Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Loft Rehab Of Rock Springs, The during CMS and state inspections, most recent first.
Dirty and Damaged Third-Floor Resident Areas: Surveyors found the third-floor hallways, dining area, and resident rooms dirty and in disrepair, with food debris, sticky substances, dust, black scrapes, peeling paint, missing trim, buckled drywall, and bathroom soilage. CNAs said housekeeping did not clean daily and that staff sometimes had to clean because the third floor was the "nastiest" floor. The ED said housekeeping was supposed to clean the entire floor daily, but the area remained unclean, and staff also reported leaks, peeling paint, and prior black mold issues.
A resident with cardiac disease, CHF, and type 2 DM was given their scheduled Lyrica dose while their roommate’s medications, including oxycodone, metoprolol, citalopram, and hydrochlorothiazide, were left unattended at the bedside by an LPN who left briefly to get water. During this time, the resident ingested their own Lyrica plus the roommate’s medications, which were not ordered for them. Staff, including multiple LPNs and the DON, stated that medications are not to be left at the bedside, and facility policy requires observation of medication consumption, but these practices were not followed, resulting in a significant medication error.
A resident with multiple chronic and psychiatric conditions was found to be living in a room with significant dust on a bookcase and model cars, cobwebs and dust on the windowsill and around a decorative light, and a trashcan that had reportedly not been emptied for several days. The resident stated housekeeping only comes every two or three days and does not clean well, and the housekeeping supervisor acknowledged the department is understaffed and rooms are not cleaned appropriately, contrary to the facility’s written policy requiring routine cleaning and disinfection of resident rooms.
Two residents with complex medical and cognitive conditions were involved in a physical altercation over a personal belonging, resulting in one resident sustaining a bruise. The incident, which was confirmed by both residents and documented in facility records, occurred despite an existing care plan addressing physical aggression and the facility's policy to prevent abuse.
Thirteen residents were found to be living in rooms with ceiling tiles in disrepair, visible black substance resembling mold, and persistent bathroom cleanliness issues. Staff interviews confirmed ongoing maintenance problems and unaddressed environmental hazards, with both housekeeping and administration acknowledging the deficiencies.
A resident who was cognitively impaired and dependent on staff for mobility developed a pressure ulcer that worsened over time due to the facility's failure to consistently implement pressure-relieving interventions, such as use of a low air loss mattress, and to timely revise the treatment plan despite ongoing deterioration and infection. Staff interviews confirmed lapses in following prescribed interventions and a lack of expertise in advanced wound care therapies.
A resident with a right humerus fracture experienced a six-day delay in receiving an orthopedic consult due to the facility's failure to implement a STAT order. Despite severe pain and swelling, the resident was not seen by a specialist until six days after the fall, during which time increased doses of Tramadol were required for pain management. The delay was due to a lack of communication regarding the urgency of the situation.
Two residents in an LTC facility suffered injuries due to inadequate fall interventions. One resident, with hemiplegia, fell twice from bed, hitting her head on a dresser due to missing safety measures like a scoop mattress and fall mats. Another resident, with multiple health issues, fractured her arm during assisted ambulation when her foot got stuck on a damaged threshold strip. The assisting CNA, who was pregnant, did not use a gait belt and could not provide adequate support. The facility failed to maintain safety protocols, contributing to these incidents.
A resident's medical records were found to be inaccurate and incomplete, with discrepancies in Tramadol administration documentation and missed pain assessments. Additionally, a physician's order for a sling was not timely transcribed, and a leg wound dressing change was incorrectly signed off as completed. The DON acknowledged these documentation errors, which contravened the facility's policy for accurate and timely record-keeping.
A resident with multiple medical conditions, including a fracture and cellulitis, did not receive a requested shower and wound dressing change before a doctor's appointment due to communication breakdowns among staff. The resident, who has no cognitive impairment, was not informed of her shower schedule and relied on a specific CNA who was unavailable. The facility's shower schedule was based on room numbers, and the resident's preferences were not documented or communicated effectively, leading to a deficiency in honoring resident rights.
A staff member refused to assist a resident with impaired vision and coordination issues during a toileting hygiene request, leading to a deficiency in protecting the resident from verbal abuse. The resident, who required assistance due to medical conditions, was left to clean himself after an incontinent episode, which was against the facility's policy on abuse and neglect.
A resident, dependent on staff for bathing, did not receive a requested shower and wound dressing change before a doctor's appointment. Despite being scheduled for showers, the resident was unaware of her shower days and relied on a specific CNA who was unavailable. The facility's bath schedule lacked clarity, and the Director of Nursing was unaware of the resident's unmet requests. The resident's nurse confirmed the dressing change was not completed, indicating a breakdown in communication and care coordination.
The facility failed to provide a sufficient supply of towels and washcloths, impacting residents' care. A resident reported missed showers due to linen shortages, and a CNA confirmed frequent shortages in the linen cart and closet. The laundry department struggled with staffing and budget cuts, reducing shifts from three to two, which hindered the ability to maintain adequate linen supplies. The administrator was aware of the issue but had not ordered more linens, affecting all 104 residents.
The facility failed to ensure cleanliness and repair in utility rooms and nurses stations, affecting all 105 residents. Inspections revealed issues such as a leaking sink, black substance under cabinets, and accumulated dirt and debris in utility rooms. The maintenance director confirmed awareness of the issues, and the President of Clinical Services noted neglect in cleaning duties.
The facility failed to have an RN on duty for eight consecutive hours per day, as required. During an investigation, it was found that on several dates in November 2024, no RN was scheduled to provide direct care. Interviews confirmed that the RNs present, including the Assistant Directors of Nursing, did not work on the floor for the required duration, impacting the care of all 108 residents.
The facility failed to employ a certified Dietary Manager, affecting all 108 residents. The current manager is not certified and has not completed the necessary course, yet is responsible for managing the dietary department, including regulatory oversight and staff training. This was confirmed by both the manager and the facility's administrator.
The facility failed to provide adequate support personnel for the food and nutrition service, affecting 108 residents. The dietary manager was observed managing kitchen personnel and acting as a cook due to insufficient staffing. The schedule showed only two staff members were available on several days, which the dietary manager confirmed was inadequate for timely completion of essential functions.
The facility did not adhere to the posted lunch menu, serving pork chops instead of pork loin, sliced bread instead of a dinner roll, and apple slices with cinnamon instead of apple cobbler. A resident noted frequent menu substitutions, and complaints were documented by the administrator and in resident council minutes. This issue potentially affects all 108 residents.
The facility failed to ensure a clean and safe environment for residents, with multiple rooms found cluttered and unclean, and walls in disrepair. Residents expressed dissatisfaction with housekeeping services, and staff confirmed that cleaning standards were not met. The facility's cleaning policy was not adhered to, contributing to the deficiency.
A resident with intact cognition physically abused another resident with multiple diagnoses, including Mild Intellectual Disability and Traumatic Brain Injury, in the dining room. The incident occurred despite the facility's policy against abuse, and the affected resident immediately complained of pain. A CNA witnessed the event, confirming the abuse.
Two residents with pressure ulcers did not receive prescribed nutritional supplements and wound treatments due to time constraints and supply issues. A resident with a stage four sacral ulcer was not given Arginaid, a protein supplement, and missed several wound treatments. Another resident also missed multiple wound treatments for ulcers on the sacrum and shoulder. The DON confirmed these deficiencies.
The facility failed to have physician orders for oxygen use for three residents who required oxygen therapy. The residents' care plans lacked specific details for oxygen delivery, and there were no documented physician orders for oxygen administration, despite the facility's policy requiring such orders.
The facility failed to provide sufficient RN hours on two of sixteen days reviewed, with zero hours of RN coverage on two specific days. This was confirmed by the facility's Nursing Schedule and an interview with the Administrator. At the time, the facility had 95 residents.
Dirty and Damaged Third-Floor Resident Areas
Penalty
Summary
The facility failed to ensure resident rooms, hallways, and the third-floor dining area were clean and in good repair for three residents reviewed for a homelike environment. Surveyors observed paper debris in the third-floor hallways, white patched areas on walls, food debris and sticky splatters in the dining area, and later found the same dining area still dirty with food debris and a sticky substance on the floor. Staff interviews indicated housekeeping was not cleaning the dining room daily, and CNAs stated they sometimes cleaned when able because the third floor was described as the "nastiest" floor. In resident rooms, R79's room had debris on the floor, buckled drywall, black scrape marks on multiple walls, rust-colored areas under the heater, trim off the wall near the bathroom, flaking paint, dark substances in the toilet bowl, and dust and dirt debris in the bathroom. R18's room had black scrapes on three unpainted walls, missing trim, peeling paint, and debris and dust under both beds even after housekeeping had just cleaned. R82's room had debris on the floor, a dark sticky substance in the bathroom, a large buckle in the drywall near the bathroom, black scrapes and chips on three unpainted walls, and the resident stated the wall crack had been there a long time. Additional observations included chipped trim and dark splatter on the elevator area, a third-floor shower room with a leak for approximately six weeks, peeling paint on the ceiling, and a missing floor tile in the shower area. Staff stated housekeeping was rarely around, leaks existed throughout the building, and black mold had been painted over. The Environmental Director stated housekeeping was supposed to clean the entire third floor seven days a week and that housekeepers should clean under beds and move lightweight items and dining tables, but the area remained dirty. The Administrator stated there were no plans to renovate the third floor, and work order review did not show orders or resolutions for the third-floor wall issues.
Unattended Bedside Medications Lead to Resident Receiving Wrong Drugs
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a nurse left medications at the bedside and the resident ingested pills not prescribed to them. An LPN reported that the resident received their scheduled Lyrica 225 mg along with one of their roommate’s pills after the LPN left both the resident’s and the roommate’s medications at the bedside and briefly left the room to get water. During this time, the resident took all of the roommate’s medications from the bedside table. The medication error report documented that the resident ingested their own Lyrica 225 mg plus an oxycodone tablet and additional medications—metoprolol 25 mg, citalopram 20 mg, and hydrochlorothiazide 25 mg—that were prescribed to the roommate, not to the resident. Record review showed that the resident had diagnoses including atherosclerotic heart disease, acute diastolic congestive heart failure, and type 2 diabetes mellitus without complications, and had active orders for Lyrica 225 mg twice daily and hydrocodone-acetaminophen 5-325 mg every eight hours as needed for severe pain. There were no physician orders for metoprolol, citalopram, or hydrochlorothiazide for this resident. The resident’s care plan directed that medications be administered as ordered and that the physician be notified of side effects. The facility’s medication administration policy required staff to observe resident consumption of medication, and multiple LPNs and the DON stated that medications are not to be left at the bedside, indicating that the nurse’s action of leaving medications unattended at the bedside was contrary to facility policy and expectations and led directly to the medication error.
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment for one resident. The resident, admitted on 4/9/2016, has multiple documented diagnoses including personal history of COVID-19, age-related nuclear cataract, homonymous bilateral field defects (right side), cerebral infarction, hyperlipidemia, essential (primary) hypertension, major depressive disorder (single episode), bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, vitamin deficiency, intermittent explosive disorder, nicotine dependence, alcohol abuse, and obsessive-compulsive disorder. During an observation on 03/09/26 at 10:45 AM, the resident’s room contained a black bookcase shelving unit with model cars and shelves covered in dust. The windowsill had cobwebs and dust extending from plant containers to the sill, as well as cobwebs surrounding a decorative light in the windowsill. At the same time, the resident reported that housekeeping comes to clean the room every two or three days but does not clean very well. The resident lifted a half-full trashcan and stated the trash had not been emptied for three days, and pointed to the windowsill, stating it had been dirty for a long time. On 03/10/26 at 9:44 AM, the Housekeeping Supervisor stated that the housekeeping department is understaffed and that resident rooms are not cleaned appropriately. The facility’s “Room Change Cleaning and Disinfection” policy dated 5/21/2021 states that it is the facility’s policy to ensure routine cleaning and disinfection to provide a safe, sanitary environment, including routine cleaning and disinfection of frequently touched or visibly soiled surfaces in resident rooms. The observed conditions and staff statements show that this policy was not being followed for this resident’s room.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, as evidenced by a documented physical altercation between two individuals. One resident, who had diagnoses including End Stage Renal Disease, Chronic Diastolic Heart Failure, Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Stage Five Chronic Kidney Disease, reported being grabbed and punched in the arm by her roommate during a dispute over a shirt. The resident sustained a bruise on her arm as a result of the incident and responded by hitting the other resident back and throwing a glass of water in an attempt to stop the altercation. The other resident involved, who had moderate cognitive impairment and diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Hyperlipidemia, and COPD, also confirmed the altercation but denied being harmed. The incident was corroborated by interviews and record reviews, which indicated that the altercation was initiated over a personal belonging and escalated to physical violence. The care plan for the resident with cognitive impairment had previously addressed physical aggression towards other residents. The facility's abuse policy requires protections to prevent abuse, neglect, and exploitation, including resident-to-resident altercations, but the occurrence of this event demonstrates a failure to prevent physical abuse between residents.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for thirteen out of nineteen residents reviewed for physical plant problems. Observations revealed that multiple resident rooms, including those on the fourth floor, had ceiling tiles in disrepair with a raised black substance resembling mold, as well as dirty sprinkler heads and vents. In one resident's room, the bathroom toilet had a persistent dark ring and sediment that housekeeping staff were unable to remove, despite repeated cleaning attempts and reporting the issue to maintenance and supervisory staff. The maintenance director confirmed the presence of the black substance on ceiling tiles in several rooms, and the housekeeper stated that the toilet issue had not been addressed despite being reported. Interviews with staff indicated ongoing issues with the maintenance department and acknowledged that the cleanliness of the building was suboptimal. The DON noted that maintenance had been inconsistent, and the administrator was unaware of the extent of the environmental hazards, including the raised black substance on ceiling tiles in resident rooms. Residents also reported missing ceiling tiles, chipping paint, and the presence of a black substance in their rooms and bathrooms during their stay.
Failure to Implement and Monitor Pressure Ulcer Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and monitor pressure-relieving interventions and did not re-evaluate the effectiveness of pressure ulcer treatment for a resident at risk for pressure ulcers. The resident, who was cognitively impaired and dependent on staff for mobility, was admitted without pressure ulcers but developed an unstageable pressure ulcer to the coccyx shortly after admission. The care plan and physician orders specified the use of a low air loss mattress and regular repositioning, but these interventions were not consistently implemented, as evidenced by the resident being observed on a standard mattress after a room change. Despite ongoing wound assessments documenting worsening of the pressure ulcer, including progression from unstageable to stage 4 with increased size, tunneling, and drainage, the treatment plan was not revised in a timely manner. The wound continued to deteriorate over several weeks, with repeated documentation of heavy drainage, necrotic tissue, and infection. The wound care provider continued the same treatment orders for extended periods, even as the wound failed to improve and new complications developed. Staff interviews confirmed that the resident was not on the prescribed low air loss mattress due to a room change, and the wound care nurse acknowledged a lack of familiarity with negative pressure wound therapy, which may have been beneficial given the wound's condition. Facility leadership stated that they would expect a change in treatment after two weeks without progress, but this did not occur, contributing to the ongoing decline of the resident's pressure ulcer.
Delayed Orthopedic Consult for Fractured Humerus
Penalty
Summary
The facility failed to implement a physician's STAT order for an orthopedic consult appointment in a timely manner for a resident with a right humerus fracture. This resulted in a six-day delay before the application of a cast, causing the resident severe pain and swelling. The resident, who had no cognitive impairment, fell and sustained a fracture on 2/18/2025, but was not seen by an orthopedic specialist until 2/24/2025. After the fall, the resident was assessed by a nurse practitioner who ordered immediate X-rays, which confirmed an acute transverse fracture with modest displacement. Despite the physician's order for an immediate orthopedic consultation, the facility scheduled the resident's appointment for 2/24/2025, six days after the fall. During this period, the resident experienced significant pain and swelling, requiring increased doses of Tramadol for pain management. The delay in treatment was attributed to the facility's failure to communicate the urgency of the situation to the orthopedic office. The orthopedic nurse practitioner expressed frustration upon seeing the resident, noting the lack of proper arm stabilization and the significant swelling. The facility's Director of Nursing acknowledged the oversight and the need for immediate action, which was not taken, resulting in prolonged discomfort for the resident.
Failure to Implement Fall Interventions Leads to Resident Injuries
Penalty
Summary
The facility failed to provide a safe environment and implement effective fall interventions for two residents, resulting in significant injuries. One resident, diagnosed with hemiplegia and other conditions, fell out of bed twice, hitting her head on a bedside dresser, which led to head lacerations requiring emergency medical attention and staples. The facility did not maintain the necessary safety interventions, such as a scoop mattress, fall mats, and proper bed positioning, which contributed to these incidents. Additionally, the bedside dresser was not kept at a safe distance from the bed, despite previous instructions to do so. Another resident, with multiple medical conditions including morbid obesity and diabetes, sustained a right arm fracture during an assisted ambulation to the bathroom. The assisting CNA, who was pregnant, did not use a gait belt and was unable to provide adequate support when the resident's foot got stuck on a damaged metal threshold strip. The resident's request for assistance to free her foot was not met, leading to a fall that resulted in a fracture. The facility's failure to repair the hazardous threshold strip and ensure proper use of gait belts during transfers contributed to the incident. Interviews with staff and residents highlighted the lack of adherence to safety protocols and the absence of necessary interventions. The facility's policies required specific measures to minimize fall risks, but these were not consistently implemented, leading to preventable injuries. The staff's lack of awareness and failure to maintain safety interventions were significant factors in the deficiencies observed.
Inaccurate and Incomplete Medical Records for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, identified as R1, who was reviewed for documentation. R1's medical records showed inconsistencies and omissions in the documentation of medication administration and pain assessment. Specifically, there was a discrepancy between the number of Tramadol doses recorded as removed from the narcotic supply and the number documented as administered in the Medication Administration Records (MAR). Additionally, the facility did not consistently document R1's pain levels as required, with 61 out of 90 opportunities missed. Further issues were identified with the documentation of a physician's order for a sling for R1's right upper extremity following a fall. The order was not transcribed to R1's Physician Order Sheets (POS) or MAR in a timely manner, resulting in a five-day delay. The sling was documented as discontinued on the same day it was finally added to the MAR, and there was no signature to confirm its application. This lack of documentation accuracy extended to a leg wound dressing change, which was signed off as completed despite the resident confirming it was not done on the specified date. The Director of Nursing acknowledged the documentation errors, noting that the nurses failed to record the necessary information accurately. The facility's policy on medical record documentation emphasizes the need for complete, accurate, and timely documentation to reflect the resident's experiences and progress. However, the observed deficiencies indicate a failure to adhere to these standards, resulting in incomplete and inaccurate medical records for R1.
Failure to Honor Resident's Right to Choose Shower and Wound Care Schedule
Penalty
Summary
The facility failed to honor a resident's right to choose when to have a shower and when to have a wound dressing changed, affecting one resident. The resident, who has a BIMS score indicating no cognitive impairment, expressed a preference for having her leg dressing changed after a shower before a doctor's appointment. However, the resident did not receive a shower or a dressing change as requested. The resident reported that she had not been informed of her shower schedule and had to rely on a specific CNA, who was not on duty, to accommodate her requests. The resident's medical conditions include a displaced fracture, cellulitis, hypertension, atrial fibrillation, anemia, diabetes, and morbid obesity, requiring daily wound care. Despite the resident's clear communication of her needs to the staff, there was a breakdown in communication among the staff members. The LPN on duty was not informed of the resident's request for a shower and dressing change before her appointment, and the CNA who usually assisted the resident was not present due to a call-off. The facility's shower schedule was based on room numbers, and the resident's preference for a different schedule was not documented or communicated effectively. The Director of Nursing and other staff members were unaware of the resident's unmet requests, indicating a lack of coordination and communication within the facility. This failure to accommodate the resident's preferences and ensure her care needs were met resulted in a deficiency in honoring resident rights.
Failure to Assist Resident with Toileting Hygiene
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a staff member, identified as V12, refused to assist a resident, R4, with a requested transfer, ambulation, and toileting hygiene. R4, who was admitted to the facility with medical conditions including post-procedural partial obstruction of the colon, ataxia, and dizziness, required assistance for transfers and ambulation due to impaired vision and coordination issues. On the day of the incident, R4 experienced bowel incontinence and requested help from V12 to get cleaned up. However, V12 refused to assist, telling R4 that he could clean himself, and left the room, which was witnessed by another staff member, V11. R4 reported feeling unsteady and needing assistance to balance when standing and walking, but V12 did not provide the necessary help. Instead, V12 placed R4's cane beside him and left, returning only after R4 activated the call light multiple times. The facility's policy on abuse, neglect, and exploitation defines abuse as the deprivation of services needed for residents to attain the highest physical, mental, and psychological well-being, and neglect as the failure to provide necessary services to avoid physical harm, mental anguish, or emotional distress. The administrator, V1, acknowledged the incident as abusive and terminated V12's employment.
Failure to Provide Scheduled Shower and Dressing Change
Penalty
Summary
The facility failed to provide a dependent resident with a shower and wound dressing change prior to a doctor's appointment. The resident, who has a history of a displaced transcondylar fracture of the right humerus, weakness, and cellulitis of both lower limbs, is totally dependent on staff for bathing and showers. Despite requesting a shower and dressing change before a scheduled doctor's appointment, the resident did not receive these services. The resident expressed that she had not been informed of her scheduled shower days and had not been offered a shower since returning to the facility in January. She relied on a specific CNA, who was not on duty, to provide her showers, indicating a lack of communication and scheduling issues within the facility. The facility's bath schedule only documented the resident's shower days by room number, and there was no record of the resident receiving a shower on her scheduled days. The Director of Nursing was unaware of the resident's unmet requests and stated that showers are provided based on room number unless residents prefer another time. The CNA familiar with the resident confirmed that she was not on duty the day the resident requested a shower, which likely contributed to the oversight. The resident's nurse also confirmed that the leg dressing change was not completed before the appointment, highlighting a breakdown in communication and care coordination among the staff.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to maintain an adequate supply of towels and washcloths, impacting the residents' right to a clean, comfortable environment and quality of care. Observations and interviews revealed that residents often had to wait for showers due to a lack of available linens. A resident reported that there were times when showers could not be given because there were no towels or washcloths available. A CNA confirmed that the linen cart and closet frequently lacked necessary items, and the Director of Nursing acknowledged that linen shortages were a known issue. The laundry department struggled to keep up with the demand due to staffing shortages and budget cuts. The facility had reduced from three shifts to two, making it difficult to maintain an adequate supply of clean linens. The laundry aide reported that the workload had increased, and the facility had been running behind on laundry for about a month. The administrator was aware of the issue but had not yet ordered additional linens. The deficiency affected all 104 residents in the facility, as the lack of towels and washcloths hindered the ability to provide timely and adequate personal care.
Facility Fails to Maintain Cleanliness and Repair in Utility Rooms
Penalty
Summary
The facility failed to maintain cleanliness and repair in utility rooms and nurses stations, potentially affecting all 105 residents. During an inspection, the housekeeping supervisor, V8, revealed that the housekeeping staff were responsible for daily cleaning of these areas. However, upon inspection, the 3rd floor soiled utility room was found with a sink and cabinet detaching from the wall, a black substance covering the cabinet floor, and water leaking into the under-sink compartment. The maintenance director, V9, confirmed awareness of the issue and acknowledged a maintenance request had been submitted two weeks prior. Further observations revealed that the 3rd and 4th floor clean utility rooms had accumulated dirt and debris, indicating they had not been cleaned for a significant period. The 4th floor soiled utility room had a sink with missing caulking, a disrepair backsplash, and a discolored floor with dirt and debris. Additionally, the baseboards and toe kick boards around the fourth floor nurses station were dirty and appeared neglected. The President of Clinical Services, V5, confirmed these findings and noted that the facility employed a full-time floor person who seemed to be neglecting their duties.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours per day, as required. This deficiency was identified during an investigation conducted on November 25 and 26, 2024, where it was observed that no RN was providing direct care to residents during the specified hours. The facility's staffing sheets for November 2024 confirmed that an RN was not scheduled for several dates, including November 11, 12, 15, 16, 17, 20, 21, and 25. The Assistant Directors of Nursing, identified as V13 and V14, were noted on the staffing sheets but did not provide direct care for the required duration. Interviews with the facility's Director of Nursing (DON) and Assistant Directors of Nursing revealed that the RNs present in the facility, including V13 and V14, did not work on the floor providing direct care to residents. V13 confirmed that she only spent about an hour on the floor per day and primarily worked in her office. The DON acknowledged that on the specified dates, no RN provided direct care for eight consecutive hours, affecting the care of all 108 residents residing in the facility.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 108 residents residing in the facility. On multiple occasions, it was observed and confirmed through interviews that the current Dietary Manager, identified as V3, is not certified and has not completed the Certified Dietary Manager Course. Despite this, V3 is actively managing all aspects of the dietary department, including regulatory oversight related to safe food handling, managing kitchen personnel, and training newly hired staff. The facility's administrator, identified as V1, confirmed that V3 is not certified, and the dietary personnel schedule also lists V3 as the Dietary Manager.
Insufficient Dietary Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service, potentially affecting all 108 residents. The dietary manager, responsible for managing all aspects of the dietary department, including regulatory oversight and staffing, was observed actively managing kitchen personnel and directing food sanitation and preparation activities. Due to a lack of support personnel, the dietary manager was also acting as a cook. The dietary personnel schedule provided by the administrator showed that only two staff members were scheduled to perform essential dietary services on several days, which the dietary manager confirmed was insufficient to complete essential functions in a timely manner.
Failure to Follow Posted Menus
Penalty
Summary
The facility failed to adhere to the posted and printed menus, which are required to meet the nutritional needs of residents. On the specified date, the lunch menu was supposed to include Herb Roasted Pork Loin, Candied Sweet Potatoes, Buttered Cabbage, Apple Cobbler, and a Dinner Roll. However, observations revealed that a pork chop was served instead of pork loin, sliced bread was provided instead of a dinner roll, and apple slices with cinnamon were served in place of apple cobbler. The dietary manager, V3, acknowledged the substitution of pork chops due to the unavailability of pork loin from the vendor. Interviews and record reviews further highlighted the issue, with a resident, R4, stating that the kitchen frequently makes substitutions and does not follow the posted menu. The facility's administrator provided a complaint form and resident council minutes indicating dissatisfaction with the menu adherence. The dietary manager confirmed the menu for the day and acknowledged the substitutions made. This failure to follow the menu has the potential to affect all 108 residents in the facility.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations, interviews, and record reviews. Multiple resident rooms were found to be cluttered and unclean, with piles of personal items, trash, and food debris. Specific instances included a room with piles of unfolded blankets and full trash bags, another with empty cups and candy wrappers, and a room with cases of tea and food items obstructing pathways. Additionally, the walls in some rooms were scuffed and had chipping paint. The Resident Council Meeting minutes from several months indicated ongoing dissatisfaction with housekeeping services, with residents expressing a desire for better cleaning and less complaining from staff. Interviews with facility staff, including the Director of Nursing and the Director of Housekeeping, confirmed that the housekeeping staff were not meeting the expected standards for room cleanliness. The Director of Housekeeping outlined the cleaning responsibilities, which included sweeping, mopping, and wiping down surfaces, but acknowledged that these tasks were not being adequately performed. The Maintenance Director also confirmed the need for repairs and painting of the walls in resident rooms. The facility's policy on room cleaning and disinfection emphasized routine cleaning and attention to high-touch areas, which was not being adhered to, contributing to the deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, affecting two residents. The incident occurred in the facility dining room when one resident, who has intact cognition, struck another resident in the face/temple area. The resident who was struck has a diagnosis of Mild Intellectual Disability, Schizophrenia, Weakness, Seizure Disorder, and Traumatic Brain Injury, and is completely dependent on or requires substantial staff assistance for activities of daily living. This resident was seated in a wheelchair and was mumbling, which was usual behavior, when the other resident wheeled over and punched them. The facility's policy on Abuse, Neglect, and Exploitation clearly states that each resident has the right to be free from abuse by anyone, including other residents. Despite this policy, the incident occurred, and the affected resident immediately complained of face pain after being struck. A Certified Nurse Aide present during the incident confirmed the sequence of events, noting that the resident who was struck stated that they had been hit. This incident highlights a failure in the facility's responsibility to protect residents from abuse by other residents.
Failure to Administer Nutritional Supplements and Wound Treatments
Penalty
Summary
The facility failed to provide nutritional supplements and wound treatments as ordered for two residents with pressure ulcers. One resident, identified as R1, had a stage four pressure ulcer on the sacrum and was prescribed Arginaid, a protein nutritional supplement, to aid in wound healing. Despite the order being placed in early April, the supplement was never received or administered to R1. Additionally, R1's prescribed wound treatments, including the application of Gentamicin Sulfate Cream and other dressings, were not consistently completed due to time constraints, as documented by the LPN responsible for the care. Another resident, R3, also did not receive prescribed wound treatments for pressure ulcers on the sacrum and right shoulder. The treatment records indicate multiple instances where the treatments were not completed, again due to time constraints as stated by the LPN. The Director of Nursing confirmed these deficiencies, acknowledging that the treatments were not administered as ordered for both residents.
Lack of Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to have physician orders for oxygen use for three residents (R1, R2, and R5) who were reviewed for oxygen administration. The facility's Oxygen Administration policy requires oxygen to be administered under physician orders, except in emergencies, and mandates specific care plan details for oxygen therapy. However, R1's care plan did not specify the oxygen delivery system, flow rate, or frequency, and there was no physician order for oxygen administration in R1's Order Summary Report. R1, who has diagnoses of Heart Failure and COPD, stated that they used oxygen as needed while residing at the facility. The Director of Nursing confirmed that there should be a physician's order for oxygen use and that the care plan should specify the necessary details for oxygen therapy. Similarly, R2's Order Summary Report did not document an order for oxygen administration despite R2 being cognitively intact and using oxygen. R2's Practitioner Progress Note indicated the need for continued oxygen use, and R2 was observed wearing oxygen at 2 liters per minute. R5, who was admitted to the facility and later discharged to an acute care hospital, also did not have an admission order for oxygen despite having discharge orders from the hospital for continuous oxygen use. The Assistant Director of Nursing confirmed that R5 was wearing oxygen upon admission and during their stay at the facility, but no admission orders for oxygen were listed in the medical record.
Insufficient RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. Specifically, on 5/3/24 and 5/5/24, the facility scheduled zero hours of RN coverage for a 24-hour period. This deficiency was confirmed by the facility's Nursing Schedule document and an interview with the Administrator, who verified the accuracy of the schedule. At the time of the deficiency, the facility had 95 residents, as documented in the Resident Midnight Census dated 5/6/24.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab Of Decatur | 0.2 mi | ★★★★★ | 12 | 0 |
| Decatur Rehab & Health Care Ct | 2.7 mi | ★★★★★ | 0 | 0 |
| Fair Havens Senior Living | 3.4 mi | ★★★★★ | 36 | 1 |
| Arc At Hickory Point | 3.6 mi | ★★★★★ | 24 | 1 |
| Imboden Creek Senior Living | 3.8 mi | ★★★★★ | 34 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.