care while on the phone during care, was rude, and did not pay attention to what she was doing. The resident described the CNA’s physical characteristics, stated that the CNA was talking to someone else instead of engaging with him, and reported that she was rough and rushed. The Social Service Director confirmed that the resident reported the CNA was rough with care and on the phone, and that she personally called the CNA, who is her relative, on her own cell phone outside the building and yelled at her about being on the phone during care. The Social Service Director stated she did not view the rough care as abuse because she knew the CNA and believed she was a good person, and therefore did not report the allegation as abuse to the Administrator, despite acknowledging knowledge of the requirement to report abuse immediately. The same resident later told the surveyor that the CNA had belittled him during care by telling someone on the phone that he was lazy and did not need all the help she had to give him, and that he reported this to the Social Service Director, an LPN, and a physical therapy assistant. The LPN confirmed that the resident reported that the CNA was rough with care, called him lazy, and said he could not do anything for himself, and stated she reported the issue to the DON but did not know who the Administrator was. The DON and Interim Administrator/Abuse Prevention Coordinator both stated they were not aware of this resident’s grievance or allegation of rough care. Timecard records showed that the CNA identified in this second allegation continued to work multiple shifts on various halls with full access to residents after the allegation was made and before she was suspended, and there was no investigation documented at the time of the survey. The facility’s Abuse, Neglect, Exploitation policy required immediate protection of residents and immediate reporting of alleged violations to the Administrator and appropriate agencies, but these procedures were not followed in these instances.
Failure to Treat Resident With Dignity During Toileting Assistance
Penalty
Summary
The facility failed to honor a resident’s right to be treated with dignity and respect when a CNA required the resident to clean another resident’s feces from a toilet seat before assisting her with toileting. The resident, who was documented as cognitively intact and requiring partial to moderate assistance with toileting hygiene and transfers, reported that while being helped to the bathroom, the CNA observed feces on the toilet seat that did not belong to the resident. The CNA told the resident to use sanitary wipes to clean the feces off the toilet seat before she could use the bathroom and stated she could not help the resident until this was done. The CNA then threw the container of wipes toward the resident and waited until the resident complied. The resident stated this interaction made her feel upset, embarrassed, and disrespected, and the Administrator confirmed that the CNA did not treat the resident with dignity in this incident.
Misappropriation of Cognitively Intact Resident’s Funds by CNA
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property when a certified nurse assistant (CNA) took a check from the resident’s personal checkbook without permission and used it to pay her own rent. The facility’s Abuse, Neglect, and Exploitation policy dated 2/11/25 states the facility will develop and implement policies and procedures that prohibit and prevent abuse and misappropriation of resident property. A State Report Investigation dated 1/12/26 documented that the CNA, later identified as V15, removed a check from resident R4’s checkbook, wrote the check for $975.00, and signed R4’s name. R4’s Minimum Data Set documented that R4 was cognitively intact, and during an interview R4 confirmed that a staff member had stolen a check from her checkbook, which she kept in her room, and used it to pay rent without her knowledge, with the issue first noticed by her son. The Administrator confirmed that V15 CNA had taken the check from R4’s checkbook and used it to pay her rent.
Failure to Secure Residents During Van Transport Results in Serious Injury
Penalty
Summary
The facility failed to ensure that two residents were properly secured in their wheelchairs during van transportation, resulting in one resident sustaining serious injuries. Specifically, one resident with multiple complex medical conditions, including chronic kidney disease, COPD, Parkinson's disease, and a history of falls, was being transported in a facility van when the driver abruptly braked, causing the resident to fall forward from the wheelchair and suffer fractures to the humerus, tibia, and fibula. The investigation revealed that the seatbelt did not properly lock in place, and the shoulder belt was broken and would not tighten. The lap belt was also missing from another seat, and these issues had been previously reported to facility administrators but were not addressed. Interviews and observations confirmed that the van's wheelchair securement system was malfunctioning, with missing and broken belts, and that the van should not have been in service. The maintenance director and a technician from the mobility company verified that the occupant securement system was not fully functioning, and the last inspection had occurred several months prior. Another resident in the van at the time was not injured but reported that neither the lap nor shoulder belt was in use. The failure to maintain the van's securement system and to ensure residents were properly secured directly led to the accident and resulting injuries.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide a copy of a resident's medical records in a timely manner after a request was made by the resident's Power of Attorney. The resident had resided at the facility for a week before being transferred to a hospital and did not return. The family member, acting as Power of Attorney, reported making a formal request and signing for the medical records, but only received evasive responses from the facility. The Medical Records staff confirmed that the request was received months earlier and, because it came from a lawyer, was forwarded to corporate, but the records had not been sent out as of the time of the survey. The Administrator acknowledged that the records had only recently been sent and agreed they should have been provided much earlier.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations, interviews, and record reviews. During an initial tour, several unmade beds were observed, with some lacking linen and others containing soiled linen. One cognitively intact resident reported that staff did not make the bed daily, left dirty dishes in the room, and did not change sheets after providing bed or sponge baths. The resident's family member corroborated these findings, noting trash, used gloves, napkins, dirty dishes with old food, flies, and dirty linen present in the room during a visit. Another resident, who is severely cognitively impaired and dependent on staff for activities of daily living, was found in an unmade bed with the top sheet touching the floor and multiple used glasses and meal covers with thickened liquids left in the room. Staff interviews confirmed that beds should be made in the morning and dirty dishes removed after meals, but these tasks were not completed as required. Resident council meeting minutes from several months documented ongoing complaints about inadequate housekeeping, unclean floors, lack of clean linen after showers, and bedside tables not being cleaned, as well as certified nurse aides not making beds.
Failure to Secure Catheter Tubing, Cover Drainage Bag, and Document Output
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter by not securing the catheter tubing to the lower extremity, not covering the urinary collection bag with a dignity cover, and not consistently documenting urinary output every shift as ordered by the physician. Multiple observations confirmed that the catheter tubing was left dangling from the bedside and the urinary collection bag was uncovered and exposed to the hallway. Staff interviews corroborated these findings, and it was confirmed that the facility's policy requires the use of a securement device for the catheter tubing, covering the drainage bag, and recording urinary output every shift. Record review showed that the resident had physician orders for catheter care, including weekly changes of the securement device and documentation of urinary output every shift. However, the resident's output tracker revealed inconsistent documentation, with only one day showing output recorded for all three shifts. The facility's catheter care policy also mandates the use of privacy bags for drainage bags and proper securement of tubing, which was not followed in this case.
Failure to Timely Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse involving one resident to the state survey agency as required by its Abuse, Neglect and Exploitation policy. The policy mandates that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes—immediately, but not later than two hours if the allegation involves abuse or results in serious bodily injury, or within 24 hours if not. The Director of Nursing (DON) received an allegation of verbal abuse from the resident's daughter and a separate allegation of physical abuse from a CNA, but did not report either incident to the state agency. The DON admitted to not knowing the abuse policy and acknowledged the failure to report. No documentation was provided to show that any abuse allegations had been reported to the state agency since February.
Failure to Assess, Notify, and Manage Pain and Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents, resulting in significant harm. In the first case, a resident with severe cognitive impairment and a diagnosis of dementia experienced sudden, severe pain with redness and swelling in the left knee. Despite multiple staff members observing and reporting the resident's pain and changes in condition over several days, there was no immediate physician notification, no comprehensive pain or physical assessment, and inadequate pain management. The resident continued to experience severe pain for five days before being hospitalized with a left femur fracture requiring surgical repair. Documentation was lacking for pain assessments, nursing assessments, and rationale for obtaining diagnostic imaging, and the resident's pain was not consistently managed or monitored as per facility policy. In the second case, a cognitively intact resident with a history of left femur fracture, hip replacement, diabetes, heart failure, and Alzheimer's disease suffered an unwitnessed fall. The initial assessment documented no complaints of pain or injury, but no neurological checks or post-fall assessments were performed for an extended period. Over the following days, the resident exhibited increasing pain, required more frequent pain medication, and demonstrated significant changes in mobility and function, including inability to bear weight and flaccid extremities. Multiple staff members observed and reported these changes, but there was a failure to recognize the change in condition and notify the physician in a timely manner. The resident was eventually sent to the hospital, where a subdural hematoma with midline shift and a dislocated hip were diagnosed, necessitating neurosurgical and orthopedic intervention. Both cases demonstrate failures to follow the facility's policies on notification of changes, pain management, and assessment following significant changes in condition or falls. Staff did not consistently assess, document, or communicate critical changes, resulting in delayed recognition and treatment of serious medical conditions. These deficiencies were confirmed through interviews, record reviews, and direct observations by surveyors.
Removal Plan
- The facility Nursing Staff was in serviced by Director of Nursing and Regional Nurse Consultant regarding pain management, evaluation and treatment, physician notifications, documentation and follow-up. All nursing staff who have not attended the in-service will be in-serviced prior to their start of next scheduled shift. Nursing staff not in-serviced will not be able to return to work until in-service has been completed.
- All residents were assessed for pain by Assistant Director of Nursing. All residents have a pain scale documented on their Medication Administration Record to be completed every shift. A nonverbal pain scale was added for residents who are not cognitively intact.
- Director of Nursing implemented daily clinical rounds with the nursing staff to ensure all acute/chronic pain is addressed, appropriate assessments are completed, and notification of the physician has been completed appropriately. Reports will be reviewed/addressed during morning clinical meeting each day. Daily morning Clinical sheets were reviewed and Director of Nursing has been completing daily.
- Director of Nursing and Assistant Director of Nursing in-serviced Nursing Staff regarding physician notification of changes by phone with follow up by fax and text message. Random review of progress notes confirm physicians have been notified by phone with condition changes.
- Each nurses station contained a list of hot rack charting for nurses to review daily. Director of Nursing is updating hot rack sheets daily with changes. Facility Nurses will use hot rack charting with their report sheet for shift to shift nursing report to assist with communication and follow up. The report sheets will be reviewed by Director of Nursing and discussed in morning QA (Quality Assurance) meetings.
- Director of Nursing provided a print out of the daily dashboard electronic clinical record. Director of Nursing is reviewing the Point Click Care Dashboard, 24-hour report, pain management, and physician notification of change, daily for four weeks, to ensure effective measures are implemented for quality resident care.
- Director of Nursing provided a pain management weekly audit sheet. This audit documents five residents are being reviewed weekly for pain management.
- The facility Pain, Change in condition, and notification of changes in-service documents Director of Nursing reviewed policies and procedures with all nursing staff. Director of Nursing will discuss pain management policy and procedure and notification of changes at monthly nursing meeting.
- Director of Nursing and Administrator held an interdisciplinary meeting to discuss changes in conditions of residents. Administrator provided quality assurance meeting notes.
Failure to Provide Adequate Supervision During Ambulation Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes with complications, morbid obesity, polyneuropathy, end stage renal disease, cellulitis, muscle wasting, unsteadiness, and lack of coordination, was not provided adequate supervision and assistance during ambulation. The resident required Contact Guard Assist (CGA) for ambulation, meaning a caregiver should maintain physical contact to help with balance. During a physical therapy session, the resident was ambulating with a walker while a physical therapy aide trailed behind with a wheelchair carrying the resident's oxygen tank. The oxygen tubing became tangled around the wheelchair, and the aide bent over to untangle it, leaving a gap and unable to maintain contact or reach the resident. As a result, the resident experienced weakness, lost balance, and fell forward, sustaining a fractured right humerus, facial contusion, multiple abrasions, and right elbow pain. Documentation and interviews confirmed that the aide was not in a position to provide the required level of assistance, and the Director of Rehabilitation acknowledged that two staff members should be used when ambulating residents with multiple pieces of equipment. The incident led to the resident being sent to the hospital for evaluation and surgical repair of the fracture.
Failure to Provide Timely Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents, resulting in significant deficiencies. For one resident with Parkinson's Disease and Alzheimer's Disease, who was dependent on staff for toileting and transfers and at high risk for pressure ulcers, the facility did not implement required repositioning and incontinence care every two hours. Staff did not consistently report refusals of care or dislodged dressings to nursing staff, and there were lapses in maintaining wound dressings. The resident was observed sitting in a wheelchair for extended periods, experienced pain, and was found with a saturated brief and an uncovered, golf ball-sized pressure ulcer on the coccyx. Documentation revealed gaps in weekly skin assessments, lack of timely physician notification, and absence of pressure-relieving interventions for the heels, despite the presence of new wounds and deterioration of existing ones. The same resident developed heel blisters that progressed to stage two and three pressure ulcers, leading to hospitalization for infection and cellulitis. After returning from the hospital, the resident developed a sacral wound that deteriorated into a stage four pressure ulcer with necrosis and slough, requiring debridement. There was no documentation of ongoing wound assessments, timely physician or dietitian notification, or implementation of recommended interventions such as offloading, repositioning, and nutritional support. Staff interviews confirmed that wound care, monitoring, and communication were inconsistent, and that staffing shortages contributed to delays in care. The wound nurse and dietitian were not made aware of the resident's wounds in a timely manner, and treatment orders were not always implemented promptly. A second resident with a history of pressure ulcers was found to have a partial thickness wound on the right buttock that was not being treated or monitored. The wound had been present for more than two days, and there was no treatment order or documentation of physician notification until the wound was identified by staff during the survey. The facility's failure to follow its own policies for wound assessment, treatment, and communication with the interdisciplinary team resulted in unaddressed and deteriorating pressure ulcers for both residents.
Removal Plan
- R52 was assessed and treated by the Wound Care Physician.
- V22 Wound Nurse was hired as the facility's full time wound nurse.
- V2 Director of Nursing and V22 Wound Nurse conducted facility wide skin checks of all residents.
- V22 Wound Nurse initiated audits that included a review of the resident skin checks, provisions of incontinence care, turning and repositioning, notifications to the physician and Registered Dietician, and monitoring of wound treatments.
- V2 Director of Nursing conducted an inservice training for nurses and Certified Nursing Assistants on the topics of skin assessments, wound assessments, identifying and reporting new and deteriorating wounds, implementing and maintaining wound treatments, notification of physician and dietitian, incontinence care, and turning and repositioning. Any remaining staff will receive this training prior to their next scheduled shift.
- V22 was in-serviced by V2 on the facility's skin and wound management programs and notification of registered dietitian and physician. V22 will be responsible for monitoring/tracking/processing of physician orders and dietitian recommendations.
- V22 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly.
Failure to Protect Residents from Verbal and Emotional Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from verbal and mental/emotional abuse by staff members. One resident, who is cognitively intact and has multiple medical diagnoses including COPD, asthma, and depression, reported being yelled at by an LPN after requesting pain medication. The resident expressed fear of retaliation and emotional distress, stating that the nurse was angry about being reported and made comments about being too busy to respond to the resident's needs. The resident's daughter confirmed the incident, and the administrator acknowledged that such behavior constitutes verbal abuse. Another resident, who requires substantial assistance with activities of daily living due to conditions such as cerebral infarction, metabolic encephalopathy, and hemiplegia, reported that a CNA took away his call light during the night shift, preventing him from calling for help. The resident also stated that staff laughed at him and were rough during transfers, causing visible distress and emotional harm. The interim DON confirmed that staff should not remove call lights or treat residents disrespectfully, and that the resident is at risk for abuse due to his level of dependency and medical conditions.
Failure to Assess, Monitor, and Manage Bowel and Wound Care
Penalty
Summary
The facility failed to properly assess, monitor, and manage the care of multiple residents, resulting in significant deficiencies in nursing care. For one resident with a history of bowel obstruction and cognitive impairment, staff did not consistently monitor or document bowel movements, failed to update the care plan with new interventions after a previous obstruction, and did not notify the physician when the resident went several days without a bowel movement. The resident was ultimately hospitalized for a high-grade small bowel obstruction after staff failed to implement bowel management medications or interventions, and there was no evidence of abdominal assessments or physician notification prior to the hospitalization. Another resident with a recent below-knee amputation did not receive timely wound care or assessment upon admission. The wound was not reported to the physician until several days after it was first identified, and no wound treatments were implemented for several days. Documentation of wound assessments and measurements was lacking, and wound care was not administered according to physician orders. During wound care, a nurse failed to change gloves and perform hand hygiene after removing the old dressing and handling the resident's personal items, increasing the risk of cross-contamination. The resident required additional surgery for wound infection and dehiscence. A third resident, who was cognitively intact and had a diagnosis of constipation, experienced prolonged periods without bowel movements while receiving medications known to cause constipation. The resident reported severe pain and difficulty with elimination, and was eventually hospitalized for fecal impaction and pyelonephritis. There was no evidence of bowel management medications being administered prior to hospitalization, and documentation showed multiple days without bowel movements. The care plan for constipation was not initiated until after the hospitalization event.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and respond to significant weight loss in a resident diagnosed with multiple conditions including COPD, chronic respiratory failure, anemia, protein calorie malnutrition, and hypokalemia. Despite a care plan that required monitoring and notification of the physician and registered dietician in the event of further weight loss, staff did not notify the appropriate medical personnel or implement new interventions when the resident experienced a weight loss of over 13% in six months. The resident's weight continued to decline over subsequent months without documented action. Record review and staff interviews confirmed that neither the physician nor the registered dietician were informed of the resident's ongoing and significant unplanned weight loss. The registered dietician had not assessed the resident since several months prior, and the nurse practitioner was also unaware of the weight loss. The facility's own policy required comparison of monthly weights and notification of significant changes, but these steps were not followed, resulting in continued weight loss for the resident.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for two residents by not accurately assessing pain, failing to notify the physician of pain, and not implementing physician orders for pain medications. One resident with cognitive impairment, Parkinson's Disease, and Alzheimer's Disease had a worsening sacral pressure ulcer and exhibited clear signs of pain, including moaning, grimacing, tearfulness, and clenched fists. Despite these symptoms and staff awareness of the resident's pain, there were no active physician orders for pain medication, and pain assessments consistently documented no pain. The resident's care plan included interventions for pain management, but these were not followed, and the physician was not notified of the resident's pain until after significant deterioration of the wound and increased pain were observed. Another resident, cognitively intact and with a history of back surgery, radiculopathy, spinal stenosis, and osteoarthritis, reported frequent pain in the lower back and knees. The resident experienced severe pain during care activities, as evidenced by yelling, moaning, heavy breathing, and tears. Although the resident had PRN orders for pain medications, there were no scheduled pain medications, and pain medication was not administered until later in the day despite the resident's requests and visible distress. Staff interviews indicated that the resident often did not request pain medication until already in pain during therapy or care, and pain assessments documented moderate to severe pain on multiple occasions. Both cases demonstrate a failure to recognize and respond to residents' pain, as required by the facility's pain management policy. Staff did not consistently assess or report pain, and physician notification and intervention were delayed, resulting in unmanaged pain and, in one case, a worsening pressure ulcer that required debridement. The facility's actions and inactions did not align with established care plans or standard pain management practices.
Insufficient Nursing Staff Resulting in Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by long call light response times and delays in wound treatments and assessments for eight residents out of 32 reviewed. The facility's own assessment indicated a need for 24 CNAs for a census of 97 residents, but staffing records showed only 19-20 CNAs were present on several days. Resident council minutes and interviews with residents consistently reported call light response times of 30-45 minutes or longer, missed or delayed showers, and cold food due to insufficient staff to deliver trays promptly. Multiple residents stated they often waited extended periods for assistance, including incontinence care, and some had not been cleaned up by late morning. Staff interviews confirmed the ongoing staffing shortages, with one LPN responsible for 32 residents and reporting difficulty completing assessments, treatments, and processing orders, often resulting in tasks being passed to the next shift and sometimes missed. The CNA/scheduler and administrator acknowledged the inability to maintain adequate staffing, with frequent call-ins and no-shows, and confirmed that the facility had stopped taking new admissions due to the staffing crisis. The deficiency directly resulted in unmet resident care needs, including delayed toileting, repositioning, and incomplete scheduled showers.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to post daily, up-to-date nurse staffing information as required, with the posted staffing sheet near the front entrance remaining dated 2/28/25 over several days of observation, including 3/3/25 and 3/5/25. This issue was confirmed by the Interim Regional DON, who acknowledged that the posted daily staffing should be updated each day. The deficiency potentially affected all 97 residents in the facility. Additional concerns identified during the survey included issues related to staffing, showers, cold food, turning and repositioning, toileting, incontinence care, infection control, and call light wait times. Resident Council Meeting Minutes from two separate dates also documented resident concerns regarding call light wait times.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, which has 150 licensed beds and 97 residents, failed to employ a qualified full-time social worker as required by its own facility assessment. During an interview, the administrator confirmed that the current staff member covering both Activities and Social Services does not possess the necessary qualifications to serve as a social worker, specifically lacking a degree in Social Work or Human Services. This deficiency was identified through interviews and record reviews, and it was noted that the lack of a qualified social worker could potentially affect all residents in the facility.
Failure to Implement Water Management Plan and Risk Assessment
Penalty
Summary
The facility failed to implement its water management plan as required, specifically by not conducting a comprehensive risk assessment to identify areas in the water system where Legionella and other pathogens could grow and spread. The water management plan, although revised, did not include documentation of the risk assessment, specific testing protocols, acceptable control measure ranges, or corrective actions for when control limits are not maintained. During an interview, the administrator confirmed a lack of access to or documentation of completed risk assessments or related activities. These failures were identified through interviews and record reviews and have the potential to affect all 97 residents in the facility.
Failure to Properly Record and Manage Resident Funds
Penalty
Summary
The facility failed to properly record and manage resident funds for five out of seven residents reviewed. During observation, surveyors found stapled plastic pill pouches containing cash taped to the underside of the narcotic section of medication carts, with residents' names written on the pouches. The amounts of money varied, and one pouch was labeled as 'lost and found.' Staff, including an LPN, stated that the money belonged to the residents and was kept in the medication carts because the business office was closed on weekends. There was no sign-out sheet or documentation system in place for tracking how much money each resident had or how much was given to them from these pouches. Further interviews with the Assistant Director of Nursing confirmed that there should have been a sign-out sheet at each medication cart, but none were present. The Corporate Business Office Manager stated that all resident money should be entered into the resident fund account and was unaware that nurses were storing residents' money in the medication carts. Review of the residents' trust fund statements showed no documentation of deposits or withdrawals related to the money found in the carts. The facility's policy requires the business office to maintain a record of all financial transactions, including deposits and withdrawals, but this was not followed in these cases.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to provide scheduled showers and necessary hygiene and grooming assistance for four residents who were unable to perform activities of daily living independently. According to the facility's Activities of Daily Living Policy, residents who cannot carry out these tasks are to receive the required care to maintain grooming and personal care. Observations and record reviews revealed that one resident, who was dependent for personal hygiene due to a history of CVA and left-sided weakness, was noted to have unclean hair, long nails, and food in his beard and on his shirt. Another resident, requiring substantial assistance due to dementia and right hemiplegia, was observed with long and dirty nails. A third resident, with hemiplegia and limited mobility, was seen on two occasions with stained clothing, long and dirty nails, and facial hair in need of shaving. Additionally, a cognitively intact resident who is dependent on staff for bathing reported during a resident council meeting that showers were not being provided as scheduled, citing insufficient staffing. Documentation confirmed that this resident missed several scheduled showers over a two-month period, with gaps in records indicating showers were not offered as required. The Director of Nursing confirmed the accuracy of the provided documentation, which supported the findings of missed care.
Failure to Serve Palatable and Appropriately Heated Meals in a Timely Manner
Penalty
Summary
The facility failed to ensure that food was palatable, served at a satisfactory temperature, and delivered in a timely manner for five residents reviewed for food satisfaction. According to the facility's policy, hot food should be held and served at a temperature no lower than 135 degrees Fahrenheit. Multiple residents reported during interviews and a resident council meeting that their food was often cold, unappetizing, and not delivered promptly, both in the dining room and in their rooms. Several residents stated that there was insufficient staff to pass trays in a timely manner, and some reported that their families brought food from home due to dissatisfaction with the facility's meals. Observations confirmed that food holding carts with resident trays remained in the kitchen for extended periods before being delivered. When food temperatures were checked, items such as fried chicken were found to be significantly below the required 135 degrees Fahrenheit, with readings as low as 100.7 degrees. Staff acknowledged that the delay in passing trays resulted in food being served too cold. The dietary manager confirmed that meals are expected to be served at the appropriate temperature, but this standard was not met during the survey period.
Failure to Maintain Resident Dignity in Activities of Daily Living
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, metabolic encephalopathy, rhabdomyolysis, and hemiplegia was observed on multiple occasions with stained clothing, long and dirty fingernails, and unshaven facial hair. The resident required substantial to maximum assistance with eating and had impairments on one side of both upper and lower extremities, as documented in the care plan and Minimum Data Set. Despite these needs, the resident was seen after meals with food and drink stains on their shirt and poor personal hygiene. Interviews with staff revealed that the certified nursing assistant was unaware of the resident's soiled condition, attributing it to staffing shortages and not being the one who returned the resident to their room after lunch. The administrator confirmed that staff are expected to follow policies and procedures to maintain resident dignity and meet their needs. The facility's policy emphasizes the importance of treating residents with respect and dignity, but these standards were not met in this instance.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents as required by its policy and the residents' care plans. One resident, who was cognitively intact and required partial to moderate assistance for transfers and ambulation, was observed sitting in a wheelchair with his breakfast tray untouched because his call light was attached to the bedrail on the opposite side of the bed, out of his reach. The resident reported being unable to request assistance to have his food reheated due to the inaccessible call light and stated he could not walk on his own. Another resident, who required staff assistance with all personal care, transfers, and bed mobility due to a history of right femur fracture, was found sitting in a wheelchair with the call light lying on the floor behind him, also out of reach. This resident stated that being unable to reach the call light happened frequently, despite a care plan intervention specifying that the call light should be kept within reach at all times.
Failure to Accurately Record and Communicate Resident's Advance Directive
Penalty
Summary
The facility failed to accurately review and record a resident's physician's orders for life-sustaining treatment, resulting in a discrepancy between the resident's documented code status and their signed advance directive. Specifically, a cognitively intact resident stated having a Do Not Resuscitate (DNR) order, and their Physician's Order for Life Sustaining Treatment (POLST), signed by both the resident and a physician, indicated DNR. However, the resident's hospital discharge orders, active profile, and physician's orders in the electronic medical record all listed the resident as full code. The care plan did reflect the DNR status, but nursing staff relied on hospital records and the electronic profile, which did not match the POLST form. This inconsistency was confirmed during interviews and record reviews, demonstrating a failure to ensure that the resident's advance directive was accurately reflected and communicated in all relevant documentation.
Failure to Provide Functional Bed Results in Resident Discomfort
Penalty
Summary
The facility failed to provide a comfortable and functioning bed for a resident who required assistance with bed mobility due to a right femur fracture, infection, and low back pain. The resident was found lying in bed with the head of the bed unevenly elevated and reported that the bed had been broken since 1:00 AM, leaving him unable to change position and causing discomfort. Despite notifying staff, no maintenance personnel responded, and the bed remained nonfunctional when both the resident and a Certified Nursing Assistant attempted to operate it. The Regional Maintenance Director later confirmed that staff should have replaced the bed rather than leaving the resident in the broken bed overnight.
Failure to Timely Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not promptly investigating and reporting an allegation of verbal abuse involving one resident. According to the facility's policy, all allegations of abuse, including verbal abuse, must be immediately investigated and reported to the state agency within 24 hours. However, after a resident reported being verbally abused by an LPN, the administrator received a call from the resident's family member about the incident but did not notify the state agency or begin an investigation until several days later. This delay in response was contrary to the facility's established procedures for handling abuse allegations.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to notify the state agency in a timely manner regarding an allegation of verbal abuse involving one resident. The administrator received a phone call from a family member reporting that a Licensed Practical Nurse was rude to the resident and caused the resident to become upset. Despite receiving this information, the administrator did not notify the state agency until several days later. Documentation confirmed that the state agency was not informed of the verbal abuse allegation until after the delay.
Failure to Immediately Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to immediately investigate an allegation of verbal abuse involving one resident. The Administrator received a phone call from a family member reporting that a Licensed Practical Nurse was rude to the resident and caused the resident to become very upset. Despite receiving this information, the Administrator did not initiate an investigation into the alleged abuse until several days later. The facility's report to the state agency confirmed that the investigation was not started until after the delay.
Failure to Coordinate PASARR Level II Evaluation for Resident with SMI Diagnoses
Penalty
Summary
The facility failed to coordinate a required Pre-Admission Screening and Resident Review (PASARR) Level II evaluation for one resident who was reviewed for PASARR II completion. The resident was admitted with diagnoses of Generalized Anxiety Disorder and Post Traumatic Stress Disorder, both of which had been present since 2016. Despite these diagnoses, the PASARR Level I evaluation completed at admission indicated that no Level II evaluation was necessary, as it did not identify any Significant Mental Illness (SMI) diagnosis. Upon interview, the Regional Interim DON confirmed that if a resident had an SMI diagnosis on admission or was later diagnosed, a PASARR Level II evaluation should have been coordinated. The PASARR Level I evaluation for this resident was not reviewed for accuracy at the time of admission, resulting in the failure to identify the need for a Level II evaluation.
Failure to Follow Physician Orders for Daily Weights and Notification
Penalty
Summary
Staff failed to follow physician orders for a resident diagnosed with Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease Stage 4. The physician had ordered daily weights to be taken every day shift, with instructions to notify the physician if there was a weight gain greater than three pounds in 24 hours or greater than five pounds in seven days. The resident's care plan also included monitoring and reporting sudden weight gain as an intervention for fluid volume overload. However, review of the Treatment Administration Records (TAR) revealed multiple missed days for daily weights across several months, including 12 missed days in December, 11 in January, 9 in February, and 3 in March. During this period, there was a documented weight gain of 12.9 pounds over two days, with no evidence that the medical provider was notified as required by the physician's order. Interviews with facility staff, including a nurse practitioner and the regional interim DON, confirmed that daily weights were necessary for monitoring the resident's condition and that staff were expected to follow physician orders. Both acknowledged that the daily weights should have been completed and documented, and that the physician should have been notified of significant weight changes as specified in the orders. The failure to consistently obtain and document daily weights, as well as to notify the physician of abnormal weight gain, constituted a failure to provide care according to the resident's written plan of care.
Failure to Monitor Bleeding Risk for Resident on Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to adequately monitor a resident's risk of bleeding associated with the use of anticoagulant and antiplatelet medications. The resident had physician orders for Eliquis (an anticoagulant) and Clopidogrel (an antiplatelet), but there were no corresponding physician orders to monitor for bleeding risks or signs of bleeding related to these medications. The resident's care plan addressed the risk of bleeding and bruising related to Aspirin and Clopidogrel, with interventions to administer medications as ordered and monitor for adverse reactions, but did not include Eliquis in the care plan. Interviews with facility staff confirmed awareness of the resident's use of both Eliquis and Clopidogrel and the associated need for close monitoring for bleeding risks. A nurse practitioner stated that the medications were prescribed for different conditions and acknowledged the necessity for monitoring. A licensed practical nurse confirmed that there should be an order for monitoring anticoagulant use and bleeding complications, typically recorded on the Treatment Administration Record, but verified that such an order was missing for this resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 215 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab Of Rock Springs, The | 0.2 mi | ★★★★★ | 16 | 0 |
| Decatur Rehab & Health Care Ct | 2.8 mi | ★★★★★ | 0 | 0 |
| Fair Havens Senior Living | 3.4 mi | ★★★★★ | 33 | 1 |
| Arc At Hickory Point | 3.6 mi | ★★★★★ | 23 | 1 |
| Imboden Creek Senior Living | 3.8 mi | ★★★★★ | 36 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.